Airway Management Quick Study Notes

Airway Management – Emergency Medicine Study Notes

Core Principles

• Airway management is a life-saving skill in EM; failure has immediate consequences.

• EM physicians are the airway experts in the hospital (anesthesia excels in controlled settings; EM must manage the uncontrolled, emergent airway).

• Early recognition of impending respiratory failure is critical: intervention before collapse prevents the need for emergent intubation.

Oxygen Delivery (Non-Invasive Options First)

1. Nasal Cannula

   • Delivers ~24–30% FiO₂.

2. Venturi Mask

   • Allows precise FiO₂ titration (e.g., 27%).

   • Useful for COPD (avoids suppressing hypoxic drive).

3. Simple Face Mask

   • Should be avoided in EM practice (unreliable).

4. Non-Rebreather Mask (NRB)

   • Max FiO₂ ≈ 55–60% (not truly 100%).

   • One-way valves prevent entrainment of room air.

5. Bag-Valve-Mask (BVM)

   • Delivers near 100% FiO₂ when used with a reservoir and good seal.

   • Can be used to assist spontaneous breathing.

6. High-Flow Nasal Cannula (HFNC)

   • Provides heated, humidified O₂ at high flow.

   • Indicated for hypoxemic respiratory failure (not hypercapnia).

Non-Invasive Ventilation (NIV)

• Revolutionary in EM → prevents intubation in 50–90% of cases (esp. CHF, COPD).

• Modes & Terms:

  • NPPV = Non-Invasive Positive Pressure Ventilation.

  • PEEP = Positive End-Expiratory Pressure.

  • CPAP = Continuous, single pressure.

  • BiPAP (Bi-Level PAP) = Different inspiratory (IPAP) & expiratory (EPAP) pressures.

• Typical starting settings:

  • 8/3 or 10/5 (IPAP/EPAP).

  • ↑ both if persistent hypoxemia.

  • ↑ IPAP only if persistent hypercapnia.

• Special case: acute pulmonary edema

  • Start high (15/10 or 18/13) to push fluid back into interstitium.

• Patient selection:

  • Must be cooperative & able to protect airway.

  • Initiate early, not as a last resort.

• Key Indications:

  • COPD exacerbation (first-line, decreases mortality).

  • Acute pulmonary edema (dramatic improvement).

  • Obesity hypoventilation syndrome.

  • Palliative/end-of-life care (alternative to intubation).

Transition to Invasive Airway

Ask 4 questions before deciding to intubate:

1. Is the patient unable to oxygenate despite best efforts?

2. Is the patient unable to ventilate?

3. Can they protect their airway?

4. Will their condition worsen inevitably (overdose, transport, progressive illness)?

If yes → prepare for invasive airway management.

Intubation Techniques

Direct Laryngoscopy (DL):

• Backup airway skill – should be mastered by all EM providers.

• Always pre-oxygenate before attempting.

Positioning:

• Goal: external auditory canal aligned horizontally with sternal notch.

• “Ramping” (shoulder and head elevation) improves view in all patients, not just obese.

Technique Pearls:

• Insert laryngoscope midline, not sweeping from the side.

• Angle slightly toward the patient’s left foot to maximize space.

• Use bimanual laryngoscopy (externally manipulate thyroid cartilage to optimize view).

Adjuncts & Backups

1. Bougie (introducer):

   • Essential, cheap, life-saving.

   • Especially useful if only epiglottis is seen (“epiglottis = airway is just beyond”).

   • Feels “tracheal clicks” when in trachea.

   • Keep laryngoscope in place while passing tube over bougie.

2. Extraglottic devices:

   • LMAs, i-gels → temporizing options if intubation fails.

3. Definitive fallback:

   • Cricothyrotomy – always possible if all else fails.

Goals of Airway Intervention

1. Correct hypoxemia.

2. Reduce work of breathing / improve ventilation.

3. Optimize strength of the respiratory “pump.”

Bottom Line:

• Master non-invasive options first (often avoid intubation).

• Intubate with preparation, positioning, and backups ready.

• Always respect the gravity of “taking away someone’s ability to breathe.”