03 Airway Management and Ventilation

A sequence for airway care

Airway care proceeds from recognizing failure to opening and clearing the airway, supporting oxygenation and ventilation, and choosing the least invasive intervention that works. A patent airway does not guarantee adequate breathing, and supplemental oxygen alone does not correct inadequate ventilation. Follow local protocols, scope of practice, and medical direction.

Assess airway, breathing, and circulation while identifying the cause and urgency of respiratory compromise. Consider patency, ventilation, oxygenation, and perfusion separately rather than assuming that one measure describes them all.

Assess airway, breathing, and risk

Check whether the patient can speak or cry and look for obstruction, blood, vomit, secretions, swelling, trauma, or foreign material. Snoring often suggests soft-tissue obstruction; gurgling suggests fluid; stridor suggests upper-airway narrowing. Absent airflow is also concerning. Suction visible secretions and reposition as needed.

Assess respiratory rate, depth, effort, chest rise, air movement, and mental status. Slow, shallow, irregular, or absent breathing; fatigue; decreasing responsiveness; and poor chest rise may indicate ventilatory failure. A tiring patient may deteriorate even when the initial oxygen saturation is acceptable.

Assess skin color, pulse oximetry, and the overall clinical picture. Pulse oximetry estimates oxygen saturation, not ventilation; it may lag behind deterioration and can be misleading with poor perfusion or motion. Use waveform capnography when available to assess ventilation and monitor advanced airways.

Anticipate difficulty with facial or neck trauma, limited mouth opening or jaw movement, obesity, airway swelling, blood or vomit, or altered anatomy. Before an advanced airway attempt, prepare suction, oxygen, monitoring, positioning, and backup devices.

Open and maintain the airway

Start with simple measures and reassess after every change. Use a head-tilt/chin-lift when trauma is not suspected; use a jaw-thrust when cervical-spine injury is possible. If these methods fail, opening the airway takes priority. Suction promptly when secretions or emesis threaten patency.

Use an oropharyngeal airway (OPA) for an unresponsive patient without an intact gag reflex. If it triggers gagging or vomiting, it is poorly tolerated and should be removed. A nasopharyngeal airway (NPA) may be useful when a patient has some airway reflexes or cannot tolerate an OPA. Avoid or use special caution with an NPA when severe midface trauma or basilar skull fracture is suspected, according to protocol. Select an appropriate size, insert gently, and never force it.

Airway adjuncts help maintain patency but do not provide ventilation by themselves. Continue to observe chest rise and air movement.

Support oxygenation and ventilation

Choose an oxygen delivery device according to the patient's condition and response, and titrate oxygen to the response and local protocol. A normal saturation does not establish that ventilation is adequate.

A spontaneously breathing patient in severe respiratory distress may benefit from noninvasive positive-pressure support such as continuous positive airway pressure (CPAP) when indicated and permitted by protocol. The patient must be breathing spontaneously and able to cooperate sufficiently. Use caution or avoid CPAP with apnea, inability to protect the airway, vomiting, or hemodynamic instability.

For apnea or inadequate breathing, provide bag-valve-mask (BVM) ventilation. Open the airway, use an adjunct when appropriate, obtain a tight mask seal, and give only enough volume to produce visible chest rise. A two-person technique often improves ventilation: one rescuer uses both hands to maintain the seal and airway position while another squeezes the bag.

Reassess chest rise, breath sounds, oxygen saturation, mental status, and capnography when available. Avoid rapid or forceful breaths because excessive ventilation can cause gastric inflation, aspiration, barotrauma, and reduced venous return.

For an adult with a pulse who is in respiratory arrest, the 2025 AHA guidance considers one breath every $6$ seconds, or $10$ breaths per minute, reasonable, with visible chest rise. During adult cardiac arrest with an advanced airway in place, deliver one breath every $6$ seconds while compressions continue, following the applicable resuscitation algorithm.

Choose an advanced airway carefully

An advanced airway is not automatically better than effective BVM ventilation. Choose the method that reliably maintains oxygenation and ventilation with the least interruption and risk. Consider the patient's condition, provider competence, available help, transport, and system performance. Evidence does not establish one device as best in every prehospital situation. BVM is the foundation; a supraglottic airway (SGA) or endotracheal intubation (ETI) may be appropriate when simpler methods are ineffective or unsuitable.

In pediatric patients, prioritize effective BVM and be especially cautious about escalating to endotracheal intubation because experience and success may be limited.

A supraglottic airway is a rescue or alternative advanced airway placed above the glottis. Confirm effective ventilation, secure the device, and monitor it continuously. It may leak or fail to protect against aspiration.

Consider endotracheal intubation when clinically indicated and within the clinician's training and system capability. Optimize positioning and preoxygenation, prepare a backup plan, and minimize interruptions. Medication-assisted intubation carries risk and should be performed only within an established protocol and a system with training, oversight, monitoring, and quality improvement. When medication-assisted intubation is used, the prehospital evidence-based guideline favors rapid sequence intubation (RSI) over sedation-only approaches, but rates the supporting evidence as very uncertain.

A surgical airway is a rescue option for a cannot-intubate, cannot-oxygenate situation when less invasive techniques have failed, if authorized by protocol and within the clinician's competence.

Confirm placement and reassess

For an endotracheal tube, use continuous waveform capnography to confirm tracheal placement and monitor the tube throughout care and transport. Chest rise and bilateral breath sounds are useful clinical adjuncts, but they are not reliable substitutes for exhaled-CO₂ confirmation. Secure the device, note its depth, reassess after movement, and respond to any change in the waveform or ventilation. Capnography also helps monitor ventilation through an advanced airway; interpret values in context because low pulmonary blood flow can affect exhaled CO₂.

If oxygenation or ventilation worsens after an intervention, do not fixate on the device. Check the patient, airway position, equipment, and ventilation technique, and return to an effective BVM strategy when needed.

Recognize and respond to complications

Match the response to the problem, reassessing the patient and the effectiveness of each intervention.

• Upper-airway obstruction or secretions: Snoring, gurgling, or poor air movement may be clues. Reposition, suction, add an appropriate adjunct, and reassess.

• Ineffective BVM ventilation: Poor chest rise, a leak, or persistent hypoxia may indicate a problem. Reopen the airway, improve the two-hand seal, check the adjunct and equipment, suction, and escalate if needed.

• Esophageal or displaced tube, or mainstem intubation: Absent or unequal chest movement, abnormal breath sounds, or an absent or changing CO₂ waveform may be clues. Ventilate with BVM while rapidly reassessing and correcting or removing a misplaced device according to protocol.

• Gastric inflation, aspiration, or barotrauma: Abdominal distention, regurgitation, worsening ventilation, or sudden deterioration may occur. Reduce excessive rate or volume, optimize technique, suction, and evaluate for complications.

• Peri-intubation hypoxia or hypotension: Falling oxygen saturation or blood pressure, or worsening perfusion, calls for stopping repeated attempts, restoring oxygenation and ventilation with the best available method, supporting circulation, and reassessing.

• Hyperventilation: Excessively rapid breaths and falling EtCO₂ in context may be clues. Slow ventilation to the indicated rate and reassess perfusion and clinical response.

In cardiac arrest, airway placement must not compromise high-quality CPR. Defer an advanced airway if inserting it would interrupt compressions until initial CPR and defibrillation efforts have been addressed.