Acta Anaesthesiol Scand 2013; 57: 654659

Printed in Singapore. All rights reserved

2013 The Acta Anaesthesiologica Scandinavica Foundation

Published by Blackwell Publishing Ltd.
ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/aas.12101

Pre-hospital airway management by non-physicians in

Northern Finland a cross-sectional survey
L. Raatiniemi1, S. Lnkimki2 and M. Martikainen3

1
Department of Anaesthesia, Central Hospital of Lapland, Rovaniemi, Finland, 2Department of Anaesthesia and Intensive Care, Oulu
University Hospital, Oulu, Finland and 3Centre for Pre-hospital Emergency Care, Oulu University Hospital, Oulu, Finland

Background: Airway management is an important skill in prehospital emergency medicine. The most optimal method
depends on the resources and experience of the emergency
medical service (EMS) providers. We wanted to study the frequency of occurrence, equipment used, problems experienced
and maintenance of skills in pre-hospital airway management by
non-physicians.
Methods: A structured questionnaire consisting of 30 questions was distributed to 383 EMS providers in three hospital
districts (population 597,521 and area 147,467 km2) in Northern
Finland.
Results: The questionnaire was answered by 226 EMS providers and 58.5% (224/383) were included in the final analyses. In
all, 82.6% (185/224) of the EMS providers were allowed to
perform endotracheal intubation (ETI) and 44.2% (99/224) could
perform ETI using sedative agents. The annual mean frequency
of using a supraglottic airway device (SAD) was 1.0 (range 020,

n = 224), for ETI it was 2.0 (range 016, n = 185) and for bagvalve-mask ventilation it was 4.3 (range 030, n = 223). The mean
frequency of drug-assisted ETI was 1.1 (range 013, n = 99).
Unsuccessful ETI had been experienced by 65.7% (119/181) of
the EMS providers. Airway management had been practised in
an operating room by 25.9% (56/216) and with a manikin by
81.3% (182/224) of the EMS providers during the past 12
months.
Conclusion: Advanced airway management procedures are
uncommon for most EMS providers in Northern Finland. Procedures, training in and maintenance of airway management
skills should be re-evaluated.

takes a longer time to perform ETI during CPR and

it reduces hands-on time compared with SADs.4 A
high success rate in using a SAD on scene and in an
operating room (OR) is reported.5,6 It can be difficult
to achieve adequate ventilation using bag-valvemask (BVM) ventilation.7 Regurgitation is more
common during CPR when BVM ventilation is used
than when using a SAD and ETI.8
ETI of an emergency patient is sometimes
challenging for an anaesthesiologist, too. In a retrospective study, anaesthesiology residents with a
minimum of 2 years experience had a 10.3% incidence of difficult intubations.9
The majority of studies on pre-hospital ETI have
shown adverse or no effect on outcome,10 although
comparing studies on pre-hospital ETI is difficult
because data and outcome measures vary greatly.11
There are some newly published studies on prehospital airway management by EMS physicians in
Scandinavia,1214 but more data on advanced pre-

dvanced airway management defined as the

use of endotracheal intubation (ETI) or a supraglottic airway device (SAD) is a very important
skill in pre-hospital emergency medicine. The most
optimal method in pre-hospital care depends on the
resources and experience of the emergency medical
service (EMS) providers. The European Resuscitation Council recommends that ETI during cardiopulmonary resuscitation (CPR) should be performed
only by experienced personnel and with minimal
interruptions of CPR.1 The Scandinavian Society of
Anaesthesiology and Intensive Care Medicine
(SSAI) guidelines recommend ETI of trauma and
medical patients only by anaesthesiologists. During
CPR, it is recommended that non-anaesthesiologists
primarily use SADs, while ETI could be attempted
by experienced EMS providers.2
There is some evidence that if advanced airway
management is performed early during CPR, it has a
positive impact on the outcome.3 Nevertheless, it

654
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Accepted for publication 10 February 2013

2013 The Acta Anaesthesiologica Scandinavica Foundation
Published by Blackwell Publishing Ltd.

Pre-hospital airway management

hospital airway management by non-physicians are

needed. The aim of the study was to produce basic
data on pre-hospital airway management performed
by non-physicians and evaluate if SSAI guidelines
for pre-hospital airway management are followed.

Methods
A structured questionnaire consisting of 30 questions was distributed to EMS providers (non- physicians) in EMS stations in three health-care districts
in Northern Finland (Supporting Information). We
did not succeed in contacting three local EMS
leaders despite numerous efforts, and two did not
want to participate in the study. A total of five EMS
stations were not included in the study. The population of the Lapland, Kainuu and Northern Ostrobothnia Hospital Districts is 597,521 (31.12.2011)
and the area is 147,467 km2. Transport time from
rural locations to a central hospital can be several
hours, and only one physician- and one paramedicstaffed helicopter emergency medical service unit
(HEMS) serves Northern Finland.
EMS is divided into four tiers: first responders,
basic level, advanced level and emergency
physician-staffed units. Tiered response is used by
regional dispatch centres. Basic level units are
mainly staffed by EMS non-paramedics with 1.5year training in EMS. Advanced level units are
staffed by EMS paramedics with 4-year training or
nurses with additional education in emergency
medicine. Some of the basic level units have
extended rights to perform procedures such as
thrombolysis of acute myocardial infarction and the
use of continuous positive airway pressure after
consultation with a physician. The most basic level
units perform ETI during CPR. Advanced level units
are normally permitted to perform drug-assisted
ETI after telephone consultation with a physician.
Indications for ETI in advanced level units are
cardiac arrest, unconscious patient and hypoxia. If
needed, ETI can be performed with other indications, too. HEMS units are dispatched from regional
dispatch centres to life-threatening emergencies.
Physician-staffed HEMS is used mainly in the
Northern Ostrobothnia Hospital District, with
approximately 2400 annual missions. Especially in
winter, the use of a helicopter is restricted because
of the weather. A rapid response vehicle is used
mainly within the city of Oulu and the vicinity and
whenever the helicopter cannot be used. Paramedicstaffed HEMS operates mainly in the province of
Lapland. HEMS paramedics are permitted to

perform drug-assisted ETI after telephone consultation with a HEMS physician.

Before distribution, the questionnaire was tested
by five volunteers. The questions mainly followed
an Utstein-type template for reporting pre-hospital
airway management.15
The Regional Ethics Committee approved the
study in January 2012, and the study period was
from February 2012 to the 30th of April 2012. The
local EMS providers were reminded during the
study period.

Results
Demographic data
A total of 383 questionnaires were delivered to EMS
providers. In all, 59% (226/383) of the EMS providers responded to the questionnaire. Two of the 226
EMS providers who responded to the questionnaire
had been on leave during the past year and were
excluded from the study. Finally 224 participants
were included in the analysis. There were no significant differences in the percentages of valid responders in the three health-care districts.
The participants had the following backgrounds:
47.3% (106/224) were EMS non-paramedics, 18.8%
(42/224) were EMS paramedics and 33.9% (76/224)
were nurses. In all, 13.4% (30/224) of the EMS providers had less than 2 years experience, 25.9% (58/
224) had 25 years experience and the majority of
the participants, 60.7% (136/224), had more than 5
years experience in emergency care.
Of the 222 participants who responded to the
question about distance from the EMS station to the
nearest hospital, 46.4% (103/222) worked in an EMS
station less than 30 min from the nearest hospital,
28.8% (64/222) 30 to 60 min and 24.8% (55/222)
more than 60 min from the nearest hospital.

Equipment
Available equipment is shown in Table 1. ETI equipment and SADs are widely available.

Use of end-tidal carbon dioxide (EtCO2)

monitoring and auscultation
To ensure correct placement of ETI or a SAD, 95.0%
(211/222) used auscultation on the patient; 84.7%
(188/222) used EtCO2. Two (0.9%) participants did
not answer the question.

Primary airway method during CPR

ETI was the primary airway method used during
CPR; it was used by 63.7% (142/223) of the EMS

655

L. Raatiniemi et al.
Table 1
Equipment.

Bag-valve-mask ventilation equipment

SAD
Laryngeal tube
Laryngeal mask airway
iGel
Intubating laryngeal mask airway
Other type of SAD
Endotracheal intubation equipment
Surgical airway
Possibility to monitor end-tidal carbon dioxide
Ventilator

Available equipment/number
of respondents

Percentage

224/224
218/224
202/222
28/222
4/222
23/222
3/222
220/224
150/224
201/224
71/224

(100.0%)
(97.3%)
(91.0%)
(12.6%)
(1.8%)
(10.4%)
(1.4%)
(98.2%)
(67.0%)
(89.7%)
(31.7%)

SAD, supraglottic airway device.

Table 2
Frequency of ETI, use of a SAD and BVM ventilation per EMS provider during the past 12 months in pre-hospital care (training with
a manikin or in an OR not included).
ETI
Frequency (mean)
Frequency (mean)
Frequency (mean)
a hospital
Frequency (mean)

Use of SAD

BVM ventilation

in pre-hospital care
2.0 (range 016, n = 185) 1.1 (range 020, n = 224) 4.3 (range 030, n = 223)
base < 30 min from a hospital 2.7 (range 016, n = 94) 0.8 (range 010, n = 103) 5.2 (range 020, n = 103)
base 3060 min from
1.8 (range 016, n = 42) 1.3 (range 010, n = 64) 4.3 (range 015, n = 63)
base > 60 min from a hospital 1.1 (range 015, n = 47)

1.4 (range 020, n = 55)

3.2 (range 030, n = 55)

BVM, bag-valve-mask; ETI, endotracheal intubation; SAD, supraglottic airway device, EMS, emergency medical service; OR,
operating room.

providers. Altogether 30.0% (67/223) used a SAD

and 6.3% (14/223) used BVM ventilation as the
primary method. One participant did not answer the
question. In all, 35.9% (51/142) of the EMS providers who used ETI as the primary method worked in
a basic level unit.

Frequency of performing airway management

per EMS provider during the past 12 months
Of the EMS providers, 82.6% (185/224) answered
that they were allowed to perform ETI in their unit.
Their profession was the following: 44.9% (83/185)
were EMS non-paramedics, 22.1% (41/185) were
EMS paramedics and 33.0% (61/185) were nurses.
The annual mean frequency of ETI in pre-hospital
care was 2.0 (range 016, n = 185). ETI had not been
performed by 38.4% (71/185), while 13.0% (24/185)
had performed five or more ETIs in a pre-hospital
setting during the past 12 months. EMS providers
working at a base located far from the nearest emergency hospital seemed to have a lower frequency of
performing ETI (Tables 2 and 3).
A total of 99 EMS providers out of 224 were
allowed to perform drug-assisted ETI. The mean

656

Table 3
Frequency of ETI during the past 12 months in pre-hospital care
(n = 185).
n
Did not perform ETIs
Performed one to two ETIs
Performed three to four ETIs
Performed five or more ETIs

71
59
31
24

38.4%
31.9%
16.8%
13.0%

ETI, endotracheal intubation.

frequency of performing drug-assisted ETI was 1.1

(range 013, n = 99) during the past 12 months. Five
or more drug-assisted ETIs were performed by 6.1%
(6/99) of the EMS providers. The total frequency of
ETIs for the EMS providers who were allowed to
perform drug-assisted ETI was 2.9 (range 016,
n = 99) in pre-hospital care, and when training in an
OR was also included, the frequency was 5.3 (range
023, n = 99). When asked which method is used if
ETI fails, 97% (96/99) said they would use a SAD
and 3% (3/99) would use a lateral recovery position
and BVM ventilation.
The EMS providers reported using the following
drugs in ETI for an unconscious patient: midazolam

Pre-hospital airway management

Table 4
Problems with endotracheal intubation by non-physicians during
their career.
Problem
Unsuccessful intubation
Difficult intubation
Misplaced tube in the
oesophagus
Misplaced tube in the main
bronchus
Hypoxia (SpO2 < 90%)
Tooth trauma
Vomiting or aspiration
Bradycardia
Hypotension

Responded to
the question

119
147
89

181
181
170

65.7
81.2
52.4

32

170

18.8

17
3
50
8
12

170
170
170
170
170

10.0
1.8
29.4
4.7
7.1

Only respondents who are allowed to perform ETI in their system

are included (n = 185).

39.4% (39/99), diazepam 65.7% (65/99), alfentanil

91.9% (91/99), morphine 21.2% (21/99) and propofol 6.1% (6/99). No one reported using neuromuscular blocking agents or ketamine.
The mean frequency of using a SAD in prehospital care during the past 12 months was 1.1
(range 020, n = 224), and for BVM ventilation it was
4.3 (range 030, n = 223) per EMS provider. One
EMS provider could not estimate BVM ventilation
frequency. A SAD had not been used by 53.1% (119/
224) of the EMS providers, while 4.9% had used one
five or more times (11/224) during the past 12
months. The frequency of using a SAD seemed to be
higher if the ambulance base was located far from
the nearest emergency hospital (Table 2).

Problems with airway management

Unsuccessful ETI had been experienced by 65.7%
(119/181) of the EMS providers during their career.
Difficult intubation defined as more than two
attempts to intubate or if an attempt lasts over 2 min
or if the larynx is not visible or the tube enters the
oesophagus had been experienced by 81.2% (147/
181) of the EMS providers. Other problems with ETI
are shown in Table 4.
The EMS providers had experienced the following problems with SADs: vomiting or clinical signs
of aspiration, 22.3% (45/202); low oxygen saturation
(SpO2 < 90%), 6.4% (13/202); air leak, 18.3% (37/
202); and cuff damage while the SAD was in use,
5.0% (10/202).Totally unsuccessful efforts to insert
the SAD had been experienced by 6.9% (14/202).

Maintaining airway management skills

Maintaining airway skills by manikin training,
anaesthesiologist-guided training in an OR, partici-

pating in airway management simulation training

and training of paediatric airway management are
shown in Table 5. We cannot say if those who had
participated in the training did it frequently or not.
The EMS providers answered that they would
need to perform 16.7 ETIs (range 2365, n = 180) and
10.2 SAD insertions (range 020, n = 218) during 1
year to be able to maintain their skills.

Discussion
The main findings of this study were, firstly, that the
frequency of pre-hospital ETIs is low. Secondly, we
found that SADs are widely available but still rarely
used. Thirdly, pre-hospital drug-assisted ETI by
non-physicians is routinely practised in Finland,
and fourthly, maintaining airway management skills
is not sufficient. Finally, unsuccessful or difficult ETI
is experienced by a majority of EMS providers.
Other studies have also shown a low ETI frequency in pre-hospital care.16,17 Low procedural frequency can have a negative impact on outcome. In a
study done by Wang et al., patient survival was
better for patients with cardiac arrest and other
medical emergencies if they were intubated by an
experienced rescuer.18 The frequency of pre-hospital
airway management seems to be lower in rural parts
of Northern Finland. At the same time, patients who
require a long transport could benefit the most from
ETI.
In our study, ETI was the most commonly used
primary method for airway management during
CPR despite the guidelines.1,2,* Previous studies
have shown that approximately 50 ETIs are needed
to achieve 90% probability of successful ETI.19,20
Contrary to ETI, using a SAD seems to be easy to
learn.21,22 Because of the low ETI frequency, most
EMS providers in Northern Finland should use a
SAD instead of ETI during CPR.
Pre-hospital drug-assisted ETI by non-physicians
is routinely practised in Finland. However, the frequency of this procedure is very low. Our results do
not support the current practice of drug-assisted
ETI. There may be a need for more physician-staffed
EMS units in Northern Finland. Education in the use
of sedative agents or rapid sequence intubation
(RSI), targeted at a few advanced level units with a
*Elvytys [Resuscitation]. Working group appointed by the Finnish
Medical Society Duodecim, the Finnish Resuscitation Council, the
Finnish Society of Anaesthesiologists and the Finnish Red Cross.
Current Care Summary. Finnish Medical Society Duodecim 2002.
http://www.kaypahoito.fi/web/kh/suositukset/naytaartikkeli/tunnus/
hoi17010 [Accessed 21 February 2011].

657

L. Raatiniemi et al.
Table 5
Maintaining airway management skills during the past 12 months (n = 224).

Participated in manikin training

Participated in anaesthesiologist-guided training in an OR
Performed anaesthesiologist-guided ETI in an OR
Performed anaesthesiologist-guided use of a SAD in an OR
Performed BVM ventilation in an OR
Participated in airway management simulation training
Participated in airway management of a paediatric patient

Answered yes

Responded to the question

182
56
49
23
54
143
85

224
216
216
216
215
223
223

81.3
25.9
22.7
10.6
25.1
64.1
38.1

ETI, endotracheal intubation; SAD, supraglottic airway device; BVM, bag-valve-mask; OR, operating room.

high frequency of ETI, could be another possible

intervention. An indication for drug-assisted ETI by
paramedics could be a situation where free airway
and/or adequate respiration cannot be achieved by
BVM ventilation, transport time to hospital is long
and a physician-staffed EMS unit is not available. In
a study done by Bernard et al., RSI was performed
by intensive care paramedics. The paramedics had
attended an additional 16-h training programme in
the theory and practice of RSI. In this study, the
paramedics achieved a 97% success rate in prehospital RSI and the patients had an increased rate
of favourable neurological outcomes at 6 months
compared with patients who were intubated in the
hospital.23
Airway management skills are not routinely practised by all EMS providers. Practice combined with
periodic feedback has shown to be beneficial in
maintaining airway management skills.24 Airway
management courses for EMS providers, systematic
supervision by anaesthesiologists and regular training with a manikin could be the tools for improved
training. Simulation training could also be beneficial
for this purpose.25 Health-care districts should systematically register procedures performed by EMS
providers. This could help target supervision.
Unsuccessful or difficult intubation had been
experienced by a majority of the EMS providers
who were allowed to intubate. The low frequency
and reported problems in ETI are alarming and
indicate a need for further research and/or intervention. Nevertheless, in our survey SADs were recognised as a back-up method if intubation failed,
and etCO2 monitoring was commonly used to
secure tube placement. These facts may reduce ETIrelated complications despite low ETI experience.
Following the SSAI guidelines for pre-hospital
airway management could be an important
intervention.

658

Limitations
Firstly, our study was a self-reporting questionnaire
study without an outsider referee. Overestimation
of procedural experience and underestimation of
the rate of problems in airway management cannot
be excluded. Secondly, only 59% of the EMS providers responded to the questionnaire. However, the
response rates from the different health-care areas
were quite similar, and we think this fact might have
reduced bias.
In conclusion, we report a low frequency of prehospital airway management and a high frequency
of problems with ETI. There is a need for improvement in maintaining airway management skills, too.
SSAI guidelines for pre-hospital airway management should be implemented.

Acknowledgements
This study was funded by research grants from the Central Hospital of Lapland.
We thank Torben Wisborg from Hammerfest Hospital,
Department of Anaesthesiology and Intensive Care, Finnmark
Health Trust, Hammerfest, Norway, for his advice in research
methodology.
Conflict of interest: None of the authors has any conflicts of
interest or competing interests in the research conducted in this
study.

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Address:
Lasse Raatiniemi
Department of Anaesthesia
Lapland Central Hospital
P.O. Box 8041
96101 Rovaniemi
Finland
e-mail: lasse.raatiniemi@gmail.com

Supporting information
Additional Supporting Information may be found in
the online version of this article at the publishers
web-site:
Translated questionnaire. English translation of
the Finnish questionnaire

659

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