Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Changes to Pennsylvania Protocols – Confirmation of Airway Placement


Here is another example of the new Pennsylvania protocols, both BLS and ALS, that go into effect by July 1, 2011 at the latest. Confirmation of Airway Placement.

A. Patient who has ET tube or alternative airway device inserted by EMS provider.[1]

This is not just for endotracheal tubes, but also for every extraglottic airway.

Exclusion Criteria:
A. None[1]

Use continuous waveform capnography (an electronic wave-form ETCO2 detector device) at all times on every glottic or extraglottic airway.

System Requirements:
A. Every ALS service must carry and use an electronic wave-form ETCO2 detector device1 for confirmation and continuous monitoring of endotracheal tube/alternative airway device placement.[1]

While this protocol has been changed, the only change has been to add the words and continuous monitoring.

Those three words are all that changed in this protocol.

Why is this change necessary?

Because too many of us just do not understand the benefits of continuous waveform capnography.

There is a phrase for these medics – Medics trying for their first unrecognized esophageal intubation.

Some may even be working on their second, third, or more esophageal intubations.

It is likely that almost all esophageal intubations are due to:

1. The tube was never in the trachea.

2. The tube was never recognized as esophageal not in the trachea.


3. The tube was left in the esophagus because the medic believed he saw the tube go through the vocal cords.

Perhaps a tiny percentage of esophageal intubations (probably much less than 5%) are due to the tube becoming dislodged with movement.

Why would anyone choose to not continuously monitor waveform capnography?

Ignorance of the benefits of continuously waveform capnography and ignorance of airway management.

Is continuous waveform capnography too complicated for paramedics?

Anyone who tells you that does not understand airway management.

Performance Parameters:
A. Review all ETI and Alternative Airway Device insertions for documentation of absence of gastric sound, presence of bilateral breath sounds, and appropriate use of a confirmation device.
B. If systems have the capability of recording a capnograph tracing, review records of all intubated patients to assure that capnograph was recorded.
C. Document ETCO 2 reading immediately after intubation, after each movement or transfer of patient and final transfer to ED stretcher.[1]

Notice that there is no requirement to document seeing the tube go through the cords.

If we rely on seeing the tube go through the cords, we will have unrecognized esophageal intubations.

If we rely on continuous waveform capnography we will not have unrecognized esophageal intubations, because they will be recognized shortly after being connected to the tube or soon after the tube is dislodged.


[1] Confirmation of Airway Placement
Pennsylvania Statewide Advanced Life Support Protocols
2032 – ALS – Adult/Peds
Page 14/128
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