creation date: 2025-10-05 11:37
tags: Interventions Incomplete
Airway Management
Background
Airway management ensures a patent airway between the lungs and the environment to maintain oxygenation and ventilation.
Note, that if indications are not met, non-invasive oxygen may be sufficient (eg. via nasal cannula).
General Steps
Airway Position & Clearance
Upper airway obstruction should be relieved by head tile, chin lift, and/or jaw thrust. Suction may be used to remove mucus or other debris, especially in infants/children.
Bag-Mask Ventilation
Bag-Mask is both crucial for pre-oxygenation (in cases of ET intubation) and for ventilation prior to connection to a more permanent oxygen source.
Nasopharyngeal / Oropharyngeal Airway
Indications & Contraindications
Adjuvant airway devices are indicated for patients who have:
- Intact gag reflex
- Trismus
- Oral trauma
- Those who have undergone oral/oropharyngeal surgery in which oral cavity should not be instrumented
These may also be attempted following failed intubation attempts prior to surgical airway.
Preparation
Procedure
Endotracheal Intubation
Indications & Contraindications
Endotracheal intubation is indicated for:
- Respiratory failure (hypoxic or hypercapnic)
- Apnea
- Reduced level of consciousness (typically GCS < 8)
- Inability to protect airway (no gag reflex)
- Rapid changes in mental status
- Airway injury or impending airway compromise
- High aspiration risk
- Laryngeal trauma (penetrating injury to neck, abdomen, chest)
Contraindications include:
- Severe airway trauma or obstruction preventing safe placement of ETT
Preparation
The patient should be pre-oxygenated for 2-3 minutes prior to intubation attempt. This will allow for several minutes before de-sating. This can be done with:
- Mask ventilation (sealed)
- High flow nasal cannula
Avoid unnecessary instrumentation and suctioning to avoid stimulating the gag reflex.
Typical sizes for the average adult are:
- 7.5 ET tube
- Mac 3 or 4
- Miller 3 or 4
Procedure
Following pre-oxygenation, an induction agent (amnestic and sedation) and a paralytic agent (paralysis) is used. These are discussed separately.
Intubation:
- Position at the head of the patient with the laryngoscope in the left hand and the stylet or bougie in the right
- Insert the laryngoscope into the mouth, if CPR is occurring simultaneously, turn the laryngoscope when inserting before rotating to the correct position to avoid bumping into provider providing compressions (do not interrupt compressions – it is priority)
- Lift the laryngoscope (do not arc or rock) to expose the pharynx
- Visualize the tongue, the uvula, and the epiglottis; anteriorly should be the larynx
- Once the larynx is identified, insert the stylet or the bougie
- Stylet: remove the stylet, leaving the ET tube behind
- Bougie: thread the ET tube and remove the bougie
- Inflate the ET tube
- Confirm placement with CO2 flow indicator
To confirm the placement of the ET tube, begin BMV and auscultate the left lungs followed by the right. If the ET tube is placed too far, the left lungs will not inflate.
Surgical Airway (Cricothyroidotomy)
Indications & Contraindications
Cricothyroidotomy is indicated for patients in which a endotracheal tube is not possible.
The only absolute contraindication to cricothyroidotomy is age in which the lower limit is suggested to be somewhere between 5-12, albeit unclear. In such cases, a needle cricothyrotomy is performed.