Ep. 45 & 46 | Airway — The First Frontier
There’s something about airway calls that stay with you.
It’s late, your job shirt is barely keeping the chill out, and there’s a granola bar wrapper shoved in your pants pocket. You’re sitting on the tailboard, replaying that one moment where everything slowed down, and all that mattered was the tube, the bag, and the view.
That’s the energy of this Fireside Chat episode: real, unfiltered airway talk. Not classroom mannequins. Not PowerPoints. The messy, humbling, real-life airway that every EMS provider knows.
This episode isn’t about lecturing. It’s about sitting down after shift, swapping stories, sprinkling in some updated airway stats, and reminding ourselves why the “little things” in airway aren’t little at all.
Back to Basics
Before we even talk about blades or fancy toys, let’s talk about what really sets airways up for success: positioning, BVM technique, and airway adjuncts.
Ramping the patient—lining the ear to the sternal notch—has been shown to improve first-pass success by about 16–17% (Baek 2021). It’s such a simple move, but it’s the difference between a clean view and a frustrating attempt.
BVM technique is another one that’s deceptively simple. Everyone swears they’re good at it…until they’re in the back of a truck at 3 AM, alone, trying to hold a seal with one hand. A 2022study found that 52% of prehospital airway complications were tied to poor BVM technique, not failed tubes (Cheskes 2022). Let that sink in.
And airway adjuncts? OPAs and NPAs are the reusable grocery bags of airway tools — humble, reliable, and way too often forgotten. Only 28% of hypoventilating patients received them before advanced attempts in one 2020 dataset (Smith 2020).
Tools, Toys, and Backup Plans
Your airway kit says a lot about you.
Some people are VL die-hards. Some won’t touch a tube without their trusty bougie. And some of us have an i-gel that’s saved more shifts than we’d like to admit. The point is: knowing your tools, and your plan B (and C), matters.
VL has changed the prehospital game. Between 2020 and 2022, studies showed about a 19% increase in first-pass success compared to DL (Zhao 2021). That’s huge — but it doesn’t mean DL is dead. When the screen fogs up like a Subaru windshield in October, you need to know how to go old-school.
Bougie use remains one of the best-kept secrets in difficult airways. One study showed first-pass success climbing from 81% to 96% when a bougie was used in challenging cases (Driver 2020). And let’s not sleep on supraglottic airways: i-gels had >92% first-attempt success in OHCA (Gong 2021). Fast. Simple. Effective.
And when the airway turns into a vomit volcano? SALAD technique (Suction-Assisted Laryngoscopy and Airway Decontamination) has proven to improve glottic view and decrease visualization time (Schroeder 2020).
The Calm Airway Is a Good Airway
You can always tell when someone is actually leading an airway. The room feels different. It’s calm, organized, intentional. There’s no frantic yelling, no five people all doing five different things.Quick mental airway assessments (LEMON, MOANS), assigning roles out loud, and staging your backups make all the difference. It doesn’t have to be a production — just clear, confident communication.
First-pass success isn’t just a number; it changes outcomes. A 2021 registry found hypoxia rates were 12% on first attempt vs 43% after multiple attempts, and hypotension was 13% vs 31% (Dodd 2021). And simply assigning roles boosted airway performance by roughly 30% in simulation studies (Brewster 2020).
Once the Tube’s In… The Work Isn’t Over
This is where flight and critical care flavor comes in. Once the tube’s in, airway management shifts from anatomy to physiology.
Preoxygenation is no longer “a step” — it’s the main event. Apneic oxygenation alone has been shown to reduce desats by 23% during prehospital RSI (Weingart 2020). Waveform capnography is non-negotiable; yet, even in 2021, 1 in 212 tubes were still found in the esophagus at ED arrival (Davis 2021).
And please… stop hyperventilating TBI patients. Over 50% of severe TBI patients are still being hyperventilated post-intubation (Wang 2020). We can do better.
Trivia Time
Of course, we couldn’t end without a little friendly competition. Jaime and I wrapped up the episode with a quick-fire airway trivia round — loser buys gas station coffee.
Here’s a peek at a few of the questions we threw at each other. Play along before you listen 👇
1. What % of airway complications are BVM-related?
2. VL improves first-pass success by how much?
3. i-gel first-attempt success in OHCA?
4. Esophageal tube rate at ED?5. Ramping improves first-pass success by…?
(Answers are in the episode 😉)
📚 References
Baek 2021 · Cheskes 2022 · Smith 2020 · Zhao 2021 · Driver 2020 · Gong 2021 · Schroeder 2020 · Dodd 2021 · Brewster 2020 · Weingart 2020 · Davis 2021 · Wang 2020
