Intubation techniques, tracheostomy care, artificial airway management, and difficult airway algorithms.
85 min estimated
Rapid sequence intubation (RSI) is the standard for emergency airway management: preoxygenate → sedation → neuromuscular blockade → intubate.
Common agents: etomidate (0.3 mg/kg) or ketamine (1–2 mg/kg) for sedation; succinylcholine (1.5 mg/kg) for depolarizing NMB (fastest onset); rocuronium (1.2 mg/kg) for non-depolarizing NMB (use if succinylcholine contraindicated).
Succinylcholine contraindications: hyperkalemia risk (burns >24h, crush injury, SCI >24h, prolonged immobilization); malignant hyperthermia history; myopathies.
Tube confirmation: primary = waveform capnography (gold standard); secondary = bilateral breath sounds, chest rise, no epigastric sounds, CXR (tube tip 2–4 cm above carina). Always confirm before securing.
Clinical Tip
If ETCO2 waveform is absent after intubation, assume esophageal intubation until proven otherwise. Immediately remove tube, bag-mask, and reattempt.
Tracheostomy provides a permanent or semi-permanent airway for patients requiring prolonged ventilation, upper airway obstruction, or secretion management. Indicated when ventilator weaning expected to take >10–14 days, upper airway tumor/trauma, chronic aspiration.
Tracheostomy tube components: outer cannula, inner cannula (removable for cleaning), obturator (used only during insertion — remove immediately after). Cuffed tubes seal airway for ventilation; fenestrated tubes allow speech.
Complications: early (hemorrhage, pneumothorax, subcutaneous emphysema, tube displacement); late (tracheal stenosis, tracheomalacia, granuloma, tracheocutaneous fistula).
Displaced tracheostomy: if <72 hours post-op, do NOT attempt to replace (tract not formed) — use oral/nasal airway, bag-mask, emergent intubation. After >72 hours, replace with same size + obturator.
Clinical Tip
Always keep a same-size and one-size-smaller tracheostomy tube and a 10 mL syringe at the bedside. In emergencies, time matters more than perfect tube fit.
The ASA Difficult Airway Algorithm guides management when initial intubation fails. Key steps: call for help, maintain oxygenation, limit attempts to 3 laryngoscopy attempts.
Rescue devices: - LMA (laryngeal mask airway): supraglottic device, doesn't protect against aspiration — bridge device - Intubating LMA (Fastrach): allows blind or fiberoptic intubation through LMA - Video laryngoscope (Glidescope, C-MAC): improves glottic visualization in difficult airways - Cricothyrotomy: surgical or needle — last resort 'can't intubate, can't oxygenate' scenario - Fiber-optic bronchoscope: awake intubation for anticipated difficult airway
Can't Intubate, Can't Oxygenate (CICO): needle cricothyrotomy (14g angiocath) or surgical cricothyrotomy immediately.
Clinical Tip
Call for help early — it's never wrong to have extra hands. The most experienced airway provider should take over after 2 failed attempts, not attempt #4.
Failed Intubation Scenario
A 65-year-old morbidly obese patient requires emergency intubation. After 2 attempts with direct laryngoscopy (grade 4 view both times), SpO2 is now 82% despite bag-mask ventilation.
What is the next step?
Insert an LMA immediately to restore oxygenation, then plan definitive airway via video laryngoscopy or surgical airway if LMA fails.
After 2 failed laryngoscopy attempts with desaturation, the priority is oxygenation. LMA is a rescue supraglottic device that can restore ventilation quickly. Once SpO2 recovers, attempt video laryngoscopy or call for fiber-optic assistance. If LMA fails and patient cannot be oxygenated (CICO), proceed to surgical cricothyrotomy immediately.
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Master ventilator modes, initial settings, troubleshooting, weaning, and complications.
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Master every drug an RT uses — bronchodilators, steroids, mucolytics, surfactants, and more.
Adult Critical Care
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