**6. Training**

On the one hand, the continuity of airway providing skills should be ensured through intermittent training, and on the other hand, knowledge about the use of newly developed devices should be obtained. Training requirements in airway

**75**

*Airway Management in Accident and Emergency DOI: http://dx.doi.org/10.5772/intechopen.96477*

**7. Pre-hospital setting**

**8. Video-laryngoscopes**

management can be divided into airway evaluation, technical aspects of tracheal intubation and alternative airway techniques, and rapid sequential intubation. Fiberoptic intubation and the use of laryngeal masks are among the most common trainings (**Figure 2**) [15]. Simulation-based airway training is also widely used. Both technical and non-technical skills of the participants can be improved with simulators [16]. However, the important fact in training is the intermittent repetition of the acquired skills and permanence. Besides, the transfer of acquired knowledge and skills to the clinical environment should form the basis of training on this subject. For this purpose, different training methods were used to teach airway management to residents and novice users. It has been reported that teaching on cadavers and expression techniques such as Pecha Kucha is effective in achieving success [17].

Pre-hospital settings are often associated with airway management challenges. Although the team is well trained, the frequency of morbidity and mortality is high due to the high risk of complications. Tracheal intubation is the ideal technique [18]. Direct and indirect laryngoscopy can be used for tracheal intubation. It has been reported that the use of video-laryngoscope by emergency medical residents resulted in less esophageal intubation than direct laryngoscopy. In a study analyzing six years retrospectively, data of 2.677 patients were examined [19]. 1.530 intubations (44.7%) were performed with a direct laryngoscope, and video-laryngoscopy was used during 1.895 intubation attempts (55.3%). While esophageal intubation incidence with direct laryngoscope was 5.1%, this ratio was 1.0% with the video-laryngoscope. It has been shown that the use of a checklist in the airway management of patients with severe trauma leads to a decrease in the rate of intubation-mediated complications [20]. Many studies have been conducted in the pre-hospital setting. The success rate and risk of complications of pre-hospital tracheal intubation depend on the experience of healthcare professionals. Intubation performed by healthcare professionals who are not skilled enough to do this significantly increases mortality. A meta-analysis, including 733 studies and data of 4772 patients, reported that tracheal intubation

should be performed in emergency medical services [21].

In recent years, video-laryngoscopes have become a popular tool for the intubation of trauma patients (**Figure 3**). Many studies are comparing direct laryngoscopy and video-laryngoscopy in trauma patients. A systematic review in which nine different studies covering 1329 patients was evaluated, the first attempt success rate was significantly higher with video-laryngoscopes [22]. Besides, the use of video-laryngoscope caused a significant reduction in Cormack and Lehane grades, improving glottic vision. Mucosal trauma decreased with the use of videolaryngoscopy (p = 0.02). In another study, data of 150 patients who underwent RSI were analyzed [23]. Better visualization was obtained in the Emergency department through video-laryngoscope than direct laryngoscopy, but the first-attempt success rate did not increase. A recent study conducted with the GlideScope, laryngoscopic grade, and the number of intubation attempts were found to be similar, and it was

concluded that intubation could be performed slightly faster [24].

On the other hand, in some studies, using a video-laryngoscope is associated with lower force application to oral structures [25, 26]. More researches are needed regarding the use of video-laryngoscopes in emergency conditions. In a study that

**Figure 2.** *Intubation through supraglottic airway devices.*

*Airway Management in Accident and Emergency DOI: http://dx.doi.org/10.5772/intechopen.96477*

*Special Considerations in Human Airway Management*

Surgical airway intervention is applied in case of unsuccessful tracheal intubation and cannot intubate-cannot oxygenate situation. Percutaneous cricothyrotomy is the most commonly used procedure. Laceration development in the posterior tracheal wall is a mortal complication. Life-threatening tension pneumothorax, pneumomediastinum, mediastinitis, and progressive respiratory failure can occur when the posterior membranous part of the trachea is injured. Ultrasonography reduces the developmental risk of these complications [13]. However, Siddiqui et al. reported that airway damage might develop despite ultrasound guidance. Also, ultrasound-

guided cricothyrotomy takes longer than the conventional technique [14].

On the one hand, the continuity of airway providing skills should be ensured through intermittent training, and on the other hand, knowledge about the use of newly developed devices should be obtained. Training requirements in airway

**5. Surgical airway**

**6. Training**

**74**

**Figure 2.**

*Intubation through supraglottic airway devices.*

management can be divided into airway evaluation, technical aspects of tracheal intubation and alternative airway techniques, and rapid sequential intubation. Fiberoptic intubation and the use of laryngeal masks are among the most common trainings (**Figure 2**) [15]. Simulation-based airway training is also widely used. Both technical and non-technical skills of the participants can be improved with simulators [16]. However, the important fact in training is the intermittent repetition of the acquired skills and permanence. Besides, the transfer of acquired knowledge and skills to the clinical environment should form the basis of training on this subject. For this purpose, different training methods were used to teach airway management to residents and novice users. It has been reported that teaching on cadavers and expression techniques such as Pecha Kucha is effective in achieving success [17].

## **7. Pre-hospital setting**

Pre-hospital settings are often associated with airway management challenges. Although the team is well trained, the frequency of morbidity and mortality is high due to the high risk of complications. Tracheal intubation is the ideal technique [18]. Direct and indirect laryngoscopy can be used for tracheal intubation. It has been reported that the use of video-laryngoscope by emergency medical residents resulted in less esophageal intubation than direct laryngoscopy. In a study analyzing six years retrospectively, data of 2.677 patients were examined [19]. 1.530 intubations (44.7%) were performed with a direct laryngoscope, and video-laryngoscopy was used during 1.895 intubation attempts (55.3%). While esophageal intubation incidence with direct laryngoscope was 5.1%, this ratio was 1.0% with the video-laryngoscope. It has been shown that the use of a checklist in the airway management of patients with severe trauma leads to a decrease in the rate of intubation-mediated complications [20]. Many studies have been conducted in the pre-hospital setting. The success rate and risk of complications of pre-hospital tracheal intubation depend on the experience of healthcare professionals. Intubation performed by healthcare professionals who are not skilled enough to do this significantly increases mortality. A meta-analysis, including 733 studies and data of 4772 patients, reported that tracheal intubation should be performed in emergency medical services [21].

#### **8. Video-laryngoscopes**

In recent years, video-laryngoscopes have become a popular tool for the intubation of trauma patients (**Figure 3**). Many studies are comparing direct laryngoscopy and video-laryngoscopy in trauma patients. A systematic review in which nine different studies covering 1329 patients was evaluated, the first attempt success rate was significantly higher with video-laryngoscopes [22]. Besides, the use of video-laryngoscope caused a significant reduction in Cormack and Lehane grades, improving glottic vision. Mucosal trauma decreased with the use of videolaryngoscopy (p = 0.02). In another study, data of 150 patients who underwent RSI were analyzed [23]. Better visualization was obtained in the Emergency department through video-laryngoscope than direct laryngoscopy, but the first-attempt success rate did not increase. A recent study conducted with the GlideScope, laryngoscopic grade, and the number of intubation attempts were found to be similar, and it was concluded that intubation could be performed slightly faster [24].

On the other hand, in some studies, using a video-laryngoscope is associated with lower force application to oral structures [25, 26]. More researches are needed regarding the use of video-laryngoscopes in emergency conditions. In a study that

**Figure 3.** *Tracheal intubation using video-laryngoscopes.*

included 4041 emergency room patients over three years, the GlideScope was used for tracheal intubation in 540 patients. It was reported that there was no significant difference in the success rate and unsuccessful tracheal intubation rates in the first attempt when compared with the conventional method [27].
