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.
See also “Cricothyrotomy.”
Clinical features of partial 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
Red flags for an at-risk airway 
- Loss of airway protective reflexes
- Airway obstruction
Urgently manage acute or rapidly-progressive stridor as it can indicate > 50% airway obstruction with a high risk of respiratory failure and difficult intubation. Continuously monitor patients with red flags for an at-risk airway and exercise caution when transporting these patients away from a supervised setting, (e.g., for imaging studies). 
- 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.
Head-tilt/chin-lift maneuver 
- Description: repositioning the head and neck to open the airway
- Tilt the patient's head posteriorly to 15–30° of atlantooccipital 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.
- Contraindication: suspected cervical spine injury
Used only in spontaneously breathing patients
- Description: positioning of the patient in a lateral decubitus position with slight neck extension
- Indication: temporary airway compromise that can be reversed with positioning (e.g., due to procedural sedation or acute alcohol intoxication)
Delivery of positive pressure ventilation to patients with absent or impaired respiratory effort using a bag-valve-mask unit
- Rescue ventilation: cardiac arrest, respiratory failure, accidental oversedation, failed intubation attempt (i.e., when has been exceeded)
- Bridge to intubation: following induction of apnea by administration of sedatives and muscle relaxants
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 
- Adults: 500–600 mL (6–7 mL/kg) tidal volume at 10–12 breaths/minute
- Children: 20–30 breaths/minute
Confirm adequacy of BMV
Ensure oxygen is attached to the bag-mask apparatus!
Pitfalls and troubleshooting
Pitfalls and troubleshooting of bag-mask ventilation
|Poor mask seal or difficulty opening airway|
|Poor chest rise|
|Hypoxia during apneic period|| |
|Obese patient|| |
|Bearded patient|| |
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 soft flexible tube inserted through the nares into the nasopharynx to prevent the tongue from occluding the airway
- Indications: current or potential oropharyngeal obstruction
- Contraindications 
- Sizing rule: nostril to the ipsilateral tragus
- Lubricate the tube.
- Consider topical decongestant to decrease the risk of epistaxis (e.g., oxymetazoline ). 
- 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.
- Prehospital advanced airway management, e.g., out-of-hospital cardiac arrest
- Surgical procedures requiring general anesthesia but not endotracheal intubation
aspiration than . offer less protection against
- 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; similar to the LMA, but the mask is anatomically-molded, noninflatable, and made of a soft gellike 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.
Confirmation of correct placement 
- Air movement heard on auscultation of chest
- Visible chest rise and fall
- Continuous CO2 waveform on capnography
- Stable or improving oxygenation
Troubleshooting the LMA 
Difficulty ventilating the patient through a supraglottic airway suggests the device is malpositioned.
- Reposition the patient's head and neck and/or perform airway opening maneuvers.
- Deflate and reinflate mask (cuff may be hyperinflated or hypoinflated).
- Withdraw, advance, or rotate the device.
- Remove and reinsert the device or change size (a larger size may be required).
- Switch to a different airway adjunct.
- Endotracheal tube (ET tube): a flexible hollow tube designed to enter the trachea via the oropharynx or the nasopharynx, facilitate gas exchange, and protect the airway from aspiration
- Endotracheal intubation: placement of an in the trachea below the vocal cords
Rapid sequence intubation/induction (RSI): commonly used when patients are at risk of aspiration
- Goals: maximize first-pass success, reduce the risk of aspiration
- Technique: rapid induction of anesthesia and paralysis followed by immediate intubation without intervening attempts at ventilation 
- Differences from traditional intubation
- Weight-based bolus doses of short-acting are used without titration.
- BMV is not performed
Indications for endotracheal intubation 
- Airway obstruction: e.g., anaphylaxis, peritonsillar abscess, angioedema
- Airway protection
- : : e.g., , , multisystem trauma, k
- Absolute: Presence of a valid and/or
- Identify any management, e.g., using the .
- Call an airway management expert if a is anticipated.
- Ensure necessary equipment is available and functioning (see “. ”)
- Definition: administration of 100% oxygen prior to induction 
- Target SpO2: as close to 100% as possible
- Methods 
Once preoxygenation has begun, keep the mask firmly applied to the face in order to obtain the maximum benefit.
Intubation medications 
Induction agents for intubation 
- Sedates the patient, thereby reducing airway reflexes and facilitating intubation
- Commonly used agents include propofol, etomidate, and ketamine.
- The choice of induction agent depends on patient characteristics and operator experience.
- The duration of bolus doses is typically short (∼ 10 minutes) and infusions or repeat bolus dosing are required for ongoing sedation (see “Adjunctive care of ventilated patients” for suggested medications and doses).
|Induction agents for intubation|
|Drug and dose||Common applications||Advantages||Disadvantages|
Paralytic agents for intubation 
- Better visualization of glottic opening
- Decreased risk of airway injury
Classes of (NMJ blockers)
- 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 (i.e., those with renal impairment, burns, crush injuries, denervation, neuromuscular disease, prolonged abdominal sepsis) because it can cause life-threatening 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.
- 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 styleted ET tube.
- Once the tip is at the glottis, remove the stylet and gently advance until the cuff is past the cords.
- Inflate the cuff.
- Secure the tube once proper placement is confirmed.
Ensure equipment to manage a is available at all times.
Intubation via videolaryngoscopy 
- Technique is similar to except for the following:
Confirmation of ET tube placement 
- Direct visualization of endotracheal tube markers
- Auscultation: breath sounds audible over both lung fields
- Condensation: consistently visible in the tube during exhalation
CO2 detection: gold standard of successful endotracheal intubation 
Colorimetric capnometer: a qualitative CO2 detector connected between the tube and the BMV equipment
- A visual indicator changes color from purple to yellow upon contact with CO2.
- Consistent color changing with each breath > 3 times correlates with tracheal placement.
- EtCO2 level displayed numerically on the monitor : real-time quantitative
- If capnometry is inconclusive: bronchoscopy or esophageal detector device 
- : real-time quantitative EtCO2 displayed as a waveform
- Colorimetric capnometer: a qualitative CO2 detector connected between the tube and the BMV equipment
- 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.