The goal of airway management: Ensure adequate oxygenation and ventilation of the patient.
Just the Facts
- Airway management can be addressed with a number of tools and techniques. Not all situations require advanced airways and management is not always a linear process. Choose the right tool for the right job and apply the necessary amount of aggressive intervention to address the problem at hand.
- Optimal airway management is a team process. Use shared mental modeling and teamwork to ensure best practices and optimal outcomes.
- Oxygen is a drug used to treat hypoxia. It is indicated when signs and symptoms of hypoxia are present or in undifferentiated conditions where hypoxia is likely. In general, oxygen should be administered to maintain oxygen saturation at 94-95% (≥90% in COPD patients). Follow local protocol.
- Adequate ventilation assures the removal of sufficient amounts of carbon dioxide. Capnography provides an excellent assessment of this capability, but also remember altered mental status, diminished lung sounds and inability to speak can all point to inadequate ventilation.
Proper head position in airway management – The Head Elevated Sniffing Position
Optimal positioning of a patient for airway management is achieved by flexing the cervical spine and extending the atlanto-occipital joint (C1 and C-2).
Proper position is evidenced by:
- Ear aligned with suprasternal notch
- Face parallel to the ceiling
Quick Tips (Patient Positioning)
The head elevated sniffing position is not always effective (particularly in bariatric patients). If it is not effective, consider the “ramp position.”
- Raise the patient’s torso to a 45-degree angle
- Provide a plateau to the patient’s head
Success here will is also measured by ensuring that the patient’s ear is aligned with the suprasternal notch and the patient’s face is parallel to the ceiling.
An electric suction device should be able to manufacture 300 mmHg of suction pressure when occluded and 30 Lpm of suction while flowing.
Face Mask Ventilation
Indications for Face Mask Ventilation
Short term ventilator control of an apneic patient or enhancement of tidal volume in a breathing patient in respiratory failure.
Side Effects of Face Mask Ventilation:
- Gastric distention
- Excessive tidal volume and increased intrathoracic pressure
Face Mask Ventilation Performance Points
The key requirements for optimal face mask ventilation are mask seal and an open airway. Best practices to achieve both requirements include:
- A properly sized mask (covering from the bridge of the nose to the cleft of the chin and wide enough to cover the entire mouth).
- Two hands used to secure the mask to the face (consider the “thenar eminence” technique for two-handed bag mask ventilation.
- The head elevated sniffing position
- An airway adjunct (OPA or NPA or both)
Quick Tips (Face Mask Ventilation)
- If face mask ventilation fails, always focus troubleshooting steps to ensuring mask seal and an open airway. Common problems include large beards interfering with mask seal and large body habitus requiring different patient positioning to achieve an open airway (ramp position).
- Consider elevating the head of the stretcher to at least 30 degrees for all patients being ventilated. This elevation reduces the decrease in functional residual capacity in the lungs caused by a pure supine position.
- When using face mask ventilation to pre-oxygenate prior to intubation or when attempting to ventilate a severely hypoxic patient, consider applying a nasal cannula flowing at 15 Lpm to aid in oxygenation and denitrogenation.
Just the Facts – Excessive ventilation is harmful.
- Ventilate only to observable chest rise and if using a manometer, when possible, keep ventilation inspiratory pressure to no more than 25 mmHg.
- Hyperventilation results in hypocapnia and cerebral vasoconstriction. When possible, use external feedback to assure appropriate rates of ventilation. Use capnography to aid ventilation (beware of this technology in poorly perfused patients)
2017 American Heart Association recommended rescue breathing rates:
- Adult – 1 breath every 5-6 seconds (10-12 breaths per minute)
- Pediatric: 1 breath every 3-5 seconds (12-20 breaths per minute)
There are many different airway devices intended to open the airway but not go through the glottic opening (King, LMA, etc.). You should be familiar with the indications, specific insertion techniques, contraindications and limitations of the device your state, region or service utilizes.
Indications for a Supraglottic Airway:
- Temporary protection of an airway that does not require the absolute isolation of the trachea afforded by endotracheal intubation.
- Failed intubation
Quick Tips (Supraglottic Airways)
- Often supraglottic airways can be inserted without the need to stop chest compressions, making them a valuable tool in cardiac arrest management. Follow local protocol.
- In most cases, the presence of a gag reflex contraindicates the use of a supraglottic airway.
- Use capnography to assure proper placement of any advanced airway, including supraglottic airways.
Advantages of Endotracheal Intubation:
- Complete tracheal isolation
- Impedes gastric distention during ventilation
- Eliminates the need to maintain a mask seal
- Offers direct route for suctioning
Disadvantages of Endotracheal Intubation:
- Requires specialized training and expertise
- High-risk skill (deadly if performed incorrectly)
- Specialized additional equipment (laryngoscope, etc.)
- Direct visualization of vocal cords can be challenging
- Bypasses PEEP by glottic opening
- Bypasses warming and filtering of air by upper airway structures
Indications for Endotracheal Intubation:
- Long-term airway isolation and protection
- Unsecured airway/risk of aspiration
- Risk of airway collapse (anaphylaxis, burns, etc.)
- Respiratory failure (clinical course would require mechanical ventilation)
Performance Goals for Intubation:
- Prepare patient
- Prepare equipment and team
- Ensure preoxygenation/denitrogenation
- Sedate and paralyze (if using rapid sequence intubation)
- Visualize the trachea
- Advance the tube
- Confirm the tube
- Secure the tube
Pre-Intubation Preparation – The Patient
- Proper positioning (head elevated sniffing position, ramp position).
- At least 30 degrees of elevation. No supine position unless absolutely necessary.
- Administer high concentration oxygen to increase oxygen saturation to as close to 100% as possible. Consider nasal cannula at 15 Lpm, CPAP.
- In an apneic patient, ensure at least 3 minutes of face mask ventilation paired with high concentration oxygen.
- In a breathing patient, ensure at least eight vital capacity breaths with supplemental high concentration oxygen and/or CPAP.
- Consider hemodynamic effects of intubation. Is there a need for fluid bolus or pressors prior to intubation?
Pre-intubation Preparation – The Team
- Ensure proper personal protective equipment for all team members.
- Pre-procedure huddle. Review steps of the procedure, team member roles, and failed airway procedure.
- Check equipment (laryngoscope blade and bulb, endotracheal tube, ready bougie).
- Ensure failed airway equipment is ready.
Endotracheal Intubation Procedure
- Properly prepare patient –ensure appropriate preoxygenation, denitrogenation. Ensure adequate sedation and paralysis (when appropriate).
- Properly prepare team – everyone knows their roles and the procedure (including failed airway procedure).
- Insert blade, identify landmarks (epiglottis, posterior notch).
- Consider bimanual laryngoscopy to improve the view.
- Advance bougie or endotracheal tube.
- Pass tube to appropriate depth (visualize guide on the tube).
- Remove laryngoscope, inflate the cuff, attempt to ventilate.
- Confirm placement (waveform capnography, chest rise, lung sounds).
- Secure tube using a commercial tube holding device.
- Reassess the patient.
Quick Tips (Endotracheal Intubation)
- Proper preoxygenation and denitrogenation will extend safe apnea time. Do not rush. Take time to adjust and clearly identify landmarks.
- Do not allow hypoxia through multiple failed attempts. If you are unable to identify landmarks after two attempts, consider alternative plans such as a different intubator or supraglottic airway.
- Intubation is not about brute strength. Subtle movements of the laryngoscope result in optimal intubation conditions.
- Waveform capnography is the gold standard for confirmation. If capnographic changes are not immediately obvious, your tube is misplaced and you must remove it.
Just the Facts
- There is no way to fully predict a difficult airway. Always be ready before you pick up a laryngoscope.
- There are four ways to get air into a patient: face mask ventilation, supraglottic airway, endotracheal intubation and surgical airway. One of these methods will work.
- One of the worst enemies of executing a well-planned failed airway plan is situational stress. Take a moment to calm yourself. Consider resilience breathing, positive self-talk, and teamwork.
Failed Airway Procedure
Note: Failed airway procedures vary greatly depending on the local protocol, equipment, and scopes of practice. The following is intended to be a general guide, not a comprehensive plan. Always practice your specific plan and follow local protocols.
- Take a breath. Control your personal airway. Manage your stress.
- Get help. Say the words failed airway. Ensure the entire team understands the situation.
- Ask yourself, is this intubation essential? Can we manage the patient with basic maneuvers or a supraglottic airway? If so, do it.
- If intubation is essential, ensure that reoxygenation is occurring with face mask ventilation (buy time).
- Make your next pass your best pass.
- Could another intubator be successful? If so try it.
- Can you readjust the patient position or your position? Have you optimized the conditions around you?
- Would bimanual laryngoscopy improve your view?
- Would different equipment (such as a straight laryngoscope blade or a bougie) help?
- Can you consider another technique such as video laryngoscopy?
- Do not repeat unsuccessful attempts without making a significant change to the procedure.
- Do not repeat unsuccessful attempts at intubation. Move on if it is not working.
- If three attempts are unsuccessful and no obvious improvements toward success are forthcoming, move to a surgical airway.