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T hink back to the last time you used a BVM (bag-valve mask) on an unrespon- sive patient while the ambulance headed toward the nearest emergency depart- ment. While wiping away the vomit or other bodily fluids, you may have thought, This isn't nearly as easy as it was in class with the manikins. With that experience in mind, if anyone were to ask you if bagging works, you most certainly would say, "Yes." Maybe more so in some cases and less so in others; but does bagging work? Absolutely! And if asked if bagging is your best choice? More than likely you would respond, "Probably not," especially if endotracheal tube (ETT) placement was quick, easy and virtually foolproof. But since ETT placement is typically none of those things, bagging, while an acceptable choice, shouldn't be your only choice. And the good news is that there is indeed a better way… alternative airways! Also known as extraglottic devices, these airways are inserted into the patient without the need for visu- alizing the vocal cords. They are effective alterna- tives to endotracheal intubation as well as bag-mask ventilation. Some of these devices, called supraglottic airways, sit right on top of the vocal cord structures. Others sit in the esophagus and have balloons to seal above and below the ventilation outlets, so the air coming out can only go into the airway. Either design provides an excellent alternative for airway manage- ment. But with choices come questions, so let's explore some questions and answers about alternative airways. Who: BLS vs. ALS vs. Nurses vs. Physicians The answer to this question is easy: all of the above. Research shows novices can successfully place a King airway, LMA or i-gel airway. The training and skills required are minimal, and certainly less demanding than bag-mask ventilation or endotracheal intuba- tion. 1–3 So the only barriers to using these alterna- tive airways are local scope of practice, availability, remembering you have them and, occasionally, pride. These devices are in the paramedic and advanced EMT scope of practice in nearly every jurisdiction, and in the EMT-Basic scope in many. They are stocked in most ambulances, many emergency departments and probably every operating room. In most ORs these devices are more common than intubation. Just ask your last paramedic student about their experience in the OR trying to get live intubations. What: The Choices Out There There are a huge variety of devices available in the alternative airway arena. They may be generally cate- gorized as those that sit above the glottis (supraglottic, see Figure 1) and those that sit behind it (retroglot- tic, see Figure 2) in the esophagus. Within each of these categories, devices vary by whether they 1) have adult and pediatric sizes, 2) allow the stomach to be emptied or at least vented and 3) have specific design modifications that allow an endotracheal tube to be placed through them. With some alternative airways, placing an ETT can be done blindly, but it is preferable to do this with a flexible scope or optical stylet once in the more controlled environment of the ED or OR. For a list of selected disposable alternative air- way devices for prehospital or hospital use, see the accompanying sidebar on page 44. We recommend Figure 1: Laryngeal mask (supraglottic) and associated anatomy. Ambu Understanding the options between the BVM and the ETT By Scott DeBoer, RN, MSN, CPEN, CEN, CCRN, CFRN, EMT-P, Darren Braude, MD, EMT-P, Michael Seaver, RN, BA, & John Pisowicz, RN, BSN, NRP, PI EMSWORLD.com | OCTOBER 2015 39 Figure 2: King airway (retroglottic) and associated anatomy. Ambu