Although all emergency airway management situations share this feature, identification of a difficult airway might influence the provider either to be more or less likely to intubate the patient before transport. Consider, for example, the following two cases, each with an anticipated 10-minute transport time:

Both patients have clear indications for securing the airway, although the decision making, particularly with respect to urgency, should be quite different.

In the first case, if the patient is not deteriorating further, it often is best to defer intubation to the ED, where a more formal and controlled neuroprotective RSI can be performed and there are additional options, such as flexible endoscopy, for this difficult airway. The patient’s respiratory status, and his or her oxygen saturation, are adequate. Training must emphasize that preservation of vital functions equates to gas exchange, and does not necessarily equate to endotracheal intubation. Additionally, the patient has a chronic difficult airway, one that will not become increasingly difficult if intubation is delayed. The provider and system medical directors must be wary of the technical imperative—that operators generally will perform an authorized procedure more often
than it is required or indicated. In fact, there is growing evidence that in certain situations, prehospital intubation may not improve outcomes, and may even lead to worse outcomes, and may even lead to worse outcomes.

In the second case, the operator is forced to actively manage the airway despite predicted difficulty with laryngoscopy. Even a brief delay, such as a 10-minute transport, allows time for further deterioration, increasing the threat to the patient and making intubation progressively more difficult. The decision to intubate here is clear, and the provider must proceed deliberately down the EMS Difficult Airway Algorithm (Fig. 30-1).

The preintubation airway assessment is essential to identify patients likely to present difficulties for laryngoscopy, bag-mask-ventilation (BMV), extraglottic device (EGD) placement, or cricothyrotomy based on a focused examination of external anatomic features (see Chapter 2). This evaluation permits one to make appropriate airway management plans (Plans A, B, and C) that are most likely to be successful.

The patient with acceptable oxygen saturations and a short transport time displaying predictors of difficult laryngoscopy might be better served by a timely transport to the nearest ED, where
there are more resources and skilled personnel. This is particularly the case when the difficult airway is chronic or stable, and is not the reason the patient requires intubation. For example, consider the 40-year-old patient above, who had experienced sudden collapse. Suppose that the anticipated transport time is not 10 minutes, but 20 minutes. Suppose also that preintubation assessment identifies that the patient has had head and neck surgery and radiation for cancer, and has limited mouth opening, neck scarring, and some distortion of anatomy. The difficult airway here is stable and will not worsen during transport to an ED, thus making even more compelling the decision to defer intubation until after ED arrival. This extends the window of time that is “acceptable” for transport without intubation because the risk/benefit ratio argues in favor of taking the patient, unintubated, to the ED. This is in stark contrast to the second patient described above with upper airway burns and stridor. Consider this patient in the context of a 5-minute transport time. Here, regardless of how short the transport time is, the likelihood of imminent deterioration both compels intubation and argues for undertaking this at the earliest opportunity. Thus, both the nature and the “stability” of the difficult airway become key factors in the “intubate versus transport” decision. This has been identified as ‘context sensitive’ airway management.