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.
Clinical features of partial upper airway obstruction 
Clinical features of complete airway obstruction 
- Inability to speak or cough
- Inaudible breath sounds
- Paradoxical movement of the chest and abdomen
- Profound hypoxia
Features suggestive of an at-risk airway 
- Basic airway maneuvers are used:
- All patients require monitoring with pulse oximetry.
- Most patients should receive supplemental oxygen (see “Oxygen therapy”).
- Patients requiring basic airway maneuvers are at high risk of further airway deterioration; prepare for an advanced airway for most patients.
Initial airway opening maneuvers
All patients 
- 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.
- Tilt the head of the patient posteriorly to 15–30° of atlanto-occipital extension.
- Lift the chin with the fingers to pull the tongue and oropharyngeal soft tissue anteriorly.
- Use the thumb of the same hand to apply pressure below the lip, slightly opening the mouth.
- Maintain this “sniffing position” to align the oral, pharyngeal, and laryngeal axes.
Spontaneously breathing patients only: the recovery position
- Description: positioning of the patient in a lateral decubitus position with slight neck extension
General overview 
- Definition: delivery of oxygen and provider-assisted breaths using a bag-valve-mask unit to patients with inadequate ventilation
Create a mask seal
- EC-clamp technique (one-person technique): commonly used in elective perioperative situations when the provider is alone
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 
- One provider makes a seal and opens the airway with both hands:
- The second provider delivers breaths.
Set minute ventilation
- Aim: Deliver 500–600 mL (6–7 mL/kg) volume at 10–12 breaths/minute. 
- 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
Pitfalls and troubleshooting of bag-mask ventilation
|Poor mask seal or difficulty opening airway|
|Poor chest rise|
|Hypoxia during apneic period|| |
Oropharyngeal airway (OPA) 
- Description: a rigid curved device placed in the mouth to prevent the tongue from occluding the airway
- 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) 
- 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
- Lubricate the tube.
- Select the wider nostril.
- Insert gently without forcing.
- Aim posteriorly, not superiorly.
- Twist the tube back and forth for ease of passage.
- If resistance is encountered, stop and attempt on the contralateral nostril.
- Definition: a collection of advanced airway devices that are inserted via the oropharynx to provide ventilation from above the glottis
- Contraindications: Avoid in conscious patients with an intact gag reflex.
- Caution: does not offer complete protection against aspiration, unlike an endotracheal tube
- Laryngeal mask airway (LMA): a supraglottic device consisting of an inflatable mask attached to the end of a tube
- 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)
- Choose the appropriate size for the patient:
- Small adult: size 3
- Medium adult: size 4
- Large adult: size 5
- LMAs and LTAs: inflate cuffs fully to check for leaks before deflating.
- Lubricate the tip of the device, being careful not to block ventilatory openings.
- Place the patient in the sniffing position.
- Open the patient's mouth wide.
- 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).
- Insert the device.
- 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).
- LMAs and LTAs: Inflate the cuff.
- Confirm supraglottic tube placement.
Pitfalls and troubleshooting of supraglottic airways
- Difficulty bagging or poor ventilation
- Air leak: Adjust cuff volume (if possible), then follow the troubleshooting steps above.
General principles 
- Defined as placement of a cuffed endotracheal (ET) tube below the vocal cords via or videolaryngoscopy
- Mostly commonly placed orally (orotracheal intubation), although it may be placed nasally (nasotracheal intubation)
- Typically, sedation and paralysis are required to tolerate the procedure and subsequent mechanical ventilation. 
- Use modified rapid sequence intubation/induction (RSI) in an emergency (when patients have not fasted).
- Goals: maximize first-pass success, reduce the risk of aspiration
- Involves the rapid induction of anesthesia and paralysis, followed by intubation 
- Differs from traditional intubation in two ways:
Indications for endotracheal intubation 
- Inability (or anticipated inability) to maintain the airway; : e.g., general anesthesia, airway obstruction or reduced GCS (see “Clinical features of airway obstruction”)
- Failure (or pending failure) of ventilation or oxygenation; : e.g., in severe acute asthma or COPD (see “”)
- Conditions in which there is a high risk of deterioration: e.g., multisystem trauma, anaphylaxis, severe septic shock
- All patients should be assessed for conditions that can complicate intubation.
- See “Identification and management of difficult airways” for further information.
- Definition: administration of 100% oxygen prior to induction to denitrogenate air in the lungs 
- 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: 
Intubation medications 
Typically two classes of medication are given prior to intubation, a sedating (induction) agent and neuromuscular blocking agent to paralyze the patient.
Induction agents 
- 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) 
- Clinical applications
- Depolarizing NMJ blockers: e.g., succinylcholine
- Nondepolarizing NMJ blockers: e.g., rocuronium
- If ongoing paralysis is required, an infusion is necessary (see “Adjunctive care of ventilated patients” for suggested medications and doses).
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 
- 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.
- Wear appropriate PPE.
- Choose the correct ET tube size. 
- Gently open the patient's mouth.
- Insert the laryngoscope blade, using the groove to sweep the tongue aside.
- Advance steadily until the tip is at the vallecula and the epiglottis is visible below it.
- Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords.
- Insert the ET tube with the stylet.
- Once the tip is at the glottis, remove the stylet and gently advance until the cuff is past the cords.
- Inflate the cuff to protect the airway from secretions and form a seal around the tube.
- Secure the tube once proper placement is confirmed.
Confirmation of tube placement 
- Auscultation of bilateral breath sounds over the lungs
- Consistent condensation visible in the tube upon exhalation
- Direct visualization of endotracheal tube markers
- 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. 
Tracheal tube introducer/gum-elastic bougie (GEB) 
- 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)
Flexible fiberoptic intubation 
- Known or
- Backup for failed intubation
Pitfalls and troubleshooting
|Pitfalls and troubleshooting of endotracheal intubation |
|Poor visualization during direct laryngoscopy|| |
|Difficult passage through vocal cords|
|Hypoxia before successful intubation|
|Avoiding displacement while securing tube|
|Unilateral bronchial intubation|
|Sudden deterioration postintubation|
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.
- Sufficient spontaneous breathing
- Presence of protective reflexes (swallowing and coughing reflex)
- Adequate level of consciousness (e.g., opening the eyes, following requests)
- Clinical stability
- Adequate reversal of neuromuscular blockade
- For patients receiving longer-term mechanical ventilation, consider and perform a prior to extubation.
- 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: 
Do not extubate patients unless an adequately trained provider is available to reintubate if needed.
Acute management checklist: endotracheal intubation
- Preoxygenate the patient.
- Attach patient to continuous cardiac monitoring and monitor oxygen saturations.
- Ensure appropriate equipment is assembled and is functioning.
- Induce anesthesia, followed by neuromuscular blockade.