Regardless of the location of the patient, airway evaluation and management are the first priority of the health care provider in any emergency setting. The austere environment in which prehospital providers must function (e.g., poor positioning and lighting, disruptive surroundings, and limited assistance) demands that airway care be carried out both thoughtfully and skillfully to ensure the best outcomes.

Every prehospital provider must acquire and maintain the necessary skills to ensure that adequate gas exchange can be assured until arrival at the hospital, regardless of the device used or the technique used.

Endotracheal intubation is a common advanced airway procedure used in the prehospital setting. The incidence of difficult intubation in emergency medical services (EMS) is 11%. Studies of prehospital endotracheal intubation have reported success rates from 75% to 96.6%. This highly variable success rate, coupled with the dire consequences of failure, has been the foundation of much discussion concerning how to best manage the airway in the prehospital setting.

The introduction of medication-assisted intubation (e.g., rapid sequence intubation) has led EMS systems to ensure that their advanced providers are trained in the use of alternative airway devices in addition to BMV, in order to rescue the airway should intubation following paralysis and/or sedation fail. The growth of experience with and research in the prehospital use of these airway devices has led EMS medical directors to examine their use as an alternative to endotracheal intubation for advanced providers, and as an alternative to BMV for basic-level providers. In their 2005 guidelines, The European Resuscitation Council recommends that if ventilation cannot be provided through an endotracheal tube, alternative airway devices should be used for ventilation in the management of cardiac arrest. The American Heart Association guidelines are less directive, stating that their use “appears to be safe.”

The approach to airway management in EMS is the same as in the ED or the OR. Chapters 1, 2 and 3, provide the framework with which to approach airway management in the prehospital setting. In this chapter, we introduce alternative airway devices available for prehospital use. In 2007, the National Association of EMS Physicians published a position statement on the use of alternative airway devices in the prehospital setting. We discuss the devices available and their prehospital use. For discussion of surgical airways, please refer to Chapter 18.

Simple-to-use devices such as the King LT, laryngeal mask airway (LMA), and the Combitube have been introduced and validated in the prehospital care setting. These devices may be used in two ways: as an alternative to endotracheal intubation in the cardiac arrest (or deeply comatose) patient by basic life support (BLS) providers, or as a rescue device in the setting of failed intubation by advanced life support (ALS) or critical care providers. The actual number of alternative devices available to a specific EMS system is limited by protocols, training, cost and equipment.

All EMS providers who perform advanced airway interventions should also have at least one alternative airway device at their immediate disposal.

An emerging alternative to endotracheal intubation in the respiratory failure patient is prehospital noninvasive ventilation. Several case series have shown continuous positive airway pressure (CPAP) or bi-level ventilation to be feasible and potentially beneficial in the prehospital setting. Further study is necessary to validate its effectiveness and safety.