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Airway Management

Theresa M. Schwab, MD

Key Points

• Rapid-sequence intubation (RSI) is the preferred method

for endotracheal tube placement in the emergency

department.

• The decision to intubate should always be made on

clinical grounds. Time permitting, assess for factors

predictive of a difficult airway before RSI.

INTRODUCTION

Successful airway management depends on the prompt

recognition of an inadequate airway, the identification of

risk factors that may impair successful bag-valve-mask

(BVM) ventilation or endotracheal t ube (ETT) placement,

and the use of an appropriate technique to properly secure

the airway. The decision to intubate is a clinical one and

should be based on the presence of any 1 of 3 major conditions: an inability to successfully protect one's airway

against aspiration/occlusion, an inability to successfully

oxygenate the blood (hypoxemia), or an inability to successfully clear the respiratory byproducts of cellular

metabolism (hypercapnia). Additional indications including the desire to decrease the work of breathing (sepsis),

the need for therapeutic hyperventilation (increased intracranial pressure [ICP]), and the need to obtain diagnostic

imaging in noncooperative individuals (altered mental

status) should be taken into account on a patient-bypatient basis.

Techniques for the management of unstable airways

range from basic shifts in patient positioning to invasive

surgical intervention. Standard basic life support recommendations such as the head-tilt chin-lift maneuver may

open a previously occluded airway. Oropharyngeal and

nasal airway adjuncts are both simple to use and highly

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