2 Airway Techniques and Tube Placement

Priorities in airway management

Airway management aims to maintain a patent airway and deliver oxygen and ventilation while minimizing harm. These techniques are for trained responders and clinicians working within their scope of practice and local protocols. In an emergency, prioritize oxygenation and ventilation; repeated attempts to establish an advanced airway must not delay them.

Opening the airway

In an unresponsive adult, loss of muscle tone can allow the tongue to obstruct airflow. If neck injury is not suspected, open the airway with a head tilt–chin lift. If head or neck trauma is suspected, a trained rescuer should first use a jaw thrust without head extension. If that does not open the airway, use a head tilt–chin lift as needed: adequate ventilation takes priority over avoiding all neck movement.

Remove a visible object from the mouth, but do not perform a blind finger sweep.

Basic airway adjuncts

An oropharyngeal airway (OPA) holds the tongue away from the posterior pharynx. Use it in an unresponsive patient without an intact gag reflex. If the reflex is present, the device may trigger gagging, vomiting, or laryngospasm. Select the size and insert the device using the technique taught for that device; incorrect placement can worsen obstruction, so reassess air movement and ventilation afterward.

A nasopharyngeal airway (NPA) passes through a nostril into the pharynx and may be better tolerated when a gag reflex remains. Avoid it when severe facial or basilar skull injury is suspected; an OPA is preferred when basilar skull fracture or severe coagulopathy is suspected. Follow the device’s sizing and insertion instructions, and stop if there is significant resistance or bleeding. Either adjunct can help make bag-mask ventilation more effective when appropriately selected.

Supraglottic airways

A supraglottic airway (SGA), such as a laryngeal mask or laryngeal tube, sits above the vocal cords and provides a channel for ventilation without placing a tube in the trachea. It can be used as a primary advanced airway or as a rescue option when bag-mask ventilation is difficult or intubation is unsuccessful.

SGAs are often quicker to place than an endotracheal tube, but they do not provide the same tracheal seal. Aspiration protection is limited, and ventilation may leak if the device is poorly positioned or airway pressures are high.

Use the correct size and follow the device instructions. After insertion, connect ventilation and assess chest rise and air entry; check for leak or obstruction and monitor exhaled carbon dioxide when available. Reposition or replace the device if ventilation is ineffective, and secure it once it is functioning.

Endotracheal intubation

Endotracheal intubation (ETI) places a tube through the vocal cords into the trachea. It is an advanced procedure for appropriately trained clinicians.

Before an attempt, prepare suction, oxygen and ventilation equipment, the tube and laryngoscope, monitoring, and a backup plan such as bag-mask ventilation or an SGA. Preoxygenate when feasible. During cardiac arrest, do not allow an airway attempt to cause avoidable interruption of chest compressions. The choice and timing of an advanced airway depend on the patient, setting, and operator skill.

With laryngoscopy, identify the laryngeal landmarks and pass the tube through the vocal cords under direct or video visualization. If the landmarks are not identified, do not advance the tube blindly. Inflate the cuff according to device guidance, ventilate, and promptly confirm placement. Limit repeated attempts: if intubation fails, return to effective oxygenation and ventilation and move to the backup plan.

Confirming and monitoring tube placement

For an endotracheal tube, continuous waveform capnography is the preferred, most reliable method of confirming and monitoring tracheal placement, used together with clinical assessment. A persistent exhaled carbon-dioxide waveform supports tracheal placement. Also assess chest rise and bilateral breath sounds, and listen over the epigastrium for signs of gastric ventilation. Secure the tube and recheck its position after movement or any change in ventilation.

Capnography confirms that the tube is communicating with the trachea; it does not by itself establish ideal tube depth. Unequal breath sounds or absent left-sided air entry may indicate that the tube is too deep in the right main bronchus. Chest radiography is commonly used after initial resuscitation to assess depth.

During prolonged cardiac arrest or very low cardiac output, exhaled carbon dioxide may be low or initially undetectable despite correct placement. Interpret the waveform in its clinical context and alongside other checks. Continue capnography after confirmation to detect disconnection or displacement.

Putting the choices together

Open the airway first, choosing the opening maneuver according to whether trauma is suspected. Select an OPA only when the gag reflex is absent, and use an NPA cautiously, avoiding it when major facial or basilar skull injury is suspected. An SGA can provide an advanced or rescue airway, while ETI requires trained clinicians and a backup plan. Confirm an endotracheal tube with continuous waveform capnography plus clinical assessment, then secure it and reassess its position.