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Airway management

Last updated: August 26, 2021

Summarytoggle arrow icon

Airway management is the practice of evaluating, planning, and using a wide array of medical procedures and devices for the purpose of maintaining or restoring a safe, effective pathway for oxygenation and ventilation. These procedures are indicated in patients with airway obstruction, respiratory failure, or a need for airway protection (e.g., for general anesthesia or due to an aspiration risk).

Basic airway maneuvers are the most important first step and consist primarily of positioning, supplemental oxygen, and bag-mask ventilation with or without adjuncts. Patients with serious or persistent airway compromise typically require advanced airway devices, which consist of supraglottic devices, endotracheal tubes, and surgical airway devices.

In endotracheal intubation, a tube is inserted orally (or nasally) into the trachea to allow gas exchange, often via mechanical ventilation. The tube can be placed under direct visualization with the help of a laryngoscope or with video-assisted laryngoscopy. Correct placement is established based on multiple measurements, including exhaled CO2 and evidence of bilateral breath sounds on auscultation. Common complications of endotracheal intubation include hypoxia, hypotension, airway trauma, accidental esophageal intubation, and aspiration.

Surgical airways may be performed in an emergency, particularly as part of a cannot intubate, cannot ventilate (CICV) scenario, or placed for long-term mechanical ventilation. Patients with surgical airways are vulnerable to a sudden loss of the airway due to displacement or blockage of the tubes with secretions.

Airway management is used for patients with signs of airway obstruction and for patients whose airway is considered at-risk due to a potential loss of protective airway reflexes.

Clinical features of partial upper airway obstruction [1]

Clinical features of complete airway obstruction [1]

Features suggestive of an at-risk airway [2]

  • Reduced GCS (traditionally ≤ 8) [3]
  • Ability to comfortably tolerate an oral airway
  • Inability to swallow secretions
  • Features of a condition potentially requiring deep sedation or general anesthesia

These maneuvers may be used alone or combined with basic airway adjuncts and bag-mask ventilation.

All patients [4]

  • Head-tilt/chin-lift maneuver
    • Description: a method of opening the airway that involves head and neck repositioning. It should be avoided if there is concern for C-spine injury.
    • Technique
      1. Tilt the head of the patient posteriorly to 15–30° of atlanto-occipital extension.
      2. Lift the chin with the fingers to pull the tongue and oropharyngeal soft tissue anteriorly.
      3. Use the thumb of the same hand to apply pressure below the lip, slightly opening the mouth.
      4. Maintain this “sniffing position” to align the oral, pharyngeal, and laryngeal axes.
  • Jaw-thrust maneuver
    • Description
    • Technique
      1. With the patient supine, place fingers behind the angles of the lower jaw.
      2. Move the jaw anteriorly to pull the base of the tongue and soft tissues away from the airway.
      3. Use the thumbs to open the mouth slightly.

Spontaneously breathing patients only: the recovery position

General overview [5][6]

Procedure

Create a mask seal

  • EC-clamp technique (one-person technique): commonly used in elective perioperative situations when the provider is alone
    1. With the patient supine, lift the jaw towards the mask using the 3rd, 4th, and 5th fingers of one hand, forming an E-shape.
    2. Squeeze the mask onto the face with the thumb and index finger of the same hand, forming a C-shape.
    3. Deliver breaths with the second hand.
  • Two-person bag-mask-ventilation technique: used in emergency settings in which the patient is deteriorating or ventilation is difficult, since it is more effective [7][8][9]
    • One provider makes a seal and opens the airway with both hands:
    • The second provider delivers breaths.

Provide breaths

  • Set minute ventilation
    • Aim: Deliver 500–600 mL (6–7 mL/kg) volume at 10–12 breaths/minute. [11]
    • Procedure: Squeeze the bag slowly and gently over approx. 1 second before allowing it to fully reinflate. Repeat every 5 seconds.
    • Adjust based on the clinical situation: E.g., follow compression-to-breath ratio in patients undergoing CPR without an advanced airway (e.g., 30:2).
  • Confirm adequacy of BMV

Ensure oxygen is attached to the bag-mask apparatus!

Anticipation and management of BMV complications

Efficacy of BMV may be affected by provider technique or patient factors (such as obesity, reduced lung compliance, or craniofacial abnormalities).

Pitfalls and troubleshooting of bag-mask ventilation

Challenge Recommendations
Poor mask seal or difficulty opening airway
Poor chest rise
Inadvertent hyperventilation
  • Commonly occurs in stressful resuscitation scenarios. Can lead to:
  • Prevention
    • Maintain steady pressure and depth of bag compression.
    • Count seconds between breaths delivered.
Hypoxia during apneic period

Factors that contribute to difficult BMV can be remembered with the MOANS mnemonic: Mask seal, Obstruction/Obesity, Age > 55 years, No teeth, Stiff lungs/Sleep apnea.

These devices may be used alongside bag-mask ventilation or airway opening maneuvers to improve airway patency.

Oropharyngeal airway (OPA) [4]

  • Description: a rigid curved device placed in the mouth to prevent the tongue from occluding the airway
  • Indications
    • Unconscious patients with a large tongue, obstructed nasal passages, or copious nasal secretions
    • Typically used as a bridge to intubation
  • Contraindications: conscious patient with intact gag reflex
  • Sizing rule: from the incisors to the angle of the mandible, or corner of the mouth (oral commissure) to the earlobe
  • Insertion technique
  • Further management: Toleration of an oropharyngeal airway indicates an at-risk airway; preparations should be made for intubation.

Nasopharyngeal airway (NPA) [4]

  • Description: a long flexible tube inserted into the nostril and down into the nasopharynx to prevent the tongue from occluding the airway
  • Indications: conscious or unconscious patients with current or potential oropharyngeal obstruction
  • Contraindications: facial fractures, basilar skull fractures
  • Sizing rule: nostril to the ipsilateral tragus
  • Insertion technique
    1. Lubricate the tube.
    2. Select the wider nostril.
    3. Insert gently without forcing.
    4. Aim posteriorly, not superiorly.
    5. Twist the tube back and forth for ease of passage.
    6. If resistance is encountered, stop and attempt on the contralateral nostril.

General overview

Options [6][12]

  • Laryngeal mask airway (LMA): a supraglottic device consisting of an inflatable mask attached to the end of a tube
    • Second-generation LMAs feature safety adaptations such as bite blocks and a drainage tube.
    • Intubating LMAs (ILMA) feature additional adaptations to allow passage of an ET tube through the LMA.
  • i-gel®: a type of supraglottic airway that is similar in structure to the LMA. However, the mask is anatomically-molded, noninflatable, and made of a soft gel-like material.
  • Laryngeal tube airway (LTA)
    • An airway device consisting of a tube with 2 inflatable cuffs and ventilation holes between them.
    • Intubating LTAs feature additional adaptations to allow passage of an ET tube through the LTA.

Procedure [2][6]

  1. Choose the appropriate size for the patient:
    • Small adult: size 3
    • Medium adult: size 4
    • Large adult: size 5
  2. LMAs and LTAs: inflate cuffs fully to check for leaks before deflating.
  3. Lubricate the tip of the device, being careful not to block ventilatory openings.
  4. Place the patient in the sniffing position.
  5. Open the patient's mouth wide.
  6. Hold the device firmly (at the junction of the tube and mask for an LMA, at the bite block for an i-gel®, or at the connector for an LTA).
  7. Insert the device.
    • LMA and i-gel®: Insert smoothly along the hard palate and downwards with the outlet facing caudally.
    • LTA: Insert the tube rotated at 45–90° from midline (towards concave lateral) until past the base of the tongue, where it should be rotated back to midline (towards concave up).
  8. Stop when the device has passed the base of the tongue and resistance is felt (LMA or i-gel®) or the connector reaches the teeth (LTA).
  9. LMAs and LTAs: Inflate the cuff.
  10. Confirm supraglottic tube placement.

Pitfalls and troubleshooting of supraglottic airways

  • Difficulty bagging or poor ventilation
    1. Reposition the patient's head and neck (see “Initial airway opening maneuvers”).
    2. Withdraw, advance or rotate the tube.
    3. Remove and reinsert the device or change size (a larger size may be required).
    4. Switch to a different adjunct.
  • Air leak: Adjust cuff volume (if possible), then follow the troubleshooting steps above.

General principles [2][6]

Indications for endotracheal intubation [2]

Contraindications

Preassessment [2][16]

Preoxygenation

  • Definition: administration of 100% oxygen prior to induction to denitrogenate air in the lungs [17]
  • Rationale: lengthens safe apnea time to prevent desaturation, which can cause organ dysfunction (e.g., hypoxic brain injury, cardiac dysrhythmia) and death
  • Target SpO2: as close to 100% as possible
  • Methods: [18]
    • First line: oxygen delivered by a nonrebreather device at high flow rate (10–12 L/min) for 3 minutes
    • Alternative (if 3 minutes of preoxygenation is not possible): 8 breaths (vital capacity inspirations)

Preoxygenation is vital for patients with risk factors for rapid desaturation during the apneic period (e.g., critical illness, obesity, preexisting lung disease).

Intubation medications [2][6]

Typically two classes of medication are given prior to intubation, a sedating (induction) agent and neuromuscular blocking agent to paralyze the patient.

Induction agents [2]

  • Used to induce a state of sedation, which reduces airway reflexes and facilitates intubation
  • Options include:
  • The choice of induction agent depends on patient characteristics and operator experience.
  • The duration of bolus doses is typically short (∼ 10 minutes) and infusions are required for ongoing sedation (see “Adjunctive care of ventilated patients” for suggested medications and doses).

Neuromuscular blockade (NMJ blockers) [2]

Avoid succinylcholine in at-risk patients (including those with known renal impairment, burns, crush injuries, denervation, neuromuscular disease, or abdominal sepsis) because of the risk of hyperkalemia!

Intubation via direct laryngoscopy [6]

  • Positioning: Place patient in sniffing position unless C-spine injury is suspected.
  • Technique: The majority of patients should have received induction agents and been preoxygenated. Equipment should always be on hand to manage a failed intubation.
    1. Wear appropriate PPE.
    2. Choose the correct ET tube size. [20]
    3. Gently open the patient's mouth.
    4. Insert the laryngoscope blade, using the groove to sweep the tongue aside.
    5. Advance steadily until the tip is at the vallecula and the epiglottis is visible below it.
    6. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords.
    7. Insert the ET tube with the stylet.
    8. Once the tip is at the glottis, remove the stylet and gently advance until the cuff is past the cords.
    9. Inflate the cuff to protect the airway from secretions and form a seal around the tube.
    10. Secure the tube once proper placement is confirmed.

Avoid rocking the laryngoscope on the teeth; it can cause dental injury and aspiration of tooth fragments.

Confirmation of tube placement [21]

  • Auscultation of bilateral breath sounds over the lungs
  • Consistent condensation visible in the tube upon exhalation
  • Capnometry
    • Colorimetric capnometer: a qualitative CO2 detector connected between the tube and the BMV equipment
      • A visual indicator changes color from purple to yellow upon contact with CO2.
      • Consistent color changing with each breath > 3 times correlates with tracheal placement.
    • Capnography: measurement of end-tidal CO2
  • Direct visualization of endotracheal tube markers
    • Distal tube markers should be seen advancing past the vocal cords.
    • Proximal numbered tube markers should indicate approx. 21–23 cm at the patient's teeth.
  • Imaging (e.g., CXR):

Intubation is an aerosol-generating procedure that carries a high risk of transmission of respiratory pathogens to healthcare workers. Appropriate PPE for all participating providers is essential. [22]

Adjuncts may be used for anticipated difficult airways or by novice practitioners learning intubation.

Tracheal tube introducer/gum-elastic bougie (GEB) [6][23]

  • Description
    • A long, semirigid, plastic introducer used to facilitate passage of the ET through the vocal cords using the Seldinger technique
    • The tip is slightly bent to allow passage through the epiglottis and to provide tactile feedback as it “clicks” over the tracheal rings.
  • Indications: difficult intubation (e.g., C-spine immobilization) when the laryngeal inlet is partially visible, invisible, or narrower than expected (e.g., secondary to edema)

Videolaryngoscopy [6][24]

Flexible fiberoptic intubation [25]

Pitfalls and troubleshooting of endotracheal intubation [6][26]
Challenge Recommendation
Poor visualization during direct laryngoscopy
  • Suction blood, secretions, or vomitus.
  • External laryngeal manipulation to align glottis with line of sight
  • Repositioning
    • Adjust height or stretcher and/or slide patient closer to provider.
    • Enhance sniffing position: Extend the neck further or place the head on a larger pillow.
    • Ramp position: Place a pillow or rolled blanket under the patient's shoulders and elevate the head even further.
Difficult passage through vocal cords
  • Lubricate tube tip.
  • Rotate tube 90°.
  • Mold the stylet to have an enhanced curve or hockey-stick bend for a hard-to-reach larynx.
  • Remove the stylet once the tip of the ET tube makes contact with the laryngeal inlet.
  • Try a smaller ET tube.
Hypoxia before successful intubation
Vomiting
Avoiding displacement while securing tube
  • Hold the ET tube between the index finger and thumb while resting the other fingers against the patient's mandible.
  • Maintain alignment of markers at the patient's teeth while applying the securing mechanism.
Esophageal intubation
  • Suspect if confirmatory signs are absent.
  • If SpO2 < 90%,
    • Remove the tube.
    • Perform rescue ventilation prior to the second attempt.
  • If there is no desaturation, repeat laryngoscopy and reattempt intubation.
Unilateral bronchial intubation
  • Suspect if there is difficulty bagging, low SpO2, or auscultation of air only over right lung field.
  • Withdraw ET tube until there is equal air entry bilaterally, SpO2 normalizes, and bagging becomes easy.
Sudden deterioration postintubation
  • Troubleshooting of mechanical ventilation: Use DOPE mnemonic. [27][28]
    • Displacement/disconnection: Check for new esophageal or unilateral bronchial intubation
    • Obstruction: Check for mucus plugs, kinks, or patient biting on the tube.
    • Pneumothorax
    • Equipment failure

The decision of when to extubate depends on the reason for intubation (e.g., for general anesthesia versus for critical illness), patient factors, and operator skill. Patients may deteriorate, requiring reintubation. Reintubation can be challenging due to postextubation laryngeal edema. Therefore, extubation should only be performed if a skilled intubator is present.

Extubation criteria

Procedure

  • Preoxygenate with 100% FiO2.
  • Consider placing a bite block.
  • Suction airways to minimize the risk of aspiration (e.g., of fluids, foreign material).
  • Remove the securing mechanism and deflate the cuff.
  • Remove the ET tube as the patient exhales.
  • Always be prepared for reintubation, as extubation may fail due to: [29]

Do not extubate patients unless an adequately trained provider is available to reintubate if needed.