Who Should Manage the Airway?

In a recent special issue of RESPIRATORY CARE, Daniel Talmor presented a very nice review of airway management during a mass-casualty event.1 He rightly pointed out that only experienced clinicians should perform intubation in these circumstances, and that training clinicians for the sole purpose of providing intubation during a mass-casualty event is unwise. He also listed anesthesiologists, certified registered nurse anesthetists, intensivists, and emergency medicine physicians as clinicians who the literature shows are able to “successfully manage the airway.” However, the literature also shows that respiratory therapists (RTs) can be trained to perform emergency endotracheal intubation efficiently and safely. In a small study of 50 consecutive intubations, McLaughlin and Scott2 found that the RTs involved successfully intubated all patients. The mean number of attempts was 1.48, and most patients were successfully intubated in less than 1 min. In a larger study, with over 800 intubations, at Duke Medical Center,3 Thalman and colleagues found a 95% intubation success rate among RTs. Ninety-two percent of the intubations were accomplished with fewer than 3 attempts. Moreover, well-trained RTs at Butterworth Hospital in Grand Rapids, Michigan, had a 90% intubation success rate when physicians failed.4 At my community hospital, RTs in my department have provided intubation since 1992, with a group success rate always around 90%, and with a very low incidence of complications. In addition, the American Association for Respiratory Care Clinical Practice Guideline for Management of Airway Emergencies5 recognizes registered RTs as clinicians capable of being trained to be primary providers of endotracheal intubation. The key, of course, is training. With good initial training and periodic recertification, including book study, RTs can perform emergency intubation with good proficiency.6 Community hospitals are not immune from masscasualty events and may not be staffed with anesthesiologists and intensivists at all times of the day and night. In that setting, RTs may prove particularly valuable when disaster strikes and multitudes of patients require intubation in a short period of time.