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Emerg Med J. 2007 April; 24(4): 311.
PMCID: PMC2658254

Counting angels

The question “how many angels can dance on the head of a pin?” is sometimes used as a rhetorical illustration of the futility of meaningless or esoteric debate, and in the paper by Clements et al,1 which discusses whether children in the prehospital environment should be treated with a cuffed or uncuffed tracheal tube, the authors come quite close to trying to count those angels.

Contrary to the image conjured up of teams of paediatric airway specialists poised to descend on sick children in the community, the reality is somewhat different. The vast majority of children will be treated by paramedics and ambulance technicians—sometimes assisted by volunteer immediate care physicians or general practitioners—very few of whom are likely to possess that rare combination of skill, equipment and drugs necessary to intubate children outside hospital in reasonable safety.

Most seasoned emergency physicians will have seen cases of unrecognised tracheal tube misplacement in prehospital care, and it is partly in recognition of the disaster that accompanies such events that the Joint Royal Colleges Ambulance Liaison Committee has recently signalled that it wants to readdress the value of the tracheal tube in paramedic practice.2 Yet, there are still those diehards within the UK's ambulance services who cling to the notion that the tracheal tube is the gold standard of prehospital airway management, despite compelling evidence to the contrary.3,4 The increasing availability of affordable, portable, electronic capnometers goes only part of the way to addressing the overall problem, since these will not prevent those unnecessary periods of intensified hypoxaemia that accompany repeated failed attempts at intubation. We need to keep reminding ourselves that patients die from a failure to oxygenate and a failure to ventilate, not from a failure to intubate, and there is now a growing view that supraglottic airway devices are better and safer options in the hands of non‐anaesthetists who work in the prehospital environment. It could even be that supraglottic airway devices are superior to the tracheal tube in the hands of those few skilled anaesthetists who do venture out into the community, but I can find no evidence that a comparative trial has ever been undertaken to test this hypothesis.

Clements et al are right in saying that we should always be ready to challenge doctrine, but I would suggest that the doctrine that most needs to be challenged is the one that confers gold standard status on the tracheal tube in prehospital care. If the trend away from intubation continues, the question as to whether a child's tracheal tube should be cuffed or uncuffed could soon become irrelevant for the vast majority of prehospital providers.


Competing interests: AMM is clinical adviser to The Laryngeal Mask Company, St Helier, Jersey, Channel Islands, UK, and also to Intavent Orthofix, Maidenhead, UK, and a distributor of LMA devices in the UK and Eire. Both are unsalaried positions, but the author has received payment for advisory work undertaken for both companies in connection with the use of LMA devices in prehospital care.


1. Clements R S, Steel A G, Bates A T. et al Cuffed endotracheal tube use in paediatric prehospital intubation: challenging the doctrine? Emerg Med J 2007. 2457–58.58 [PMC free article] [PubMed]
2. Clark T, Sagar A, Whitmore D. Developing paramedic practice 2006 at the RCA. Ambulance UK 2006. 21300
3. Deakin C D, Peters R, Tomlinson P. et al Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emerg Med J 2005. 2266–67.67 [PMC free article] [PubMed]
4. Katz S H, Falk J L. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001. 3762–64.64 [PubMed]

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