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Airway management: "the times they are a-changin".

Airway management has and will always be a priority in resuscitation efforts. The ‘‘ABCs’’ of resuscitation are in part an acronym of convenience meant to remind us to focus our management priorities. Traditionally, these priorities have included early endotracheal intubation and success was measured in part by completion of this procedure. Improved airway management patient outcomes depend on successful maintenance of physiologic parameters (oxygenation and hemodynamic status), not on placement of a polyvinyl endotracheal tube (ETT) alone. The prehospital world has served as a reminder that during resuscitation, we may have become too intubation focused, at the cost of the physiologic priority of oxygenation. This evidence does not mean that direct laryngoscopy (DL) and intubation were a cause of harm but that physiologic goals must supersede tube placement as a desired end point. Before equating ‘‘A’’ with intubation, it is important to consider the following: Is it a ‘‘crash’’ situation, where airway control needs to be done immediately? Does the patient have difficult airway features? How experienced is the clinician poised to perform the procedure? Is help nearby? Answers to these key questions are more likely to positively influence outcome than any decision surrounding which airway device to use. Since the introduction of the Macintosh laryngoscope in the 1940s, airway management has seen little change over time. Alternatives techniques to intubation such as the Bullard laryngoscope and the Lightwand (Trachlight) gained some ‘‘pocket’’ traction for the relatively few who were able to master skill in their use. The laryngeal mask airway (LMA) definitively changed the airway management landscape by providing a userfriendly rescue approach to failed oxygenation, a path that previously would have meant commitment to a surgical airway. More recently, an exponential rise in new airway equipment risks ‘‘device confusion,’’ whereby a clinician may lack clarity on which device is most appropriate for the patient or scenario. The availability of new indirect technology, such as the videolaryngoscope (VL), has led some clinicians to suggest that the DL be relegated to a museum. This momentum away from DL and toward VL is likely unstoppable. Clinicians considering this change in practice need to do so with caution.