9-1-2026 Advanced Airway Management

4 physiologic effects of CPAP

maintains bronchiolar dilation by stenting during forceful exhalation (pressure around the bronchioles from exhalation make them collapse)

increases minute alveolar volume by allowing for increased TV per resp cycle (MAV= RR x (TV-DS)

positive pressure in alveoli reduces edema formation

rests the pt by reducing WOB. May help prevent need for intubation in patients with Acute respiratory failure (ARF)

sizes and types of ET tubes, insertion depths, and criteria for selection

range from 2.5 mm- 9mm ID (internal diameter)

2.5-5mm comes in cuffed or uncuffed, and 5-9mm are cuffed

insertion depth

19-23cm for adult, 3x tube size for peds

size selection:

adult female- 7.5 (generally)

Adult male- 8.0 generally

pediatrics- can use braselow tape in field, class= (age +16)/4. Can use size of pt pinky or nare

have 3 sizes availble (size you calculate, and 1 above + below)

CUFFED ARE ALWAYS PREFERED.

list parts of ET tube and describe

bevel- slant at distal end. fascilitates placement through cords, better visualization through tip.

Murphys eye- opening in distal portion on lateral wall. If end becomes obstructed by tissues or other objects, air can still get in.

cuff- inflatable balloon at end of ET, produces seal against tracheal wall preventing gastric contents from entering trachea. Pressure monitored via Pilot Balloon.

Vocal cord guide- black line(s) at distal end of tube indicating where the cords should lie during proper placement. Prevents placing too deep.

Radiomarker- thin blue line running length of ET tube, facilitates x-ray placement confirm.

connector or adapter- located at proximal end, attaches the ETT to BVM or ventilator, usually 14-15mm

list all items that should be availble before Intubation begins

Suction

PPE

Larygoscope handle and blades

stylet

10 cc syringe

lubricant

padding to elevate head/shoulders

stethoscope

ETCO2 monitor

securing device

alternate rescue airway

Gum bougie if availble- (used to put in first and feel tracheal rings, then thread ETT over)

How do we evaluate the PT airway in prep for Advanced airway placement

LEMON

L- Look- evidence of difficult airway, trauma, teeth issues, facial hair, tongue, piercings

E- Evaluate- Interdental distance (3 fingers is good), hyomental distance (3), thyrohyoid distance (2)

M- Mallampati- say “ah”, what structures you can see. class/grade of 1-4

O- Obstruction- airway swelling soft tissues, trauma, piercings, etc

N- Neck mobility- can they move their neck to align axis

what pt characteristics may indicate a difficult intubation

history of difficult intubation or trauma to pharynx/trachea

poor neck mobility

Obesity- large short neck

thyromental distance- chin to hyoid to thyroid is less than 4 finger widths

interdental less than 2

pharyngeal view mallampati class 3 or 4

poor laryngeal view

correct position for placement of different blades

straight (miller) blade- lifts the epiglottis directly- placed posterior to epiglottis

curved (macintosh)- inserted into vallecula lifting epiglottis indirectly- placed anterior to epiglottis

correct head positioning for intubation

sniffing position- by placing towel under head and neck. “flex the neck and extend the head”

ear is on horizontal plane with the sternum

at least 4 inches of lift

what 3 axes must be aligned for good visualization of vocal cords

oral, pharyngeal, trachea/laryngeal

2 risks when inserting laryngoscope blade into mouth

teeth and dentation damage

soft tissue damage like tongue and lips

precautions to takes when insertinb blade to avoid damage

use cross finger technique on MOLARS not incisors

introduce blade very carefully avoiding bumping teeth, or pinching tongue or lips between blade and teeth

utilize gentle but deliberate pressure (up and away) when attempting to visualize cords

5 anatomical landmarks progressively visualized during laeyngoscopy in order

tongue (sweep left), right tonsil, tip of epiglottis, arytenoids, laryngeal view

ELM and BURP

ELM- external laryngeal manipulation- intubator uses hand to manipulate thyroid cartilage for a better view of the glottis opening. Another rescuer may then hold it. AKA bimanual intubation

BURP= backwards, upwards, rightwards pressure. Done by assisstant to better see cords. Differs from ELM bc assistant does it

volume of air and goals for proper inflation of ET cuff

goal is no air leaking across cuff during ventilation

overfilling of cuff can lead to tissue damage and tracheal tears. ALLOW SYRINGE TO PUSHBACK

adult- 10ccs can be up to 20 depending on style of tube

pediatric- 5-10cc syring depending upon tube size`

why and how do we secure ETT

prevents dislodgement of tube

use a tube tamer with the channel facing down so we can suction. Can also use tape.

methods for confirming placement

SEE SEE HEAR HEAR CO2

See it pass through cords

see chest rise

hear no epigastric sounds

hear bilateral breath sounds

check ETCO2 wave form and number]

BVM compliance

pt improvement

AFTER moving pt, reconfirm all and revisualize tube in trachea

condensation and tube depth are not reliable confirmations

what can cause etco2 levels to be 0

esophageal placement

someone is dead

techniques to successfully manage a difficult airway

reposition head, airway adjunct, try 2 person BVM bagging

HELP= (head elevated larygoscopy position) ramp under head, neck, and shoulders. Align airway axes

Equipment utilization- stylet with effective shaping, suction

switch blades

ELM

rescue airway

gum bougie

video laryngoscopy if availble

steps in trouble shooting an ET tube when a pt is not ventilating

DOPE

Displacement of the tube

Obstruction (mucous, blood, aspirated food)

pneumothorax (likely due to increased intrapulmonary pressure from PPV)

Equipment (check for malfunction like cuff deflation or other things)`

Sizes for igel and LMA and criteria for selection

small to large sizes 1-5 and some half sizes. STANDARD adult size is 4

kg weight range for pt is noted on distal end next to the size. Size closest to pts weight and estimated airway size should be used. size up or down depending on ease or difficulty of placement

criteria for SGA vs ETT

ETT should be placed when less invasive methods are ineffective/inappropriate and do not meet pt care goals.

intubate- airway swelling/inflamation from asthma, burns, trauma, obstruction); aspiration protection (continuous vomiting or bleeding), including AMS with loss of airway reflexes; when anatomy does not allow seating of SGA (like in trauma).

SGA- when intubation criteria are not occuring and the pt requires advanced airway with ventilatory assistance (cardiac arrest, trauma with no airway damage, medical issues with no airway swelling/inflamation. - pediatrics are strongly suggested to use SGA over intubation if BVM/OPA is ineffective

PEEP, use, and proper settings

used to prevent alveolar collapse and secondary to maintain airways open in bronchiolar constriction states

should be used with BVM and in conjunction with CPAP. extreme care with ventilation in BVM, adequate time must be allowed for exhalation.

5cmH20 initial PEEP setting. Increase 2-3 cmH2O increments as needed allowing time for pt to adjust. Goal is to reach lowest PEEP possible needed for adequate ventilation.

PEEP of 15 or higher you should consult med control

what is the initial fio2 of CPAP

30%

What is a CPAP trio?

there are different attachements to the O2 bottle that can up the fio2 to either 60% or 90%

you could also add a NC for additional O2

a combitube is a

dual lume (tube) airway

how do you size a NG tube

nose-earlobe-xyphoid process

what is IVI

inadvertent ventilatory inattentiveness

to fix this, have one person with the sole job of ventilating

CPAP

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

pediatric is not a C/I, we just dont do it in EMS

combitube

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

Igel

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

LMA

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

Inflate cuff with appropriate amount of air (labeled on tube)

direct laryngoscopy

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

ET intubation

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

can also cause ICP bc of nerve stimulation

Nasotracheal intubation

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

NG decompression

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

tracheal suctioning

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

insert a little bit use 3-5cc of sterile NS for loosening of mucus

at end of suctioniing, be sure you dont “flick” gunk everywhere

Trach care/vent

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

cricothyrotomy

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

TTJI- what does this stand for?

general procedure, Indications, CI, advantages, disadvantages, complications and precautions

transtracheal jet insufflation

how to choose proper size of catheter for tracheal suctioning

(ID of ETT or Trach tube -1) x2

it will be #french

tracheotomy

surgical procedure used to create opening

tracheostomy

the airway created by the surgery

larygectomy

surgical procedure to remove the larynx

full- this is when you must use a BVM over stoma

partial- air still moves through to the mouth

stoma

an opening or hole through which they breath through

laryngectomy considerations

you cannot orally intubate them, there are 2 seperate passageways.

what is an obturator

similar to a stylet in ET tube but for trachs

what should I do if a trach becomes dislodged

1. deflate the cuff

2. pull it out

3. cover it with gauze and tape, or a finger then use a BVM over the mouth

4. reassess

If something weird is going on with a trach what should i do?

1. Deflate the cuff

2. cover it

3. BVM them normally

P and cm for ET Intubation