Advanced Airway Management Techniques to Use in an Emergency

Advanced airway management goes beyond simple airway management techniques you might learn in a single class. Advanced airway techniques fall into three broad categories, each with a wide variety of techniques and skills a practitioner must master. 

Intubation 

Intubation includes a wide range of techniques, including: 

• Laryngeal mask airway (LMA): Laryngeal mask airways come in many forms. The classic LMA and pro-seal LMA are ideal for pediatric populations, with significant data supporting their safety and efficacy. Maintaining a good seal is critical for safety. A manometer can gauge the inflation pressure of the cuff. 
• Orotracheal intubation: The gold standard for emergency suction, orotracheal intubation is ideal for aspirating patients and those who cannot clear their airway. Various techniques can address specific needs. For example, Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) rapidly decontaminates the airway of a patient who is vomiting or bleeding.  
• Nasotracheal intubation: Nasotracheal intubation is an alternative to orotracheal intubation for sporadically breathing patients with deteriorating airways.  
• Combitube and other blind insertion devices: Blind insertion device are designed for providing rapid ventilation when a patient is in respiratory distress. They can be life-saving for patients in emergency settings, but can be contraindicated for certain patient groups. 

Surgical Airways 

Surgical airways are a rare occurrence in emergency medicine, particularly among EMS providers. This points to the need for ongoing training because EMS providers may not get much practice—even though surgical airways may fall within their scope of practice. 

In emergency situations in which the airway is fully obstructed, cricothyrotomy can establish a patent airway. Needle cricothyrotomy is an effective option for pediatric patients, but it is a temporary measure because of the small size of the air path the needle creates. Surgical cricothyrotomy is a viable alternative to oral intubation in patients with massive trauma for whom needle cricothyrotomy is not a viable option. 

Cricothyrotomy is generally safer and easier than tracheotomy. In some emergency situations, first responders and medical providers may opt for a tracheotomy. Tracheotomies may be within the scope of practice for paramedics, but are typically not within the scope of practice for EMTs. 

Rapid Sequence Intubation

Rapid sequence intubation treats a sedated and paralyzed patient. Emergency departments may perform RSI when the right medication and equipment is available. As with all artificial airways, diligent management of the airway after intubation is critical for preventing serious complications. 

Indications for Advanced Airway Management 

In general, providers should begin with the least invasive, lowest-risk airway management techniques, and proceed to surgical management techniques only when other procedures fail or are clearly unlikely to work. The most common indications for advanced airway management include: 

• Traumatic airway injury
• Apnea 
• Hypoxia
• Change of mental status or reduced consciousness 
• High aspiration risk
• Penetrating abdominal or chest injuries 

Mastering Advanced Airway Management 

Advanced airway management saves lives and reduces complications. Yet many first responders are uncomfortable with advanced airway management or with specific techniques. Regular training, including drilling in high-pressure scenarios, can sharpen providers’ skills and ensure they do not hesitate to appropriately manage the airway when doing so becomes necessary. 

The right equipment increases the efficacy of every airway management technique. Portable emergency suction machines enable first responders to establish a patent airway no matter where the patient is. The right device delivers consistent, reliable suction to quickly clear the airway. For help finding the right device for your agency, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device. 

Editor's Note: This blog was originally published in February 2020. It has been re-published with additional up to date content.