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Before the arrival of an emergency medical service unit, ventilation given by bystanders must employ techniques that do not require special equipment. Safar, Elam, and Ruben first showed that obstruction of the upper airway by the tongue and soft palate occurs commonly in victims who lose consciousness or muscle tone and that ventilation with manual techniques is markedly reduced or prevented by such obstruction.13 Subsequently, Safar et al4,5 developed techniques that prevent obstruction by extending the neck and jaw and applied these in conjunction with mouth-to-mouth ventilation. The “gold standard” today for airway maintenance during resuscitation is intubation of the trachea, which provides a route for ventilation with oxygen, allows suctioning of the upper airway, protects the airway from aspiration of gastric contents, and prevents inflation of the stomach.


Airway management should be mastered by all properly trained prehospital personnel. This involves both airway assessment and airway control. Compromise of the airway may occur suddenly or slowly and progress over time; therefore, continuous assessment of the airway is vitally important. Pulse oximetry is helpful in identifying hypoxia, although hypoxia may be a relatively late sign of airway compromise. It is therefore important to evaluate breathing pattern, level of consciousness, and shortness of breath continuously.


When endotracheal intubation of children was added to paramedic practice, fifteen of 177 (approximately 8%) children were either intubated esophageally or dislodgment of the endotracheal tube were unrecognized; fourteen of these fifteen children subsequently died.6 Accordingly, invasive pediatric airway equipment was removed from emergency medical service units in Los Angeles County; instead, bag-valve-mask ventilation was recommended. A similarly alarming experience was seen in Orlando, Florida, when the esophagus was intubated in eighteen of 108 (approximately 16%) patients being managed by the emergency medical services.7 This suggests that the skills and experience of a rescuer performing basic and advanced airway management may determine if these maneuvers achieve effective oxygenation and carbon dioxide elimination or result in extremely serious complications, such as severe neurologic impairment, or even death.8


Endotracheal intubation is the “gold standard” for providing emergency ventilation. Thus, every advanced emergency medical service provider must acquire and, especially, maintain intubation skills. Such a goal may be difficult to guarantee because of the large numbers of individuals who require training and/or the infrequent performance of intubations. This experience is similar to observations of the emergency medical services in Houston, Texas, where airway device-related complications were associated more with training with the devices than with the devices themselves.9 This confirms that the success rate of airway management interventions depends on three factors: (a) initial training, (b) continuous quality assurance, and (c) actual frequency of performing the specific intervention. For example, when the actual frequency of performing endotracheal intubation is relatively low, as in the case of the Los Angeles County emergency medical services (e.g., 2584 trained individuals performing 420 actual endotracheal intubations over 33 months), it is ...

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