Chapter 39

39: Advanced Airway Management
Cognitive Objectives (1 of 5)
8-1.1 Identify and describe the airway anatomy in the
infant, child, and the adult.
8-1.3 Explain the pathophysiology of airway
compromise.
8-1.4 Describe the proper use of airway adjuncts.
8-1.5 Review the use of oxygen therapy in airway
management.
8-1.6 Describe the indications, contraindications, and
techniques for insertion of nasal gastric tubes.
8-1.7 Describe how to perform the Sellick maneuver
(cricoid pressure).
8-1.8 Describe the indications for advanced airway
management.
8-1.9 List the equipment required for orotracheal
intubation.
8-1.10 Describe the proper use of the curved blade
for orotracheal intubation.
8-1.11 Describe the proper use of the straight blade
for orotracheal intubation.
8-1.12 State the reasons for and proper use of the
stylet for orotracheal intubation.
8-1.13 Describe the methods of choosing the
appropriate size endotracheal tube in an adult
patient.
8-1.14 State the formula for sizing an infant or child
endotracheal tube.
8-1.15 List complications associated with advanced
airway management.
8-1.17 Describe the skill of orotracheal intubation in
the adult patient.
8-1.18 Describe the skill of orotracheal intubation in
the infant and child patient.
8-1.19 Describe the skill of confirming endotracheal
tube placement in the adult, infant, and child
patient.
8-1.20 State the consequences of and the need to
recognize unintentional esophageal
intubation.
8-1.21 Describe the skill of securing the endotracheal
tube in the adult, infant, and child patient.
Affective Objectives (1 of 2)
8-1.22 Recognize and respect the feelings of the
patient and family during advanced airway
procedures.
8-1.23 Explain the value of performing advanced
airway procedures.
8-1.24 Defend the need for the EMT-B to perform
advanced airway procedures.
8-1.25 Explain the rationale for the use of a stylet.
Affective Objectives (2 of 2)
8-1.26 Explain the rationale for having a suction
unit immediately available during
intubation attempts.
8-1.27 Explain the rationale for confirming breath
sounds.
8-1.28 Explain the rationale for securing the
endotracheal tube.
Psychomotor Objectives
8-1.29 Demonstrate how to perform the Sellick
maneuver.
8-1.30 Demonstrate the skill of orotracheal intubation in
the adult patient.
8-1.31 Demonstrate the skill of orotracheal intubation in
the infant and child patient.
8-1.32 Demonstrate the skill of confirming endotracheal
tube placement in the adult patient.
8-1.33 Demonstrate the skill of confirming endotracheal
tube placement in the infant and child patient.
8-1.34 Demonstrate the skill of securing the
endotracheal tube in the adult patient.
Anatomy and Physiology
of the Airway
Basic Airway Management
• Airway is always assessed first.
• Advanced techniques are used after basic
management.
• The first step is opening the patient’s airway.
• Once the airway has been cleared, determine the
need for an airway adjunct.
Gastric Tubes
• Provide channel into patient’s stomach
• Nasogastric tubes: Inserted through the nose
• Orogastric tubes: Inserted through the mouth
• Nasogastric tubes: Contraindicated in a patient with
major facial, head, or spinal trauma
Equipment
• Proper-sized tubes
• Catheter-tipped 60-mL
syringe
• Water-soluble lubricant
• Emesis container
• Tape
• Stethoscope
• Suctioning unit and
catheters
Gastric Tube Insertion
• Measure the tube.
• Lubricate the distal end of the tube.
• Place the patient in proper position.
• Pass the tube until you reach the tape marker.
• Confirm proper tube placement.
• Aspirate air and stomach contents with the
syringe.
• Secure the tube in place with tape.
Sellick Maneuver
• Visualize the cricoid
cartilage.
• Palpate to confirm its
location.
• Apply firm pressure on the
cricoid ring.
• Maintain pressure until
intubated.
Endotracheal Intubation
• Insertion of a tube into the trachea in order to
maintain the airway
• Orotracheal intubation: Through the mouth
• Nasotracheal intubation: Through the nose
• EMT-Bs only intubate patients who are:
– Unresponsive with no gag reflex
– In cardiac arrest
Equipment (1 of 2)
• BSI equipment
• Proper-equipment endotracheal tube
(ET tube)
• Laryngoscope handle and blade
(visualized technique)
• Stylet or light stylet
• 10-mL syringe
• Oxygen, with BVM device
Equipment (2 of 2)
• A suctioning unit with rigid and soft-tip catheters
• Magill forceps
• Towels for raising the patient’s head and/or
shoulders
• A stethoscope
• Water-soluble lubricant for tubes and scopes
• A commercial securing device or tape
Laryngoscope
• Sweeps the tongue out of the way and aligns the
airway
• Has a light powered by batteries in handle
• Has blades that connect to handle
– Blades are curved or straight.
– They range in size from 0 to 4.
Curved Blade
Straight Blade
Endotracheal Tubes
• Tubes come in many sizes, from adult to

infant.
• Normal tube-to-teeth mark is usually around
22 cm.
• Diameter for normal adult male ranges from
7.5 to 8.5 mm.
• Diameter for normal adult female ranges from
6.5 to 8.0 mm.
• Use tape or chart for pediatric sizes.
Stylet
• Plastic-coated wire may be inserted in the ET
tube to add rigidity and shape to the tube.
• Bend the tip of the stylet to form a gentle curve
in adults.
• Bend the tip of the stylet to form a hockey stick
shape for an infant and child.
• Confirm that the stylet is not sticking out past
the end of the ET tube.
Syringe
• Use the 10-mL syringe to
test for air leaks in the
ET tube before
intubation.
• After the ET tube has
been properly inserted,
inflate the cuff with 5 to
10 mL of air.
• Remove the syringe from
the pilot balloon to
prevent air from leaking.
Other Equipment
• Oxygen
• A suctioning unit
• A BVM device
• Magill forceps
• Towels for raising the patient’s head or
shoulders
• Secondary confirmation device
• C-collar backboard
The Intubation Procedure
• First EMT-B applies AED.
• Second and third EMT-B
perform CPR.
• Fourth EMT-B prepares and
intubates patient.
Visualized (Oral)
Intubation (1 of 2)
• Open airway.
• Insert an oropharyngeal airway.
• Preoxygenate the patient.
• Assemble equipment.
• Position the head and neck.
Visualized (Oral)
Intubation (2 of 2)
• Grasp laryngoscope with left hand.
• Visualize vocal cords.
• Insert ET tube.
• Inflate balloon.
• Confirm placement.
• Secure tube.
Blind (Nasal) Intubation (1 of 2)
• Many of the steps are the same as those for oral
intubations.
• Check for gag reflex.
• Insert tube through nostril.
• Pass tube through vocal cords as patient is
inhaling.
Blind (Nasal) Intubation (2 of 2)
• Release the jaw and hold tube against nostril.
• Inflate cuff.
• Attach the BVM device.
• Secure the tube.
Intubation Complications
• Intubating the right • Patient vomiting
main stem bronchus
• Soft-tissue trauma
• Intubating the
esophagus • Mechanical failure
• Aggravating spinal • Patient intolerant of the
injuries ET tube
• Taking too long to • Decrease in heart rate
ventilate
Multilumen Airways
• Inserted without direct
visualization
• Provide ventilation when
placed in either trachea or
esophagus
Esophageal Tracheal
Combitube (ETC)
Combitube Contraindications
• Conscious or semiconscious patients with gag
reflex
• Children younger than 16 years
• Adults shorter than 5'
• Patients who have ingested a caustic substance
• Patients with esophageal disease
Inserting the ETC (1 of 2)
• Assemble and check the
proper equipment.
• Apply water-soluble lubricant
to the ETC.
• Position the patient.
• Lift the lower jaw and tongue.
Inserting the ETC (2 of 2)
• Guide the ETC along
the base of the tongue.
• Inflate the blue and
then the white pilot
balloon.
• Ventilate the patient.
• Monitor the patient.
Removing the ETC
• Be prepared to suction patient.
• Deflate both balloon cuffs.
• Gently remove the tube.
Pharyngeotracheal Lumen Airway
(PtL)
PtL Contraindications
• Conscious or semiconscious patients with
gag reflex
• Children younger than 14 years
• Adults shorter than 5'
• Patients who have ingested a caustic
substance
• Patients with esophageal disease
Inserting the PtL (1 of 2)
• Assemble and check equipment.
• Lubricate tube with water-soluble
lubricant.
• Position the patient.
• Lift the lower jaw and tongue.
• Hold the PtL so that it curves in
the same direction as the
pharynx.
Inserting the PtL (2 of 2)
• Inflate balloon cuffs.
• Ventilate patient through
the short, green tube.
• Evaluate placement.
• Verify that the patient is
receiving adequate
ventilations.
• Monitor the patient.
Removing the PtL
• Be prepared to suction the patient.
• Deflate balloon cuffs.
• Gently remove the tube.
Laryngeal Mask Airway (LMA)
LMA Contraindications
• Asthma
• COPD
• Leaking mask
• Active vomiting
• Esophageal diseases
Inserting the LMA (1 of 2)
• Assemble and check
equipment.
• Open the airway.
• Select proper size.
• Hold LMA down.
• Remove oropharyngeal device
and begin insertion.
Inserting the LMA (2 of 2)
• Insert until you feel
resistance.
• Stabilize the tube.
• Inflate mask.
• Insert bite block and
secure the LMA.

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39: Advanced Airway Management

• Tubes come in many sizes, from adult to

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