Basic airway management begins with opening and maintaining the airway. The main goal is to prevent the tongue from blocking the airway. For a non-trauma patient a head-tilt chin-lift method is preferred. For a trauma patient the jaw-thrust with spinal neutralization method is used.  If you have to pick between airway and spine always pick airway first.

Evaluating the airway is always a top priority. Normal respirations should be quiet, effortless, and with equal chest rise. Ventilatory assistance is required if the patient is breathing less than 8 times per minute. A non-breathing patient should receive two slow and smooth breaths lasting 1 second in length to evaluate the airway passage for a blockage.

An oropharyngeal (OPA) airway is used to help establish a patients airway when a gag reflex is not present. OPA’s come in many sizes. To ensure proper size the rescuer should measure by placing one end of the device on the corner of the mouth and the other end to the earlobe. To insert the OPA, hold the device at its flange end and insert it into the mouth with the tip pointing toward the roof of the patient’s mouth. Once the distal end of the OPA reaches the posterior wall of the pharynx, rotate the OPA 180 degrees so that it is positioned over the tongue. The flange should rest on the lips when properly inserted. Use of the OPA does not eliminate the need for maintaining proper head position. It is also acceptable to rotate the device at 90 degrees.

The NPA is used when the oral pharynx is not accessible or the patient has a gag reflex. The device is contraindicated in patients with facial fractures and used with caution if skull fractures are present. To ensure proper size the rescuer should measure from the corner of the nose to the earlobe. Lubricate the device prior to placement with a water based substance. When inserting the NPA in an emergency on should pick the largest and straightest nostril. Place the bevel of the NPA to the nasal

septum. Hold the device like you would a pencil and slowly insert the NPA into the patient’s nostril until the flange is flush with the nostril. Do not force the device. Use of the OPA does not eliminate the need for maintaining proper head position.

Mouth-to-mask breathing is the preferred method of ventilating a nonbreathing patient. It is a simple one person device, and because of the two-handed mask seal it provides excellent ventilatory volumes. The device when not connected to supplemental oxygen will deliver 16% oxygen to the patient. When attached to >10 LMP of supplemental oxygen the device delivers approximately 50% oxygen.

The bag-valve-mask (BVM) consists of a one-way valve, self-inflating bag, oxygen reservoir, and a transparent mask. The device delivers 21% oxygen concentration with room air and once connected to high flow supplemental oxygen it can deliver up to 80 to 100% oxygen concentration. The BVM technique commonly creates a poor seal around the patient’s mouth and is designed for two trained rescuers to use. The BVM typically delivers less volume than mouth-to-mask technique. When using a BVM during a cardiac arrest the rescuer needs to be aware of the pop-off valve status because greater ventilatory pressure is usually required. This device is most effective when the patient is intubated and the BVM is attached to an endotracheal tube (ETT) because the trachea is then isolated.

If supplemental oxygen is not available, tidal volumes and inspiratory times should be approximately 10mL/kg (800mL) and delivered over 1 second which is sufficient to make the chest rise.

If supplemental oxygen is available, lower tidal volumes are recommended. A tidal volume of approximately 6 to 7mL/kg (500mL) is given over 1 second. The delivery of lower tidal volumes should reduce the risk of gastric inflation and its consequences.

Sellick’s maneuver reduces gastric inflation during ventilatory efforts. By placing downward pressure on the cricoid cartilage the diameter of the esophagus is decreased therefore restricting the flow of air into the stomach.

If a patient’s airway is compromised by fluids, turn the victim head to one side and remove large particles. Once suction is available the remaining fluids and fine particles should be removed. For oral suctioning the pressure should be set at approximately 300mmHg and suction limited to 15 seconds. For tracheal suctioning the pressure should be around 80 to 120mmHg and suction time limited to 5 seconds. Only suction on the way out and always measure for proper advancement depth of the suction catheters.

The ETC allows ventilation of the lungs and reduces the risk of aspiration of gastric contents. The device is blindly inserted to ventilate the trachea, regardless of esophageal or tracheal placement. If the tube is placed in the trachea the distal cuff is inflated with up to 15 to 20mL of air. If the ETC was placed in the esophagus inflate the proximal cuff with up to 100mL of air to seal the pharynx and inflate the distal cuff with up to 15 to 20mL of air to seal the esophagus. Air will then be directed to the trachea. Contraindications: gag reflex present, suspected esophageal disease, ingestion of caustic substance and patients less than 4 feet tall (37F or 39F size). 41F size is for 5 feet to 6 foot 7 inch patients.  37/39F is for patients that are 4 feet to 5 feet.  All patients must be over 14 years of age to use.  Do not use if caustic ingestion or esophageal trauma is present.

A duel-lumen tube that allows either tracheal or esophageal placement. The PTL is blindly inserted just like the ETC. Consists of two parallel tubes of equal length and two balloon cuffs that inflate simultaneously when air is blown into the inflation port with a bag-valve device. When inflated one cuff closes the oropharynx and the other cuff secures the esophagus or trachea depending on distal placement. Contraindications: gag reflex present, patients less than 5 feet tall, patients less than 14 years old, suspected esophageal disease, and ingestion of caustic substance.

The LMA may be used as an alternative to either the endotracheal tube (ETT) or the face mask with either spontaneous or positive-pressure ventilation. The LMA may be used as the primary airway, as a channel for an ETT, or as an option in the management of a difficult airway when intubation is unsuccessful. The device consists of a tube that is fused to a elliptical, spoon-shaped mask at a 30-degree angle. The LMA comes typically in 5 sizes, number 1 through 5.  Size 3 fits a 30 to 50kg pt and size 5 is for 70kg and greater. When inserted, the tube protrudes from the patient’s mouth and is connected to a ventilation device. The mask is advanced until resistance is felt. Then the mask is inflated, it provides a low-pressure seal around the laryngeal inlet. When the LMA is properly placed, the black line on the tube should rest in the midline against the patient’s upper lip. The LMA is contraindicated if a risk of aspiration exists.  Some physicians prefer to rotate the LMA 90 degrees during insertion but the standard way is directly in.  Also KY gel should be added the the distal posterior portion of the LMA.  Do not use if caustic ingestion or esophageal trauma is present.

ETT intubation is the airway of choice for all critical patients who cannot protect their own airway. Tube advancement is directly into the trachea and a cuff is inflated with up to 10mL of air to secure the trachea. Advantages to ETT intubation are isolation of the trachea, reduction in the risk of aspiration, eliminates the need to maintain a mask seal, direct route for tracheal suction and certain medications can be administered via the ETT. Disadvantages are that it takes more skill than other airway devices, ETT can be dislodged easily, and takes more equipment than other methods to secure an airway. It is also recommended to use a commercial grade tube tie device to secure the ETT.

Tube sizes:  range from 2.5 mm to 9 mm.  Size 7 to 8 for men and size 6 to 7 for women.  If patient is less than 8 years of age it is not recommended to inflate the cuff.

Blades:  Miller (Wisconsin or straight)  comes in 5 sizes.  MacIntosh is a curved blade and comes in 5 sizes.
Miller is placed on the epiglotis and lift.  MacIntosh is placed in the Vallecula and lifted to raise the epiglottis. 

Stylet provided shape and rigidity to the ETT while placing.

Patients should be hyperventilated and well oxygenated for 2 minutes at a rate of 24 per minute before placement of an advance airway device. The attempt to establish the airway device should take no longer than 30 seconds to complete. If the device cannot be established within 30 seconds the patient should be hyperventilated again for 2 minutes before the next attempt.

Whenever airway assistance is being provided the rescuer should ensure proper ventilation of the patient two ways: with primary confirmation techniques and secondary confirmation techniques. Primary confirmation techniques include 5-point auscultation, bilateral chest expansion, and mask or tube condensation. In secondary confirmation techniques, esophageal detector devices are preferred for intubation confirmation in adult cardiac arrests; end-tidal CO2 detectors (capnography, capnometry, capnometer) are preferred in non-cardiac arrest victims.

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