Emergency Medical Services (EMS) personnel are often the first healthcare providers to reach a patient experiencing a severe medical crisis. Airway management is a primary concern for EMS providers, as securing the airway allows for controlled delivery of oxygen and ventilation. The procedure known as endotracheal intubation (ETI) is one method of achieving this definitive control. Whether an Emergency Medical Technician (EMT) performs this advanced skill is complex, depending heavily on the provider’s specific training level and the medical protocols authorized in their local jurisdiction.
Understanding Endotracheal Intubation
Endotracheal Intubation is a medical procedure where a flexible plastic tube is inserted through the patient’s mouth or nose directly into the trachea. The primary purpose is to establish a definitive, sealed airway, allowing for mechanical ventilation and preventing aspiration (stomach contents entering the lungs). A small cuff at the tip of the tube is inflated after placement to create this seal and secure the tube in place.
The procedure is typically required for patients unable to breathe adequately, such as those in cardiac arrest, severe respiratory failure, or deep coma. Field intubation uses a specialized tool called a laryngoscope to visualize the vocal cords and guide the tube. While ETI has long been considered the standard for advanced airway control, its use in the prehospital setting is controversial due to potential higher failure and complication rates compared to a controlled hospital environment.
Levels of EMS Providers and Airway Authorization
The ability to perform endotracheal intubation is strictly regulated by the provider’s level of certification and local medical director protocols. The three main levels of prehospital care providers are the Emergency Medical Technician (EMT), the Advanced EMT (AEMT), and the Paramedic. The standard EMT, often referred to as EMT-Basic, is trained in basic life support (BLS) and is authorized to perform essential skills like basic airway maneuvers, suctioning, and Bag-Valve Mask (BVM) ventilation.
Standard EMTs are not authorized to perform ETI; this skill is outside of their nationally recognized scope of practice. ETI is primarily reserved for Paramedics, who represent the highest level of prehospital care. Paramedic training includes extensive education in advanced life support (ALS) procedures, such as ETI and the administration of a wide range of medications.
Advanced EMTs (AEMTs) bridge the gap between basic and advanced care, receiving intermediate training beyond the basic EMT. The AEMT scope of practice often includes advanced skills like intravenous (IV) therapy and the use of some advanced airway devices. In many jurisdictions, AEMTs are not authorized to perform ETI but are instead trained in the use of alternative, simpler advanced airway devices.
Alternative Airway Devices Used by EMTs
Since basic EMTs do not perform ETI, their primary focus remains on effective manual ventilation and the use of simpler adjuncts. The foundational tool for all EMS providers is the Bag-Valve Mask (BVM), a noninvasive device used to manually deliver oxygen and positive pressure ventilation. EMTs are also trained to use basic airway adjuncts, such as the oropharyngeal airway (OPA) and the nasopharyngeal airway (NPA), to physically open the patient’s airway by preventing the tongue from blocking the throat.
An increasingly common alternative to ETI is the Supraglottic Airway (SGA) device, often within the scope of practice for AEMTs and, in some cases, basic EMTs. SGAs, such as the King Tube or Laryngeal Mask Airway (LMA), are designed to be inserted “blindly,” without requiring the provider to visualize the vocal cords. These devices seal the airway above or around the larynx, providing a rapid and effective method of ventilation that requires less training and is associated with a lower risk of complication than ETI.
Evolving Standards in Prehospital Airway Management
Modern evidence-based medicine has led to significant shifts in how prehospital airway management is approached. Research comparing ETI and SGAs in out-of-hospital cardiac arrest patients suggests that the simpler supraglottic devices can lead to comparable patient outcomes. Studies show SGAs often result in a higher first-pass placement success rate and a shorter time to successful airway placement compared to ETI performed by paramedics.
This evidence has prompted some EMS systems to move away from ETI as the default advanced airway choice, even for Paramedics, in favor of standardized SGA deployment. The emphasis has shifted toward rapid, reliable oxygenation and ventilation, which SGAs can often provide more quickly in the uncontrolled prehospital environment. This trend acknowledges the difficulty of performing ETI in the field and the logistical benefits of using a device that requires less time and fewer attempts.