Airway Management

Every patient is unique, and this means expert airway management demands a critical, creative, adaptive approach. However, first responders should follow established protocols and guidelines to get the best results. A simple algorithm can help guide decision-making in airway management while still allowing room for flexible problem-solving. Follow these guidelines to speed up treatment and reduce errors if you encounter a difficult airway:


How to Assess the Likelihood of a Difficult Airway 

Airway management for every patient should begin by assessing the likelihood of a difficult airway. Some key predictors include: 


  • Problems with patient cooperation, such as when a patient has a cognitive or mental health disability or when the patient is a child 
  • A large tongue 
  • Dental structures that are loose or may become loose
  • 3-3-2 rule assessment that suggests difficulty 
  • A higher Mallampati score 
  • Any condition that could obstruct the airway 
  • Trauma to the face, head, or neck 
  • Difficulties with neck mobility 
  • Conditions that make it difficult or unsafe to move the patient
  • The presence of a beard 


Also consider the patient’s history of airway management, and whether any specific forms of airway management—such as intubation, supraglottic airway, mask ventilation, laryngoscopy, or surgical airway—have proved difficult. Weigh this information in light of your current airway management goals. For instance, a patient who previously had difficulties with a surgical airway may not have any trouble with mask ventilation, but may again present challenges if a surgical airway is necessary.


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Weigh Your Options for Delivering Supplemental Oxygen

As you consider strategies for how to manage a difficult airway or encounter a degree of difficulty, deliver supplemental oxygen to the patient if at all possible. This can buy time for decision-making and reduce the risk of complications, especially in critical care and emergency settings. 


Compare Your Options for Difficult Airway Management 

If the patient presents a high risk of difficult airway, compare your options for managing their airway. Begin with the strategy that is most likely to be effective, adapting your equipment and technique as necessary. For example, for a patient with a short thyromental distance, using smaller laryngoscope blades may help overcome airway difficulties. 


Develop Alternative Strategies 

If the first airway management strategy fails, compare backup alternatives: 


  • Awake intubation versus intubation after induction of anesthesia 
  • Non-invasive versus invasive intubation techniques 
  • Video-assisted laryngoscopy to aid intubation


Sometimes backup can also help. If an airway proves difficult, call for assistance. You may be able to successfully manage the airway with a second pair of hands, or you may find that a more experienced provider has better luck.


Agencies should establish clear decision trees for managing common airway issues. For example, if awake intubation fails, proceed to intubation with general anesthesia, and if this fails, try awakening the patient and ventilating them with a face mask.


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Use the Right Equipment

The right equipment is always critical to successful advanced airway management, but in the event of a difficult airway, it is indispensable. Ensure that you have a variety of tubes, catheters, and other airway management supplies that are appropriate for children, adults, and geriatrics.


Portable emergency suction allows you to deliver care promptly without moving injured patients or subjecting uncooperative patients to further stress. But not all portable suction machines are the same. You need one that delivers reliable, consistent suction and features a long battery life. Compatibility with the equipment you already have is also important. For help choosing the right machine 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 June, 2020. It has been re-published with additional up to date content.