Airway Management

Intubation techniques, tracheostomy care, artificial airway management, and difficult airway algorithms.

advanced85 min estimated3 lessons

Endotracheal Intubation and Tube Confirmation

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.

RSI: preoxygenate → sedate → NMB → intubate; no bag-mask between NMB and intubation
Gold standard confirmation: waveform capnography (continuous ETCO2)
CXR tube tip: 2–4 cm above carina (at level of aortic knob/T4)
Succinylcholine contraindicated: hyperkalemia risk, burns >24h, SCI, myopathies
Rocuronium 1.2 mg/kg: alternative NMB; reversed with sugammadex

Clinical tip

If ETCO2 waveform is absent after intubation, assume esophageal intubation until proven otherwise. Immediately remove tube, bag-mask, and reattempt.

Tracheostomy: Care and Complications

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.

Remove obturator immediately after tracheostomy insertion — it blocks airflow
Displaced trach <72 hours post-op: do NOT replace — bag-mask, oral airway, intubate
Inner cannula must be cleaned every 8 hours minimum
Fenestrated trach allows speech when cuff deflated and inner cannula capped
Cuff pressure: maintain 20–30 cmH2O — check q8h to prevent tracheal necrosis

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.

Difficult Airway Algorithm and Rescue Devices

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.

LMA: supraglottic, does NOT protect airway — use as bridge or rescue only
Video laryngoscopy: improves grade 3–4 views; learning curve required
CICO: needle cric (14g) or surgical cric — do not delay
Limit to 3 laryngoscopy attempts before switching to rescue strategy
Fiber-optic intubation: gold standard for anticipated difficult airway (awake technique)

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.

Clinical cases

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.

NBRC pearls

ETCO2 waveform = gold standard confirmation; no waveform = esophageal until proven
Succinylcholine contraindications are NBRC-tested — memorize them
Trach complications: early vs late — NBRC distinguishes these
Displaced trach <72h = medical emergency requiring oral intubation

Memory tricks

RSI: 'Prime, Sedate, Paralyze, Intubate, Confirm' — never skip confirmation
Succinylcholine CI: 'BHMS' — Burns, Hyperkalemia risk, Myopathy, SCI
CICO: 'Can't In, Can't O2 → Cut' (cricothyrotomy)

Common mistakes

Relying on bilateral breath sounds alone for intubation confirmation (esophageal can sound bilateral)
Not removing obturator after tracheostomy insertion
Attempting to reinsert displaced tracheostomy <72h (stoma not established)
Making 4+ laryngoscopy attempts before calling for help

Airway Management

Endotracheal Intubation and Tube Confirmation

Tracheostomy: Care and Complications

Difficult Airway Algorithm and Rescue Devices

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics

Airway Management

Endotracheal Intubation and Tube Confirmation

Tracheostomy: Care and Complications

Difficult Airway Algorithm and Rescue Devices

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics

Lessons

Endotracheal Intubation and Tube Confirmation

Tracheostomy: Care and Complications

Difficult Airway Algorithm and Rescue Devices

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics

Lessons

Endotracheal Intubation and Tube Confirmation

Tracheostomy: Care and Complications

Difficult Airway Algorithm and Rescue Devices

Clinical cases

NBRC pearls

Memory tricks

Common mistakes

Related topics