Prehospital airway management: why the bag-valve-mask still comes first

Ask a room of paramedics which airway skill they would most like to practise and many will say intubation or supraglottic devices. Ask which skill has saved more of their patients and the honest answer is usually the bag-valve-mask. Prehospital airway management is not a ladder to climb as fast as possible. It is a way of keeping oxygen moving into a patient until someone, somewhere, can secure a definitive airway safely.

That framing changes how crews behave under pressure. The goal is oxygenation and ventilation. Devices are means to that end.

This article covers principles, not procedures. Scope of practice, indications and drug-assisted airway management vary across Canada, so your service's medical directives and the provincial ALS/BLS standards always take precedence.

#Prehospital airway management: oxygenation is the goal, not the tube

Patients do not die from a lack of intubation. They die from a lack of oxygen. A crew that spends several minutes on a difficult advanced airway attempt while saturation falls has prioritised the device over the patient.

Keeping that in view helps with a few common traps:

• Task fixation: focusing on "getting the tube" while losing track of time and saturation.
• Skipping steps: jumping to an advanced device without first trying simple positioning and adjuncts.
• Equating difficulty with failure: a hard BVM seal is usually a technique problem, and fixable.

#BVM first: technique that actually works

A well-performed bag-valve-mask ventilation solves most prehospital airway problems. Poorly performed, it causes gastric inflation, aspiration risk and false confidence. Good technique includes:

1. Positioning. Align the airway, often by raising the head so the ear canal sits level with the sternum, where appropriate and not contraindicated.
2. Basic manoeuvres. Head tilt, chin lift or jaw thrust, chosen to suit the patient and any spinal concerns.
3. Adjuncts. Oropharyngeal or nasopharyngeal airways, sized correctly, to keep the tongue out of the way.
4. A two-person seal. When possible, one provider holds the mask with both hands while the other squeezes the bag. It is markedly easier than one-handed technique.
5. Gentle, controlled ventilation. Slow, steady breaths with just enough volume to see the chest rise, avoiding hyperventilation.

If the seal or chest rise is poor, step back through the list before escalating. Most "can't bag" situations improve with better positioning and a second pair of hands.

#Basic before advanced, and why order matters

The stepwise approach is not about doing less. It is about ensuring each escalation happens from a position of safety. A supraglottic airway or intubation attempt is far safer when the patient arrives at it well oxygenated, with suction ready and a fallback agreed.

Escalation commonly makes sense when basic measures cannot maintain oxygenation and ventilation, when the airway needs protection the basics cannot provide, or for a prolonged transport where a more secure airway clearly helps. Who can escalate, and to what, is set by local directives.

#Preoxygenation: buying time before you need it

Preoxygenation means filling the lungs with oxygen before any planned interruption to breathing. It extends the time the patient can tolerate apnoea before desaturating, which is the margin you work in during any advanced attempt.

In general terms, effective preoxygenation involves:

• Starting early, as soon as an advanced airway is being considered
• Using a good mask seal and appropriate oxygen delivery as set out in your directives
• Positioning the patient upright where possible, since it can improve lung volumes
• Continuing oxygen delivery during the attempt where your protocols allow

Patients who are critically ill, obese, pregnant or very young can desaturate quickly even after good preoxygenation. Expect it, and plan for it.

#Failed-airway thinking: decide before you start

The time to plan for a failed airway is before the first attempt, not during the third. Strong teams say the plan out loud.

A useful pre-attempt briefing covers:

• Plan A: the first device and approach
• Plan B: the immediate fallback, often a supraglottic device or return to BVM
• Plan C: what happens if oxygenation cannot be maintained, including whatever rescue options your scope allows
• The trigger: a clear limit on attempts and a falling saturation threshold, as defined locally, that ends an attempt
• Roles: who watches the monitor and calls time

Guidelines such as those from the Difficult Airway Society emphasise limiting attempts and moving to the next plan rather than persisting. The language may differ in Canadian directives, but the logic is the same: a failed attempt is a signal to go back to oxygenation.

#For training leads: practise the boring parts

Airway training often goes straight to the advanced device. The skills that fail in the field are usually more basic, and decision-making under stress is the hardest of all.

• Run two-person BVM drills regularly, with feedback on seal and chest rise.
• Build scenarios where the BVM is the right answer, so learners practise choosing not to escalate.
• Require a verbal airway plan before any advanced attempt in a scenario.
• Add a failed first attempt and assess whether learners return to oxygenation promptly.
• Debrief on time awareness, since task fixation is rarely visible to the person doing the task.

Scenario practice, whether in a sim lab or through a decision-training platform such as Imedica, lets crews rehearse the decision to escalate or step back without a real patient's oxygen on the line.

#The takeaway

Prehospital airway management is about keeping oxygen moving. Master the BVM, escalate in steps, preoxygenate before you interrupt anything, and agree on the failed-airway plan out loud before you start. The device is just a tool. The plan is what keeps the patient safe.

Drafted for Imedica Field Notes. Physician review of this article is pending.