Basic Airway Management and Decision Making (1)

S E C T I O N I I
Respiratory Procedures
emesis and aspiration limit the use of some techniques, such

C H A P T E R 3 as awake intubation. In trauma patients, the risk for cervical
spine injury limits optimal head and neck positioning for
BMV and laryngoscopy. All these factors increase the risk for
Basic Airway Management complications from emergency airway management,6,7 and
approximately 0.5% to 1% of all emergency airways require
and Decision Making a surgical approach.6,8 The increasing use of video laryngoscopy
may reduce the incidence of emergency surgical airways.
Brian E. Driver and Robert F. Reardon
BASIC AIRWAY MANAGEMENT TECHNIQUES
B asic airway procedures are often overlooked in favor of

more exciting intubation devices and techniques, but basic
procedures are critically important and often lifesaving.
Opening the Airway
The first concern in the management of a critically ill patient
Establishment of a patent airway, oxygenation, and bag-mask is patency of the airway. Upper airway obstruction commonly
ventilation (BMV) remain the cornerstones of good emergency occurs when patients are unconscious or sedated. It can also
airway management (Videos 3.1–3.11).1,2 These techniques can be due to injury to the mandible or muscles that support the
be used quickly and in any setting. They allow practitioners hypopharynx. In these situations, the tongue moves posteriorly
to keep apneic patients alive until a definitive airway can be into the upper airway when the patient is in a supine position.
established.2 Upper airway obstruction caused by the tongue can be relieved
Extraglottic devices, such as laryngeal mask airways (LMAs) by positioning maneuvers of the head, neck, and jaw; the use
and the King Laryngeal Tube (LT), are also important for the of nasopharyngeal or oropharyngeal airways; or the application
initial resuscitation of apneic patients and for rescue ventilation of noninvasive positive pressure ventilation (NPPV).
when intubation fails.3–5
This chapter describes basic airway skills, including opening
the airway, oxygen (O2) therapy, BMV, and extraglottic airway
Manual Airway Maneuvers
(EGA) devices. These are the skills that providers can rely on Airway obstruction in unconscious patients is often due to
when other airway techniques are difficult or impossible. posterior displacement of the tongue (Fig. 3.1A). Research in
Mastery of these skills will help providers manage difficult, patients with obstructive sleep apnea using NPPV supports
anxiety-provoking emergency airways. the concept that the airway collapses like a flexible tube.2,9
Upper airway obstruction often causes obvious snoring or
stridor, but it may be difficult to discern in some patients.
THE CHALLENGE OF EMERGENCY All unconscious patients are at high risk for upper airway
AIRWAY MANAGEMENT obstruction.
More than 40 years ago, Guildner10 compared different
Although other specialists are sometimes available, most techniques for opening obstructed upper airways and found
emergency airways are managed by emergency medicine that the head-tilt/chin-lift and jaw-thrust techniques were both
providers.6 Airway management in the emergency department effective (Fig. 3.1B and C). The jaw-thrust maneuver (anterior
(ED) is unique and significantly different from airway manage- mandibular translation to bring the lower incisors anterior to
ment in the controlled setting of an operating room. Addition- the upper incisors) is the most important technique for opening
ally, conventional airway management tools may be ineffective the upper airway.2,11
in the uncontrolled emergency environment. Major challenges It is widely accepted that the jaw-thrust-only (without head
include hypoxia; shock; full stomach, and the presence of emesis, tilt or chin lift) maneuver should be performed in patients
blood, or excessive secretions in the airway. Many patients are with suspected cervical spine injury,12 but there is no evidence
uncooperative and combative, making it impossible to properly that it is safer than the head-tilt/chin-lift maneuver.13 The
examine the airway before choosing an intubation technique. American Heart Association (AHA) concluded that airway
Medical history, allergies, and even the current diagnosis are maneuvers are safe during manual in-line stabilization of the
often unknown before emergency airway management begins. cervical spine but highlighted evidence that all airway maneuvers
Time constraints, lack of patient cooperation, and risk for cause some spinal movement. Both the chin-lift and the
39
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40 SECTION II Respiratory Procedures
Manual Airway Maneuvers
Base of
tongue
Glottis
A B C
Figure 3.1 Manual airway maneuvers. A, The most common cause of airway obstruction in an
unconscious patient is the tongue. Initial maneuvers for opening the airway include B, head tilt/chin
lift and C, jaw thrust. The jaw-thrust maneuver is the most important technique.
jaw-thrust maneuvers have been shown to cause similar sub- The Triple Airway Maneuver
stantial movement of the cervical vertebrae.14–18 However, there The “triple airway maneuver” is described by some authors
is no evidence that this movement worsens existing spinal cord as a valuable method for maintaining a patent upper airway.2,12
injury or causes new spinal cord injury in patients with cervical The most common description of this maneuver is head tilt,
spine fractures. Most experts believe that airway interventions jaw thrust, and mouth opening.2,12 Evidence demonstrates that
performed for patients with cervical spine injury are safe.19–21 the upper airway is more patent when the mouth is closed.23–25
The AHA recommends that “if healthcare providers suspect Although the triple maneuver is commonly mentioned in the
a cervical spine injury, they should open the airway using a anesthesia literature as a valuable technique, no studies exist
jaw thrust without head extension. Because maintaining a patent to support the assertion that this technique is more effective
airway and providing adequate ventilation are priorities in CPR, than the head-tilt/chin-lift or jaw-thrust maneuvers.
use the head tilt–chin lift maneuver if the jaw thrust does not
adequately open the airway.”22
Importantly, the addition of NPPV may relieve airway
Patient Positioning
obstruction when simple manual positioning maneuvers fail. The best way to position a patient’s head and neck for opening
Meier and colleagues9 showed that adding NPPV to the chin-lift the upper airway is to mimic how patients position themselves
and jaw-thrust maneuvers decreased stridor and improved the when they are short of breath, with the neck flexed relative
nasal fiberoptic view of the glottic opening in anesthetized to the torso and with atlanto-occipital extension.2 This is known
children. The use of NPPV for patients with upper airway as the sniffing position and was described by Magill almost 100
obstruction should not be considered a definitive solution. years ago.26 In normal-sized supine adults this is accomplished
by elevating the head approximately 10 cm while tilting the
The Jaw-Thrust Maneuver head back, so that the plane of the patient’s face tilts slightly
The jaw-thrust maneuver is the most important technique toward the provider at the head of the bed (see Chapter 4,
used to open the upper airway. To perform the jaw-thrust Fig. 4.8).2,27–29 Morbidly obese patients require much more
maneuver, place the tips of the middle or index fingers behind head elevation to achieve the proper sniffing position. This
the angle of the mandible (see Fig. 3.1C). Lift the mandible can be accomplished by building a ramp of towels and pillows
toward the ceiling until the lower incisors are anterior to the under the upper torso, head, and neck or by using a Troop
upper incisors. This maneuver can be performed in combination Elevation Pillow (Mercury Medical, Clearwater, FL) or similar
with the head-tilt/chin-lift maneuver or with the neck in the device (Fig. 3.2).30–33 Rather than elevating the head by a
neutral position during in-line stabilization. standard height, the goal of head elevation is to achieve hori-
zontal alignment of the external auditory meatus with the
The Head-Tilt/Chin-Lift Maneuver sternum. This is the best position for opening the upper airway
To perform the head-tilt/chin-lift maneuver, place the tips of in morbidly obese patients.32–35
the index and middle fingers beneath the patient’s chin (see The sniffing position is contraindicated in patients with
Fig. 3.1B). Lift the chin cephalad and toward the ceiling. The cervical spine injuries. The best technique for opening the
upper part of the neck will naturally extend when the head airway in this situation is a simple jaw-thrust maneuver with
tilts backward during this maneuver. Apply digital pressure on anterior mandibular translation to bring the lower incisors
only the bony prominence of the chin and not on the soft anterior to the upper incisors (see Fig. 3.1C).2,11 In obese
tissues of the submandibular region. The final step in this patients, fat deposition on the upper back results in neck
maneuver is to use the thumb to open the patient’s mouth extension when the patient’s head is resting on the bed. In
while the head is tilted and the neck is extended. these patients, it is acceptable to carefully elevate the head
CHAPTER 3 Basic Airway Management and Decision Making 41
The technique of subdiaphragmatic abdominal thrusts to

relieve a completely obstructed airway was popularized by Dr.
Henry Heimlich and is commonly referred to as the Heimlich
maneuver.37 The technique is most effective when a solid food
bolus is obstructing the larynx. In a conscious patient, stand
behind the upright patient. Circle the arms around the patient’s
midsection with the radial side of a clenched fist placed on
the abdomen, midway between the umbilicus and xiphoid.
Then grasp the fist with the opposite hand and deliver an
inward and upward thrust to the abdomen (Fig. 3.3A). A
successful maneuver will cause the obstructing agent to be
expelled from the patient’s airway by the force of air exiting
the lungs. Abdominal thrusts are relatively contraindicated in
pregnant patients and those with protuberant abdomens.
Potential risks associated with abdominal thrusts include
stomach rupture, esophageal perforation, and mesenteric
laceration, compelling the rescuer to weigh the risks and benefits
of this maneuver.38–43 Use a sternal hand position for pregnant
Figure 3.2 The best position for opening the upper airway in morbidly
obese patients is elevation of the head, neck, and shoulders so that patients (Fig. 3.3B).
the external auditory meatus is aligned with the sternum. This can If a choking patient loses consciousness, use chest compres-
be accomplished with purpose-built pillows; however, similar results sions in an attempt to expel the obstructing agent (Fig. 3.3C).4
may be achieved with other devices or a ramp of towels and pillows. The theory is the same as the Heimlich maneuver, with high
intrathoracic pressure created to push the obstruction out of
the airway. Some data suggest that chest compressions may
generate higher peak airway pressure than the Heimlich
maneuver.44 After 30 seconds of chest compressions, remove
with a towel or pillow to move the head and neck into a more the obstructing object if you see it, attempt 2 breaths, and
neutral position even in the setting of cervical spine trauma. then continue cardiopulmonary resuscitation (CPR; 30 compres-
In young children, the sniffing position is often achieved sions to 2 breaths). Every time you open the airway to give
without lifting the head because the occiput of a child is rela- breaths, look for the object and remove it if possible, and then
tively large, so the lower cervical spine is normally flexed when continue CPR if necessary.
the child is lying supine on a flat surface. Back blows are recommended for infants and small children
Airway management is usually easiest when patients are in with a foreign body obstructing the airway. Some authors have
the supine position, but the lateral position may be best for argued that back blows may be dangerous and may drive foreign
patients who are actively vomiting and those with excessive bodies deeper into the airway, but there is no convincing
upper airway bleeding or secretions. Some evidence suggests evidence of this phenomenon.45,46 Anecdotal evidence suggests
that rotating patients to the lateral position may not prevent that back blows are effective.47–49 No convincing data, however,
aspiration.36 Patients with suspected cervical spine injury should indicate that back blows are more or less effective than
have their head immobilized with manual in-line stabilization abdominal or chest thrusts. Back blows may produce a more
if they need to be rolled to the lateral position. Airway manage- pronounced increase in airway pressure, but over a shorter
ment maneuvers will be more difficult when patients are in period than with the other techniques. The AHA guidelines
the lateral position. suggest back blows in the head-down position (Fig. 3.3D) and
head-down chest thrusts in infants and small children with
foreign body airway obstruction (Fig. 3.3E).4 The AHA does
Foreign Body Airway Obstruction not recommend abdominal thrusts in infants because they may
Awake patients with partial airway obstruction can usually clear be at higher risk for iatrogenic injury. From a practical stand-
a foreign body on their own. Intervention is required when point, back blows should be delivered with the patient in a
the patient is not moving air or has altered mental status. Some head-down position, which is more easily accomplished in
patients with upper airway obstruction can be ventilated and infants than in larger children. It is recommended that suction
oxygenated with aggressive high-pressure BMV, so always try be performed on newborns rather than giving them back blows
this if standard BMV fails. Massive aspiration of vomitus is or abdominal thrusts.50
often a fatal event because of inability of the patient and clinician Any patient with a complete airway obstruction may benefit
to adequately clear the airway. from chest compressions, abdominal thrusts, or back blows.
It is important to realize that more than one technique is often
Abdominal Thrusts (Heimlich Maneuver), Chest required to clear obstruction of the airway by a foreign body,
Thrusts, and Back Blows (Slaps) so multiple techniques should be applied in a rapid sequence
The International Consensus Conference on Cardiopulmonary until the obstruction is relieved. Perform a finger sweep of
Resuscitation and Emergency Cardiopulmonary Care4 evaluated the patient’s mouth only if a solid object is seen in the airway.
the evidence for different techniques to clear foreign body Perform CPR on all unconscious patients with airway
airway obstruction. They found good evidence for the use of obstruction. Aggressive high-pressure BMV should be
chest thrusts, abdominal thrusts, and back blows or slaps. attempted, as this may distend the trachea enough to allow
Insufficient evidence exists to determine which technique is air to bypass the obstruction. In cases in which obstructive
the best and which should be used first. foreign bodies cannot be removed under direct visualization
Heimlich Maneuvers
A B C
Heimlich maneuver Heimlich maneuver in pregnancy Chest compressions
D E
Infant back blows Infant chest thrusts
Figure 3.3 A-E, Heimlich maneuvers (see text).
and aggressive positive pressure ventilation has failed, practi-

tioners with advanced airway skills and proper equipment can
try to push a subglottic foreign body beyond the carina, usually
HI-D Big Stick suction tip
into the right main stem bronchus.
Suctioning
Patient positioning and airway-opening maneuvers are often
inadequate to achieve complete airway patency. Ongoing
hemorrhage, vomitus, and particulate debris frequently require
suctioning. Several types of suctioning tips are available. A
large-bore dental-type suction tip is the most effective in
clearing vomitus from the upper airway because it is less likely
to become obstructed by particulate matter. The tonsil tip
(Yankauer) suction device can be used to clear hemorrhage 5/16”
and secretions. Its rounded tip is less traumatic to soft tissues, suction tubing
but the tonsil tip device is not large enough to effectively
suction vomitus. Figure 3.4 HI-D Big Stick suction tip (SSCOR, Inc., Sun Valley,
A large-bore dental-type tip device, such as the HI-D Big CA) and 5/16-inch tubing.
Stick (SSCOR Inc, Sun Valley, CA) suction tip, should be
readily available at the bedside during all emergency airway
management (Fig. 3.4). The large-bore tip allows rapid clearing
of vomitus, blood, and secretions.
A limiting feature of many suction catheters is the diameter oropharyngeal airways can facilitate both spontaneous breathing
of the tubing. Vomitus may obstruct the standard 1/4-inch- and BMV. In semiconscious patients who require a head-tilt/
diameter catheter.51 A 5/8- or 3/4-inch-diameter suction tube chin-lift or jaw-thrust maneuver to open their airways, hypoxia
(Kuriyama Tubing, 5/16-inch inner diameter, 0.44-inch outer may develop because of recurrent obstruction if these maneuvers
diameter, clear; www.grainger.com) has been shown to signifi- are discontinued. Oxygen supplementation and a nasopharyngeal
cantly decrease suction time for viscous and particulate material airway may be all the support that is necessary to maintain a
(see Fig. 3.4).52 functional airway.
Keep suctioning equipment connected and ready to operate. Patients who are unresponsive or apneic are usually easier
Everyone participating in emergency airway management should to ventilate with a bag-mask device when an oropharyngeal
know how to use it. Interposition of a suction trap close to airway is in place. In the ED, patients who tolerate an oro-
the suction device prevents clogging of the tubing with par- pharyngeal airway should generally be intubated.
ticulate debris.
No specific contraindications to airway suctioning exist. Artificial Airway Placement
Complications of suctioning may be avoided by anticipating The simplest and most widely available artificial airways are
problems and providing appropriate care before and during the oropharyngeal and nasopharyngeal airways (Fig. 3.5). Both
suctioning maneuvers. Nasal suction is seldom required, except are intended to prevent the tongue from obstructing the airway
in infants, because most adult airway obstruction occurs in the by creating a passage for air between the base of the tongue
mouth and oropharynx. and the posterior pharyngeal wall. The oral airway may also
Avoid prolonged suctioning because it may lead to significant prevent teeth clenching. In cases of severe upper airway edema,
hypoxia, especially in children. Do not exceed 15 seconds for such as angioedema, these devices may not function properly
suctioning intervals and administer supplemental O2 before and or be able to bypass the obstruction. The oropharyngeal airway
after suctioning. Naigow and Powasner53 found that suctioning may be inserted by either of two procedures. One approach
consistently induced hypoxia in dogs and that it was best avoided is to insert the airway in an inverted position along the patient’s
by hyperventilation with high-concentration O2 before and after hard palate (Fig. 3.5, step 2). When it is well into the patient’s
suctioning. Hypoxia was also prevented in children by pre- mouth, rotate the airway 180 degrees and advance it to its
oxygenation prior to endotracheal (ET) suctioning attempts.54 final position along the patient’s tongue, with the distal end
When feasible, perform suctioning under direct vision or of the artificial airway lying in the hypopharynx (Fig. 3.5, step
with the aid of the laryngoscope. Forcing a suction tip blindly 3). A second approach is to open the mouth widely, use a
into the posterior pharynx can injure tissue or convert a partial tongue blade to displace the tongue, and then simply advance
obstruction to a complete obstruction. the artificial airway into the oropharynx (Fig. 3.5, step 4). No
rotation is necessary when the airway is placed in this manner.
Oropharyngeal and Nasopharyngeal This technique may be less traumatic, but it takes longer.
The nasopharyngeal airway is very easy to place. It may be
Artificial Airways easiest to place it on the patient’s right naris so that the bevel
Indications and Contraindications is facing the septum on insertion. Be sure to lubricate the
Once the airway has been opened with manual maneuvers device before insertion (Fig. 3.5, step 6). Some clinicians insert
and suctioning, artificial airways, such as nasopharyngeal and a nasopharyngeal airway to dilate the nasal passages for 20 to
Oropharyngeal and Nasopharyngeal Airways

Indications Equipment
Facilitation of spontaneous breathing and bag-valve-mask
ventilation in patients requiring head-tilt/chin-lift or jaw-
thrust maneuvers
Contraindications
Nasopharyngeal
Significant facial and basilar skull fractures
Complications Nasopharyngeal
Oropharyngeal airway
Vomiting (in patients with an intact gag reflex)
Airway obstruction (if the tongue is pushed against the posterior
pharyngeal wall during insertion)
Nasopharyngeal
Oropharyngeal
Epistaxis airway
Deterioration requiring intubation (semiconscious patient)
Review Box 3.1 Oropharyngeal and nasopharyngeal airways: indications, contraindications, complications, and equipment.
Oropharyngeal Airway Insertion
For oropharyngeal Open the patient’s

1 airway insertion, first 2 mouth with your
measure. An airway thumb and index
of correct size will finger, then insert
extend from the the airway in an
corner of the mouth inverted position
to the earlobe or the along the patient’s
angle of the mandible. hard palate.
When the airway is Alternatively, open

3 well into the mouth, 4 the mouth widely
rotate it 180°, with and use a tongue
the distal end of the blade to displace
airway lying in the the tongue inferiorly,
hypopharynx. It may and advance the
help to pull the jaw airway into the
forward during oropharynx. No
passage. rotation is required
with this method.
NASOPHARYNGEAL AIRWAY INSERTION
For nasopharyngeal Generously

5 airways, a device of 6 lubricate the airway
correct size will prior to insertion.
extend from the tip
of the nose to the
earlobe.
Advance the airway Advance the airway

7 into the nostril and 8 fully until the flared
direct it along the external tip of the
floor of the nasal device is at the
passage in the nasal orifice.
direction of the
occiput. Do not
advance in a
cephalad direction!
Figure 3.5 Oropharyngeal and nasopharyngeal airway insertion.
30 minutes before nasotracheal intubation. Simply advance it face before insertion. An oropharyngeal airway of the correct
into the nostril and direct it along the floor of the nasal passage size will extend from the corner of the mouth to the tip of the
in the direction of the occiput, not cephalad (Fig. 3.5, step 7). earlobe (see Fig. 3.5, step 1); a nasopharyngeal airway of the
Advance it fully until the flared external tip of the airway is correct size will extend from the tip of the nose to the tip of
located at the nasal orifice (Fig. 3.5, step 8). the earlobe (see Fig. 3.5, step 5).
Both oropharyngeal and nasopharyngeal airways are available Both oropharyngeal and nasopharyngeal airways provide
in multiple sizes. To find the correct size of either device, airway patency similar to that achieved with the head-tilt/
estimate its size by measuring along the side of the patient’s chin-lift maneuver. The nasal airway is better tolerated by
semiconscious patients and is less likely to induce emesis in beneficial without documented hypoxia, and it is not recom-
those with an intact gag reflex. mended by current guidelines.66,67
Administer 100% O2 to patients with carbon monoxide
Complications poisoning. The half-life of carboxyhemoglobin is 4 to 5 hours
The nasopharyngeal airway may cause epistaxis and may be in a patient breathing room air but can be decreased to
dangerous in patients with significant facial and basilar skull approximately 1 hour by the administration of 100% O2 by
fractures. Semiconscious patients with nasopharyngeal airways non-rebreather face mask at atmospheric pressure.68
may deteriorate and require intubation, so they should be There are no contraindications to O2 therapy when a definite
monitored closely. indication exists. The risks associated with hypoxemia are grave
The oropharyngeal airway may induce vomiting when placed and undeniable. Never withhold oxygen therapy from a
in patients with an intact gag reflex. It may also cause airway hypoxemic patient for fear of complications or clinical deteriora-
obstruction if the tongue is pushed against the posterior tion. Carbon dioxide retention is not a contraindication to O2
pharyngeal wall during insertion. The oropharyngeal airway therapy. Rather, it demands that the clinician administer O2
should not be used as a definitive airway. carefully and recognize the potential for respiratory acidosis
and clinical deterioration. Although the mechanism for the
development of respiratory acidosis in patients with chronic
OXYGEN THERAPY obstructive pulmonary disease (COPD) who are administered
O2 is debated, its occurrence is not.69,70 Use caution when
Adequate O2 delivery depends on the inspired partial pressure administering supplemental O2 to hypoxic patients with arterial
of O2, alveolar ventilation, pulmonary gas exchange, oxygen- carbon dioxide pressure higher than 40 mm Hg, but do not
carrying capacity of blood, and cardiac output. The easiest withhold it.
factor to manipulate is the partial pressure of inspired O2,
which is accomplished by increasing the fraction of inspired Oxygen Administration During Cardiac Arrest
oxygen (FiO2) with supplemental O2.
and Neonatal Resuscitation
The AHA guidelines for cardiopulmonary resuscitation and
Indications and Contraindications emergency cardiovascular care address the potential harm of
Resuscitate all patients in cardiac or respiratory arrest with oxygen therapy and hyperoxemia following cardiac arrest and
100% O2. The most certain indication for supplemental O2 during neonatal resuscitation, and provide recommendations
is the presence of arterial hypoxemia, defined as an arterial for best use. Recommendations from the guidelines are sum-
oxygen partial pressure (PaO2) lower than 60 mm Hg or arterial marized in Box 3.1. Although it is still prudent to administer
oxygen saturation (SaO2) less than 90%.55 Normal individuals oxygen in the prehospital and ED setting, additional research
will begin to experience memory loss at a PaO2 of 45 mm Hg, may alter these recommendations. As a general guideline, fear
and loss of consciousness occurs at a PaO2 of 30 mm Hg.56–58 of oxygen toxicity should not prevent the use of O2 when there
Chronically hypoxemic patients can adapt and function with is an indication, but use the minimum concentration of O2
a PaO2 of 50 mm Hg or lower.59 necessary to achieve the therapeutic goals.
When tissue hypoxia is present or suspected, give O2
therapy.55,60 Shock states resulting from hemorrhage, vasodila-
tory states, low cardiac output, and obstructive lesions can all
Oxygen Delivery Devices
lead to tissue hypoxia and benefit from supplemental O2. A common misconception is that oxygen delivery devices can
Whatever the cause of the shock state, administration of O2 be cleanly separated into low-flow and high-flow categories.
is indicated until the situation can be thoroughly evaluated Almost any oxygen delivery device can be used across a wide
and cause-specific therapy instituted. It is reasonable to range of flow rates. In fact, it is the source oxygen flow rate,
administer O2 to hypotensive patients and those with severe not the device applied, that is the primary driver of the FiO2
trauma until tissue hypoxia can definitively be excluded.61 received by the patient.
Respiratory distress without documented arterial hypoxemia Delivery of oxygen at low-flow rates provides gas flow that
is a common indication for O2 administration, although no is less than the patient’s inspiratory flow rate. The difference
evidence exists to support this practice.61 Unless ET intubation is between the patient’s inspiratory flow and the flow delivered
planned, respiratory distress without hypoxemia should generally by the device is met by a variable amount of room air being
not be considered an indication for oxygen supplementation. drawn into the system. Patients with normal respiratory rates
Oxygen therapy is often recommended for acute myocardial and tidal volumes will require less outside air than those in
infarction, but there is no difference in outcomes between respiratory distress, and therefore patients not in respiratory
patients receiving O2 and those receiving room air after distress typically receive a higher FiO2 than patients in respira-
myocardial infarction.62 A randomized trial of room air versus tory distress, assuming equivalent supplemental oxygen flow
O2 supplementation for patients with acute ST-elevation rates. As a patient’s inspiratory flow changes, so will the FiO2
myocardial infarction demonstrated that patients who received that they receive from a low-flow device.71,72
O2 had larger infarction size, as assessed by peak myocardial Delivery of high-flow oxygen, with rates that match or
enzymes and cardiac magnetic resonance imaging at 6 months.63 exceed the inspiratory flow of the patient (generally >30 L/min),
The AHA recommends O2 in myocardial infarction only provides a significantly higher FiO2 than low-flow. High-flow
for patients with hypoxemia, signs of heart failure, shock, or oxygen can achieve FiO2 values of more than 90%.
respiratory distress.64,65 The prongs of a nasal cannula deliver a constant flow of
Although O2 is routinely administered to acute stroke O2 that accumulates in the nasopharynx and provides a reservoir
patients, there is no convincing evidence that this practice is of oxygen-enriched air for inspiration. The FiO2 delivered by
BOX 3.1 Recommendations for Oxygen Administration During Adult and Neonate Resuscitation:
Excerpts From the Guidelines of the American Heart Association
OXYGEN SUPPLEMENTATION DURING CARDIAC ARREST saturation is 94% to 99%. Avoiding hypoxia is more important
The goals of cardiopulmonary resuscitation are to restore energy than avoiding hyperoxia.
to the heart so it can resume normal function, and ensure
adequate energy supply to the brain during resuscitation. Oxygen ASSESSMENT OF OXYGEN NEED AND ADMINISTRATION OF
is vital to these goals, and during cardiac arrest blood flow is the OXYGEN IN THE NEONATE IMMEDIATELY AFTER BIRTH238,240
major limiting factor to adequate oxygen delivery to the heart Oxyhemoglobin saturation may normally remain in the 70% to
and brain. Thus, 100% FiO2 should be administered during 80% range for several minutes following birth, thus resulting in
cardiac arrest for adults, children, and neonates to maximize the appearance of cyanosis during that time. Clinical assessment
oxygen delivery to vital organs.139,143,238 of skin color is a very poor indicator of oxyhemoglobin saturation
during the immediate neonatal period and that lack of cyanosis
OVERVIEW OF POST–CARDIAC ARREST SUPPLEMENTAL OXYGEN appears to be a very poor indicator of the state of oxygenation of
FOR ADULTS AND CHILDREN143,239 an uncompromised baby following birth.
Although 100% oxygen may have been used during initial Optimal management of oxygen during neonatal resuscitation
resuscitation, providers should titrate inspired oxygen to the becomes particularly important because of the evidence that
lowest level required to achieve an arterial oxygen saturation either insufficient or excessive oxygenation can be harmful to the
of ≥94%, to avoid potential oxygen toxicity. It is recognized newborn infant. Hypoxia and ischemia are known to result in
that titration of inspired oxygen may not be possible injury to multiple organs. Conversely there is growing
immediately after out-of-hospital cardiac arrest until the experimental evidence, as well as evidence from studies of babies
patient is transported to the emergency department or, in the receiving resuscitation, that adverse outcomes may result from
case of in-hospital arrest, the intensive care unit. The optimal even brief exposure to excessive oxygen during and following
FiO2 during the immediate period after cardiac arrest is still resuscitation. Two metaanalyses of several randomized controlled
debated. The beneficial effect of high FiO2 on systemic oxygen trials comparing neonatal resuscitation initiated with room air
delivery should be balanced with the deleterious effect of versus 100% oxygen showed increased survival when resuscitation
generating oxygen-derived free radicals during the reperfusion was initiated with air.
phase. Animal data suggests that ventilations with 100% oxygen It is recommended that the goal in babies being resuscitated
(generating PaO2 >350 mm Hg at 15 to 60 minutes after return at birth, whether born at term or preterm, should be an oxygen
of spontaneous circulation [ROSC]) increase brain lipid saturation value in the interquartile range of preductal saturations
peroxidation, increase metabolic dysfunctions, increase measured in healthy term babies following vaginal birth at sea
neurologic degeneration, and worsen short-term functional level (see later). These targets may be achieved by initiating
outcome when compared with ventilation with room air or an resuscitation with air or blended oxygen and titrating the oxygen
inspired oxygen fraction titrated to a pulse oximeter reading concentration to achieve an SpO2 in the target range using pulse
between 94% and 96%. Data from human studies is mixed, oximetry. If the baby is bradycardic (heart rate <60 beats per
with no clear evidence of harm or benefit from hyperoxia. minute) after 90 seconds of resuscitation with a lower
There is no physiologic reason to expect that a PaO2 > concentration of oxygen, oxygen concentration should be
350 mm Hg is necessary or beneficial after cardiac arrest, and increased to 100% until recovery of a normal heart rate.
very well may be harmful.
Once the circulation is restored, it is reasonable to use the ASSESSMENT OF OXYGEN NEED AND ADMINISTRATION OF
highest available oxygen concentration until the oxyhemoglobin OXYGEN IN THE NEONATE
saturation or partial pressure of oxygen can be measured. As an
Targeted Preductal SpO2 After Birth
arterial oxyhemoglobin saturation of 100% may correspond to a
1 min 60–65%
PaO2 anywhere between ~80 mm Hg and 500 mm Hg, in general 2 min 65–70%
it is appropriate to wean FiO2 when saturation is 100%. If the 3 min 70–75%
oxyhemoglobin saturation is 100%, it is reasonable to reduce the 4 min 75–80%
oxygen supplementation, provided that the oxyhemoglobin 5 min 80–85%
saturation can be maintained at ≥94%. The goal oxyhemoglobin 10 min 85–95%
nasal cannulas is determined by many factors, including the that they should not smoke while oxygen is being delivered
respiratory rate, tidal volume, pharyngeal geometry, and O2 (Fig. 3.6).
flow. Most importantly, at a constant O2 flow rate, FiO2 varies Simple masks receive a constant flow of O2 from the O2
inversely with the respiratory rate.73 Despite this limitation, source and have multiple vent holes. During inspiration the
nasal cannulas are very comfortable for patients and are the oxygen-enriched air that has accumulated in the mask, along
most common O2 delivery device. They can be used with with room air entrained through the vent holes, is inhaled.
higher flow rates for brief periods of time, but are uncomfortable During expiration, 200 mL (the approximate volume of the
to use in this manner and cause nasal dryness and irritation. mask) of exhaled gas is deposited in the mask, with the rest
Nasal cannulas are generally set to 2 to 4 L/min, which provides exiting through the vent holes. The continuous flow of O2
approximately 30% to 35% FiO2.73 Although it may seem then partially washes out the mask before the next inspiration.
intuitive, patients using a nasal cannula should be reminded The mask itself provides the reservoir of oxygen-rich gas for
Figure 3.6 This patient suffered serious facial burns and potential
airway burns when she smoked a cigarette while oxygen was being
delivered through a nasal cannula.
Figure 3.7 A standard flow meter can measure flow up to 15 L/min,

but can usually achieve flow rates > 40 L/min when fully opened to
inhalation. A complex interplay between mask volume, tidal
“flush”; the maximum possible flow rate is usually marked on the flow
volume, respiratory rate, and O2 flow determines the FiO2 meter. Flow meters capable of precisely measuring flow up to 70 L/
delivered to the patient. At a flow rate of 10 L/min, FiO2 is min are commercially available, which allow the clinician to deliver
approximately 45% to 65% in healthy patients.74 Notably, if higher flow rates and thus higher FiO2.
the flow is increased to 30 L/min, FiO2 increases to 80% to
90%.74 FiO2 approximations at lower flow rates do not account
for a patient in respiratory distress; as minute ventilation and
inspiratory flow increase, FiO2 will invariably decrease. This
is also true for partial non-rebreather masks.
A partial non-rebreather mask incorporates a bag-type
reservoir to increase the amount of O2 available during inspira-
tion, thereby requiring less outside air to be entrained. Non-
rebreathing masks are similar to partial rebreathing masks but
have a series of one-way valves. One valve lies between the
mask and the reservoir and prevents exhaled gas from entering
the reservoir. Two valves in the side of the mask permit exhala-
tion while preventing the entry of outside air. In practice, one
of these valves is often removed to permit inhalation in the
event of interruption of flow of O2 to the mask. Though the
exhalation ports may limit rebreathing of expired gas, room Figure 3.8 The Venturi mask, also known as an air entrainment
air still leaks avidly around the poorly sealed edges of the mask mask, delivers a known oxygen concentration to patients requiring
if the patient’s inspiratory flow is greater than the set flow rate. controlled oxygen therapy. Venturi mask kits include multiple color-
This outside air and the exhaled gas remaining in the mask coded interchangeable oxygen dilution jets that are selected and placed
dilute the O2 from the reservoir and prevent the mask from in the base of the mask tubing to provide a specific FiO2. Marked on
providing 100% O2. Oxygen flow to the mask should be suf- each jet is the flow rate of wall oxygen required to deliver the specific
ficient to prevent collapse of the bag during inspiration. As FiO2 associated with that diluter. For example, a blue jet provides 24%
FiO2 when 2 L/min is delivered from the wall oxygen source. There
with all oxygen devices that do not seal perfectly to the patient’s
are stepwise increments, from the white jet providing 28% FiO2 at
face, the FiO2 delivered varies with the patient’s respiratory 4 L/min, up to the green jet providing 60% FiO2 at 15 L/min. (Photo
pattern. Many clinicians have the misconception that a non- courtesy Dr. Ronan O’Driscoll.)
rebreathing mask with a source oxygen flow rate of 15 L/min
can provide an FiO2 near 100%. In practice, a non-rebreathing
mask usually delivers an FiO2 of approximately 70% when set
at 15 L/min.75,76 FiO2 increases to 90% and higher when flow The Venturi mask is a titratable oxygen delivery device that
rates are set to 45 L/min.76 This technique is rarely used because is widely available, though it is used more frequently in the
most clinicians don’t realize that higher oxygen flow rates can inpatient and intensive care unit setting than in the ED (Fig.
be achieved by simply dialing a standard flow meter to “flush” 3.8). It is important to understand that although Venturi masks
(the highest rate possible) or replacing standard oxygen flow are often referred to as high flow systems they cannot provide
meters with flow meters capable of measuring flow up to 70 L/ FiO2 above 35%. The primary advantage of the Venturi mask
min, with flush capabilities of 90 L/min (Fig. 3.7). system is that FiO2 can be precisely controlled between 21%
and 35% for patients who may not tolerate a higher or imprecise mortality in the HFNC group.86 Though the results of this
FiO2. Room air is pulled into the system through entrainment trial are not necessarily generalizable to ED patients, it does
ports and mixes with the O2 provided from the O2 source. demonstrate that HFNC provides similar oxygenation support
The proportion of entrained air—and therefore FiO2—is for patients with severe hypoxemia as compared to NPPV.
constant and determined by the velocity of the O2 jet and the This makes HFNC a useful tool for patients who do not need
size of the entrainment ports. Because the total gas flow (O2 immediate tracheal intubation and may be susceptible to lung
plus air through the entrainment ports) meets or exceeds the injury from mechanical ventilator–induced barotrauma.
patient’s inspiratory flow rate, no additional entrainment of
air occurs around the mask, thereby minimizing changes in
FiO2 as the patient’s respiratory pattern changes.71,72 The mask
Procedure
is continuously flushed by the high flow of gas, which prevents In selecting the proper delivery device, consider the clinical
the accumulation of exhaled gas in the mask. Venturi masks condition of the patient and the amount of O2 needed. Venturi
are packaged with multiple inserts, each with a different size systems should generally be used for patients who need precise
orifice for O2 inflow. FiO2 is determined by selecting the control of FiO2, such as COPD patients with chronic respiratory
appropriate colored insert and O2 flow rate according to the acidosis. Nasal cannulas and face masks set at lower flow rates
manufacturer’s instructions. All Venturi mask settings and inserts are appropriate for patients who need supplemental O2 but
provide a total gas flow of 30 L/min, which matches the do not require precise control of FiO2. Patients with significant
inspiratory flow rate of a resting adult. However, a patient in hypoxemia, end-organ dysfunction, or respiratory distress
respiratory distress may have an inspiratory flow rate of 50 to require a higher FiO2 delivery system.
100 L/min.72 If the patient’s inspiratory flow rate exceeds the Frequent clinical assessment and blood oxygen saturation
total gas flow delivered by the mask, additional air will be (SpO2) monitoring are needed in all patients receiving O2
entrained around the mask, and inspired FiO2 will decrease. therapy. Equilibration of SaO2 after changes in supplemental
This is especially true with masks rated above 35% FiO2, which O2 occurs within 5 minutes.87 FiO2 should be titrated to achieve
generally can only provide high FiO2 if minimal room air is therapeutic goals while minimizing the risk for complications.
entrained around the edges of the mask. Caution should be An SaO2 of 90% to 95% (PaO2 ≈ 60–80 mm Hg) is an appropri-
used with masks rated above 35% in patients with respiratory ate target for most patients receiving supplemental O2.61
distress because FiO2 may be significantly reduced with high Increases above these levels do not add appreciably to the O2
inspiratory flow rates. content of blood and are unlikely to confer an additional benefit.
High-flow nasal cannula oxygen (HFNC) is the deliv- One may exceed these parameters in patients with shock and
ery of heated, humidified oxygen at high flow rates (up to end-organ dysfunction, but the added risk and small potential
approximately 60 L/min) through wide-bore nasal cannulas. benefit should be considered on an individual basis.
HFNC is hypothesized to deliver a higher FiO2 than face mask An initial FiO2 of 24% to 28% delivered by Venturi mask
oxygen because the nasopharynx acts as a natural reservoir that is indicated for patients with hypoxemia and chronic respiratory
refills with oxygen after each breath,77 though at high flow acidosis.61,69 Periodic blood gas analysis or capnography is
rates face mask oxygen probably also fills the nasopharynx. imperative for those at risk for respiratory acidosis.88–90 In
HFNC requires three components: wide-bore nasal prongs, a patients with COPD-associated hypercapnia, an SaO2 of 90%
humidifier, and a gas delivery device to control flow. Whereas (PaO2 ≈ 60 mm Hg) should be the goal of O2 therapy.88–90
HFNC requires additional equipment and a brief set-up for Mechanical ventilation should be considered when oxygenation
each patient, it delivers very high FiO2 and is better tolerated goals cannot be achieved without progressive respiratory
by patients than face mask oxygen and NPPV.76,78 At flow acidosis.
rates of 15 L/min FiO2 is 70% to 80%,79 and at flow rates of
45 L/min FiO2 is 90% or higher.76 These FiO2 values remain Preoxygenation Prior to
relatively constant, even when the patient’s mouth is open.77
Commercially available HFNC systems use flow rates of 5
Endotracheal Intubation
to 40 L/min and are capable of delivering an FiO2 of close to Preoxygenation prior to ET intubation is one of the most
100%. High-flow oxygen by nasal cannula is not well toler- important aspects of emergency airway management, and is a
ated unless it is humidified, so commercially available systems different concept than supplemental oxygenation. Whereas
(Vapotherm [Exeter, NH], Fisher and Paykel Nasal High Flow the goal of supplemental oxygenation is to maintain normox-
[Auckland, New Zealand], AquinOx [Smiths Medical, St. Paul, emia, the goal of preoxygenation is to replace all nitrogen in
MN) deliver oxygen with nearly 100% humidity. HFNC the lungs with oxygen, thereby creating a reservoir of oxygen
additionally provides low levels of positive airway pressure in available to the body during the intubation process. Preoxy-
the range of 1 cm H2O to 3 cm H2O, which increases as the genation and oxygen therapy during apnea are discussed fully
flow rate increases.76,80 HFNC devices are popular in neonatal in Chapter 4.
and pediatric intensive care units and are commonly used for
respiratory support after extubation and for management of
respiratory disease in neonates.81,82
Complications of Oxygen Therapy
HFNC has been demonstrated to increase tidal volumes Worsening of CO2 retention leading to progressive respiratory
and increase end-expiratory lung volumes after cardiac surgery,83 acidosis and obtundation in patients with COPD is the com-
and was associated with lower rates of escalation to more invasive plication most likely to be seen in the ED. This phenomenon
modes of ventilation in two ED studies.84,85 A landmark trial is well documented and was first described by Barach in 1937.91
that randomized patients with acute hypoxemic respiratory It has been attributed to several mechanisms, including loss
failure without hypercapnia to receive HFNC, face mask oxygen, of hypoxic respiratory drive, ventilation-perfusion (V̇ /Q̇ )
or NPPV found similar intubation rates but lower 90-day mismatch, and decreased hemoglobin affinity for CO2 (Haldane
effect). This avoidable complication is best prevented by management.1 Manually opening the airway, properly position-
administering O2 to chronic CO2 retainers only when there ing the head and neck, placing an oropharyngeal airway device,
is an indication, administering it at the smallest effective dose, and achieving a tight face mask seal are the keys to good BMV.
and carefully monitoring clinical, capnographic, and arterial
blood gas parameters.
Exposing the brain and lung to excessive concentrations of
Indications and Contraindications
O2 can lead to toxicity and, in severe cases, can cause acute BMV is the most common initial technique for ventilation of
respiratory distress syndrome (ARDS). Injury to the pulmonary apneic patients and for rescue ventilation after failed intuba-
parenchyma occurs as a result of the formation of reactive tion.1,2 Many authors note that BMV is relatively contraindicated
oxygen species. Oxygen toxicity is of special concern in pre- in patients with a full stomach, those in cardiac arrest, and
mature neonates, in whom prolonged hyperoxemia can lead those undergoing rapid-sequence intubation.2 These patients
to retinopathy. No data describe what concentration or duration have a high risk for stomach inflation and subsequent aspiration.
of exposure to O2 leads to toxicity, but presumably both these Unfortunately, these are the patients for whom ED providers
factors and individual patient characteristics determine the most commonly use BMV. In ED situations, the need for
likelihood of toxicity. The benefits of O2 therapy in the ED ventilation and oxygenation always takes priority over potential
usually outweigh the risk for O2 toxicity. Fear of toxicity should aspiration.2
not prevent the use of O2 when there is an indication but The only contraindication to attempting BMV is when
should encourage the clinician to use the minimum concentra- application of a face mask is impossible (Fig. 3.9). It is often
tion of O2 necessary to achieve therapeutic goals. High con- impossible to achieve an effective face mask seal on patients
centrations of O2 are well tolerated over short periods and with significant deforming facial trauma and those with thick
may be lifesaving. beards. An intermediate ventilation device, such as an LMA,
In patients receiving high concentrations of supplemental is a better choice for initial ventilation in such patients.
O2, nitrogen in the alveoli is largely replaced by O2. If this O2
is then absorbed into the blood faster than it can be replaced,
the volume of the alveoli will decrease and absorptive atelectasis
BMV Technique
can occur. Airway obstruction potentiates this problem by Achieving adequate ventilation with a bag-mask device requires
preventing the rapid replacement of absorbed gas. an open upper airway and a good mask seal. Overly aggressive
BMV causes stomach inflation and increases the risk for aspira-
tion. The goal is to achieve adequate gas exchange while keeping
BAG-MASK VENTILATION peak airway pressure low. Squeezing the bag forcefully creates
high peak airway pressure and is more likely to inflate the
BMV is the single most important technique for emergency stomach. Several studies have shown that increased tidal volume
airway management.1,11,92 Bag-mask devices are widely available is associated with higher peak airway pressure and increased
and are standard equipment in all patient care settings. Although gastric inflation.93–95 Decreased inspiratory time (faster bag
the bag-mask method of ventilation appears to be simple, it squeeze) increases peak airway pressure and gastric inflation.96,97
can be difficult to perform correctly. Good BMV skills are a Therefore the best method of BMV is to provide a tidal volume
prerequisite to more advanced methods of emergency airway of approximately 500 mL delivered over 1 to 1.5 seconds.97
Bag-Mask Ventilation
Initial ventilation technique in apneic patients
Rescue ventilation after failed intubation
Contraindications
Situations when application of a face mask is impossible
(e.g., deforming facial trauma, thick beards)
Bag ventilator with
Complications reservoir attached to
Inability to ventilate supplemental O2
Gastric inflation
Oropharyngeal
airway
Nasopharyngeal Mask
airway
Review Box 3.2 Bag-mask ventilation: indications, contraindications, complications, and equipment.
The best two-handed method is to hold the mask in place

with the thenar eminence of both hands (Fig. 3.10, step 5) and
use the long fingers under the angle of the mandible to perform
a jaw thrust, while also pressing the mask firmly against the
face (Fig. 3.10, step 6). This technique allows the operator to
perform a good jaw lift (create mandibular protrusion or an
“underbite”) and create a good mask seal with the strongest
muscles of the hands (Fig. 3.11).99,100 This method is best for
patients with difficult mask ventilation, and it also allows
inexperienced providers and those with small hands to do a
better job with face mask ventilation.100 In addition, it is
important to remember to use oropharyngeal or nasopharyngeal
airways (or both) whenever face mask ventilation is difficult.
All bag-mask devices should be attached to a supplemental
O2 source (with a flow rate of 15 L/min or higher) to avoid
hypoxia. A significant problem with the bag-mask method is
the low percentage of O2 achieved with some reservoirs. The
amount of O2 delivered is dependent on the ventilatory rate,
the volumes delivered during each breath, the O2 flow rate
into the ventilating bag, the filling time for reservoir bags, and
Figure 3.9 Large beards and facial trauma make it difficult or impossible the type of reservoir used. For adults, a bag-mask device should
to obtain a tight seal against the face for bag-mask ventilation. For have an inspiratory valve, a 1500-mL bag reservoir, and one-way
this patient, a laryngeal mask airway is probably the best first-line exhalation port to provide adequate oxygenation during use.75
oxygenation device. If the bag-mask system does not have a one-way exhalation
port, room air will be entrained and the FiO2 will be diluted
significantly.
Pediatric bag-mask devices should have a minimum volume
Using a ventilator (instead of a resuscitation bag) to provide of 450 mL. Pediatric and larger bags may be used to ventilate
the proper tidal volume and inspiratory time is an alternative infants with the proper mask size, but care must be maintained
to using a bag-valve device.98 Effective ventilation and oxy- to administer only the volume necessary to effectively ventilate
genation should be judged by chest rise, breath sounds, SpO2, the infant. Avoid pop-off valves because the airway pressure
and capnography. required for ventilation under emergency conditions can exceed
A variety of mask configurations are available to facilitate the pressure of the valve.101,102
a tight seal. The most common mask used in ED situations Previously it had been contended that mask ventilation could
is a transparent disposable plastic mask with a high-volume, be made more difficult after administration of paralytic agents.103
low-pressure cuff. This type of mask eliminates the need for However, many studies demonstrate that BMV after paralysis
an anatomically formed mask and can be used for a wide variety is generally easier and provides larger tidal volumes.104–108 It
of patients with different facial features. Various mask sizes is generally not necessary to test whether the patient can be
are available. successfully mask-ventilated before administration of paralytic
For a single rescuer, only one hand can be used to achieve agents, however it is prudent to assess for markers of difficult
the seal because the other must squeeze the bag. The rescuer BMV (see Complications later).
must apply pressure anteriorly while simultaneously lifting the BMV may be the best method of prehospital airway support
jaw forward. The thumb and index finger provide anterior in trauma patients and children. Murray and colleagues109
pressure while the fifth and fourth fingers lift the jaw. The performed a large retrospective study suggesting that patients
C-E clamp technique is often the most effective if an assistant with severe head injury had a higher risk for mortality if they
is not available: the thumb and index finger form a “C” to were intubated in the prehospital setting. In the same year,
provide anterior pressure over the mask, whereas the third, Gausche and colleagues110 reported that neurologic outcomes
fourth, and fifth fingers form an “E” to lift the jaw (Fig. 3.10, and ultimate survival rates after prehospital pediatric resuscita-
steps 1 and 2). Generally, well-fitting intact dentures should be tion with BMV by emergency medical service (EMS) providers
left in place to help ensure a better seal with the mask. were as good as those with tracheal intubation.
In the ED setting it is best to hold the face mask with two
hands and have an assistant squeeze the bag. If face mask
ventilation is difficult, the most experienced provider should
Complications
hold the face mask while the less experienced provider squeezes The main complications of BMV are gastric inflation and
the bag. inability to ventilate. Langeron and colleagues111 performed a
There are two different methods for two-handed face mask large prospective study of adults undergoing general anesthesia
control. The traditional technique is the double C-E method, and reported a 5% incidence of difficult mask ventilation. The
where the thumb and index finger of both hands encircle the incidence is obviously much higher in the emergency setting.
top of the mask (Fig. 3.10, step 3) and the third, fourth, and Risk factors for difficult BMV include presence of a beard,
fifth fingers of both hands form an “E” to lift both sides of severe facial trauma, obesity, lack of teeth, age older than 55
the mandible to meet the mask (Fig. 3.10, step 4). The problem years, history of snoring, short thyromental distance, limited
with the double C-E technique is that it is difficult to perform mandibular protrusion, and decreased pulmonary compliance
a good jaw thrust with the hands in this position. (severe asthma, COPD, ARDS, term pregnancy) (Box 3.2).111–114
Bag-Mask Ventilation
One-handed technique
The “C-E” clamp Use your third,
1 technique provides the 2 fourth, and fifth
most effective seal. fingers to lift the
mandible up into
Use your thumb and the mask. It may
index finger to form a be possible to
letter “C” and provide place the fifth
anterior pressure on finger behind the
the mask. mandible and
perform a jaw
thrust.
Two-handed technique
The traditional Use the third,
3 technique is the 4 fourth, and fifth
“double C-E” method. fingers of each
hand to lift both
Use the thumb and sides of the
index fingers of both mandible to meet
hands to encircle the the mask. It is
top of the mask. difficult to do a
good jaw lift with
this method.
A better two-handed Use the long fingers

5 method is to hold the 6 under the mandible
mask in place with to do a jaw lift
the thenar eminences while also pressing
of both hands. the mask firmly
against the face.
This allows the
operator to do a
good jaw lift and
create a good seal
with the strongest
muscles of the
hands.
Figure 3.10 Bag-mask ventilation. It is best to hold the face mask with two hands and have an
assistant squeeze the bag. If face mask ventilation is difficult, the most experienced provider should
hold the mask while the less experienced provider squeezes the bag.
BOX 3.2 Risk Factors for Difficult a good technique is used, some gastric distension will generally
occur. Minor gastric distention should not be considered
Mask Ventilation
substandard in the setting of prolonged BMV.
Presence of a beard History of snoring
Obesity Short thyromental distance Cricoid Pressure (Sellick Maneuver)
Lack of teeth Limited mandibular protrusion
Age older than 55 years In 1961, Sellick described the use of cricoid pressure to prevent
regurgitation during anesthesia, and this technique has since
become known as Sellick maneuver, though more properly
termed cricoid pressure.115 The purpose of this technique is
It may be best to paralyze patients who are not spontaneously to apply external force to the anterior cricoid ring to push the
breathing but still awake enough to interfere with BMV. trachea posteriorly and compress the esophagus against the
When mask ventilation is technically difficult, higher peak cervical vertebrae. In theory, cricoid pressure compresses
airway pressure is often required to provide adequate tidal the distensible upper esophagus but not the airway because
volume. In these situations, gastric inflation is more likely and the cricoid ring is fairly rigid.
aspiration may occur. Be vigilant to recognize complications There is no good evidence that cricoid pressure prevents
early and take corrective action. Even when BMV is easy and esophageal regurgitation,116,117 though it can prevent gastric
sible to ventilate and oxygenate with a face mask, especially

morbidly obese patients and those with large beards or sig-
nificant facial trauma. In the emergency setting, EGAs can
provide temporary rescue ventilation until tracheal intubation
or a surgical airway can be performed. It is important to have
at least one of these devices immediately available when manag-
ing emergency airways. EGAs can be divided into two groups,
LMAs and retroglottic devices.
Laryngeal Mask Airways

The LMA consists of a hollow shaft or airway tube connected
to an oval inflatable masklike cuff designed to sit in the
hypopharynx facing the glottis, with the tip at the esophageal
inlet. The cuffed mask is designed to form a seal around the
glottis when the device is placed properly. Some LMAs (LMA
Fastrach, Teleflex, Buckinghamshire, UK and LMA Proseal,
Figure 3.11 A good example of bag-mask ventilation using the preferred Teleflex) have handles that allow the operator to increase seal
two-handed technique. Using this method allows the strongest muscles pressure by lifting the entire device toward the ceiling (Review
of the hands to perform a jaw thrust, which pulls the face into the Box 3.3). The first LMA, the LMA Classic (Teleflex) became
mask to create a seal. available in 1988. Since then it has been used more than 200
million times and has been described in more than 2500
academic papers.136,140 LMAs are widely considered to be
essential adjuncts for rescue ventilation and difficult intuba-
inflation during BMV,115,116,118–121 thereby reducing the risk for tion,141 can be inserted in less than 30 seconds, and provide
subsequent regurgitation and vomiting. However, cricoid effective ventilation in more than 98% of patients.136 LMAs
pressure has been demonstrated to reduce tidal volumes, increase are primary rescue adjuncts in the difficult airway guidelines
peak inspiratory pressure, and prevent adequate air exchange put forth by the American Society of Anesthesiologists141 and
when applied during BMV.118,120–129 Cricoid pressure also the Difficult Airway Society in Europe.142 Advanced Cardiac
decreases successful insertion of and intubation through Life Support guidelines suggest that the LMA is a reasonable
LMAs.130–137 alternative to face mask ventilation.139 Pediatric Advanced Life
BMV can produce gastric inflation, especially if high volume Support guidelines acknowledge the LMA as a backup device
and high pressure are used. To avoid gastric inflation, ventilate for difficult pediatric airways.143 In anesthesia practice, LMAs
with a small volume (500 mL or 6 to 8 mL/kg) and avoid high are now used for a large percentage of cases in which an ET
peak pressure by using a long inspiratory time (1 second). In tube may have been used in the past.
addition, most airway experts recommend applying cricoid This chapter describes how to insert an intubating LMA
pressure during BMV to further decrease the risk for gastric (ILMA; LMA Fastrach, Teleflex) and use it for rescue ventila-
inflation.2,138 It should be noted that the routine use of cricoid tion. Intubation through the Fastrach is described in Chapter
pressure during BMV of patients in cardiac arrest is not recom- 4. The insertion and use of the nonintubating LMA Unique
mended by the AHA guidelines for cardiopulmonary resuscita- (Teleflex) (the disposable version of the LMA Classic) and
tion and emergency cardiovascular care.139 Cricoid pressure LMA Supreme (Teleflex) will also be described because they
should be released immediately if there is any difficulty ventilat- are cheap, disposable, well tested, and widely available.
ing with a face mask in an emergency setting.117 In addition,
it is reasonable to release or relax cricoid pressure during Indications
insertion of an LMA or if ventilation with the LMA is diffi- Both ILMAs and nonintubating LMAs can be used in the
cult.116,117,136 It may also be reasonable to release cricoid pressure “cannot-intubate/cannot-ventilate” scenario with high success
during laryngoscopy and tracheal intubation (discussed in rates, and are very useful when face mask ventilation is dif-
Chapter 4). ficult because of a beard, massive facial trauma, or obesity
Some authors believe that improper technique is to blame (Fig. 3.12).
for the many reported failures of cricoid pressure.116,139 The The ILMA should be the LMA of choice for emergency
proper technique for applying cricoid pressure is to place the use. In the cannot-intubate/cannot-ventilate scenario, adequate
thumb and middle finger on either side of the cricoid cartilage, ventilation with the ILMA is possible in nearly all cases, and
with the index finger in the center anteriorly.115 Apply 30 N is more successful than the LMA.5,136,144 In this scenario ventila-
(6.7 lb) of force to the cricoid cartilage in the posterior direction with the ILMA is probably superior to bag-mask ventila-
tion.116,138 As a reference, approximately 40 N of digital force tion.145 The ILMA can also be used as a primary ventilation
on the bridge of the nose will usually cause pain.116 and intubation device for patients with difficult airways,146 and
is a reasonable alternative to BMV for reoxygenation after a
failed tracheal intubation attempt. Tracheal intubation through
EXTRAGLOTTIC AIRWAY DEVICES the ILMA can be accomplished by using a blind technique,
with a lightwand, or under endoscopic guidance (see Chapter
EGAs are devices that are blindly placed above or posterior 4 for tracheal intubation through the ILMA). Studies of difficult
to the larynx to allow rapid ventilation and oxygenation. They airway management with the ILMA show that almost all patients
are good rescue devices for patients who are difficult or impos- can be adequately ventilated with the ILMA and 94% to 99%
Laryngeal Mask Airway Insertion

Failed rapid-sequence intubation
Difficult bag-mask ventilation
Difficult intubation
Facial trauma
Obesity
Primary airway in cardiac arrest or use by emergency medical services
Contraindications Intubating LMA

Limited mouth opening (<2 cm) (ILMA/”Fastrach”)
High airway pressure
Inadequate paralysis or sedation
Complications LMA unique

Inability to ventilate (rare)
Inability to intubate
Aspiration (rare) 60-mL syringe
Review Box 3.3 Laryngeal mask airways: indications, contraindications, complications, and equipment.
A B C D
Figure 3.12 A, This morbidly obese patient was found asystolic by the emergency medical service. She
could not be intubated in the field with multiple attempts and did not survive bag-mask resuscitation.
This patient is a candidate for a laryngeal mask airway (LMA). B–D, The LMA is inserted by
depressing the jaw, introduced, advanced, inflated, and attached to a resuscitation bag. Postmortem
ventilation with the LMA was very easy. In retrospect, the LMA device should have been the first
airway adjunct chosen by the emergency medical service (and in the emergency department), totally
bypassing attempts with other methods likely to fail.
can be intubated through the device.5,136,147–154 In addition, for the trachea, the ILMA can be used to counteract anterior neck
difficult airway management the ILMA is technically easier to pressure. In this capacity, the ILMA provides temporary ventila-
use than the LMA. In the emergency setting, where obtaining tion and stabilizes the cervical spine during the surgical airway
a definitive airway (i.e., tracheal intubation) is the eventual procedure.
goal, it is more practical to use an ILMA. In addition, the Newer LMAs (and some ILMAs) feature a channel posterior
LMA Fastrach (Teleflex) is the most widely used and well- to the airway that allows an orogastric tube to be placed into
studied ILMA and is easier to insert than the LMA Classic the stomach while the device is used for oxygenation and
(Teleflex).155–159 Finally, when the head is in the neutral position, ventilation. This is particularly useful in patients with gastric
the LMA Fastrach (Teleflex) is more likely to allow successful distension after BMV, or as a primary device (instead of BMV)
ventilation than the LMA Classic (Teleflex) during in-line in neonates, infants, and children, because they are especially
stabilization of the cervical spine.160–162 prone to gastric distension with face mask ventilation.
ILMAs are especially useful in patients with difficult bag- The LMA Classic (Teleflex) (or single-use LMA Unique,
mask ventilation caused by a beard, severe facial trauma, or Teleflex) is the most extensively tested LMA for children. It
obesity because none of these factors inhibit ILMA placement. may provide a more secure and reliable means of ventilation
When brisk bleeding above the glottis makes ventilation and than bag-mask ventilation.4 The LMA allows adequate ventila-
intubation difficult, the ILMA can reduce aspiration of blood tion in 98% of adults with known difficult airways and in 90%
and facilitate blind or fiberoptic intubation. In patients requiring to 95% of those with unexpectedly difficult airways.136,163–166
urgent cricothyrotomy or percutaneous needle insertion into It is also useful as a rescue device in difficult pediatric airways.136
Two descriptive studies and 86 case reports describe use of features a firm curved shape and a bite block handle, so ease
the LMA for difficult pediatric airways.136,167–173 In these reports, of insertion may be similar to that of the Fastrach (Teleflex),
ventilation was adequate with the LMA in nearly all pediatric and it is available in all sizes from neonate to large adult.193–202
patients.136,171,173,174 Case series and case reports also suggest However, it does not facilitate tracheal intubation. The LMA
that the LMA can provide an effective rescue airway during Protector (Teleflex) is an ILMA that has recently been released,
neonatal resuscitation if BMV and ET intubation fail.175 which is similar to the LMA Supreme (Teleflex) (with gastric
access) and will allow intubation using a flexible endoscope.
Contraindications
The ILMA and LMA are contraindicated in patients with less Procedure
than 2 cm of mouth opening because they require 2 cm of The insertion and use of the LMA Fastrach (Teleflex) and
space between the upper and the lower incisors to be inserted. LMA Classic (Teleflex) will be described. Because insertion of
Any LMA is relatively contraindicated in awake patients, all ILMAs and nonintubating LMAs follow similar steps, the
especially those with a full stomach, because insertion of an procedure for the LMA Fastrach (Teleflex) will be illustrative
LMA in an awake patient will cause coughing, gagging, or of steps for ILMAs and LMAs that have a rigid body or handle,
emesis. If an LMA is inserted when the patient is awake and and the LMA Classic (Teleflex) will be illustrative for ILMAs
the stomach is full, there is a high likelihood of emesis and and LMAs that are not rigid and do not utilize a handle.
aspiration. In the ED, an LMA should be used only if the
patient is unconscious or after a paralytic agent has been given. Intubating LMAs
Once an LMA is inserted and ventilation is established, the The first step is to select the appropriate size of ILMA, based
patient should not be allowed to wake up or gag. Consider on manufacturer’s recommendations. The Fastrach ILMA
giving a long-acting paralytic agent or multiple doses of (Teleflex) is available in three sizes: size 3 for children weighing
succinylcholine after an LMA is placed and ventilation is 30 kg to 50 kg, size 4 for small adults weighing 50 kg to 70 kg,
adequate. and size 5 for adults weighing 70 kg to 100 kg (Table 3.1).
Although several studies have shown that the ILMA is safe When there is doubt about which size is appropriate, it is
and effective for ventilation and intubation during in-line probably better to use the larger size.
cervical spine stabilization, some evidence shows that the ILMA After choosing the correct ILMA, completely deflate the
causes posterior pressure on the midportion of the cervical cuff while pushing it posteriorly so that it assumes a smooth
spine.150,176–179 The clinical importance of cervical spine pressure wedge shape without any wrinkles (Fig. 3.14, step 1). Place a
caused by the ILMA is unknown, and the device is generally small amount of water-based lubricant onto the posterior surface
considered safe in patients with an unstable cervical spine injury. of the ILMA just before insertion (Fig. 3.14, step 2). Open the
Providers should be aware of this concern and make every patient’s mouth and position the posterior mask tip so that it
effort to stabilize the ILMA in these situations. is flat against the hard palate, immediately posterior to the
upper incisors (Fig. 3.14, step 3). Advance the airway straight
Types of LMAs into the mouth along the hard palate without rotation until
Several manufacturers now make LMAs as the patent on the the curved part of the airway tube is in contact with the patient’s
LMA Classic (Teleflex) expired in 2003. It is important to chin. Then rotate the ILMA completely into the hypopharynx
recognize that all LMAs are not the same. by advancing it along its curved axis. Keep the posterior of
There are four popular ILMAs. The LMA Fastrach (Teleflex; the mask firmly applied to the soft palate and posterior pharynx
www.lmaco.com) has the most clinical use and research of all until firm resistance is felt (Fig. 3.14, step 4). Cricoid pressure
the ILMAs (Fig. 3.13A). Advantages include a handle that impedes proper placement of the ILMA, so briefly release
makes placement easier and allows the operator to lift up to
improve the seal against the laryngeal inlet if needed. There
is no gastric port to allow for gastric decompression. Blind
intubation rates are significantly higher with the LMA Fastrach TABLE 3.1 Laryngeal Mask Airway, Disposable
(Teleflex) compared to the Cookgas air-Q180 (CookGas LLC, Laryngeal Mask Airway, and Intubating Laryngeal Mask
St Louis, MO; www.cookgas.com); no adequate research has Airway Size Recommendations Based on Weighta
yet been performed comparing blind intubation rates to other
devices. The Air-Q intubating laryngeal airway (CookGas LLC) WEIGHT (kg) LMA DISPOSABLE LMA ILMA
has four different models and is popular with some clinicians <5 1 — —
(Fig. 3.13B). The i-Gel LMA (Intersurgical, Berkshire, UK;
www.i-gel.com) features a thermoplastic elastomer cuff that 5–10 1.5 — —
does not need inflation, so it may be easier to insert than other 10–20 2 — —
LMAs (Fig. 3.13C).181–190 A gastric channel is present to allow
for gastric decompression using an orogastric tube. The Ambu 20–30 2.5 — —
AuraGain (Ambu, Ballerup, Denmark; www.ambu.com) is a
30–50 3 3 3
newer ILMA with gastric access that seems promising, though
little research has been performed on this device to date 50–70 4 4 4
(Fig. 3.13D).
The nonintubating LMA Supreme (Teleflex) is the latest 70–100 5 5 5
offering from the Laryngeal Mask Company (Fig. 3.13E); it
>100 6 — —
has a new mask shape that may allow a better mask seal
compared to prior models191,192 (LMA Classic, Teleflex and a
Note that only a standard LMA is available for patients less than 30 kg.
LMA Unique, Teleflex) and a gastric evacuation channel. It ILMA, Intubating laryngeal mask airway; LMA, laryngeal mask airway.
A B C
D E
Figure 3.13 Popular intubating laryngeal mask airways (LMAs) and the LMA Supreme (Teleflex)
A, LMA Fastrach (Teleflex), which has a handle that makes insertion easier and allows the operator
to increase the seal pressure if needed, but has no gastric port. B, Air-Q (Cookgas LLC), which
has four variations (disposable, reusable, noninflatable cuff, and blocker with gastric port). C, I-gel
(Intersurgical), features a noninflatable cuff and gastric port. D, Ambu AuraGain (Ambu), features a
gastric port. E, LMA Supreme (Teleflex), a nonintubating LMA with a rigid shape to make insertion
easier and a gastric port.
cricoid pressure while the device is rotated into its final position, glottic opening allows optimal ventilation and facilitates tracheal
wedged into the proximal esophagus.133,134,203 After insertion, intubation. Before adjusting the ILMA, consider the patient’s
the airway tube should emerge from the mouth directed position and degree of relaxation because both may affect ILMA
somewhat caudally. Without holding the tube or handle, inflate function. The ILMA works best in the neutral or sniffing
the mask cuff (Fig. 3.14, step 5). The entire device will normally position; cervical extension may interfere with proper placement.
slide backward a bit when the cuff is inflated. Frequently, only The patient should not react to ILMA placement with coughing
half the maximum cuff volume is sufficient to obtain a good or gagging because this may interfere with proper placement.
mask seal. Do not overinflate the cuff because this may make Have a single operator perform the adjustment maneuvers by
the seal worse. See the instruction manual for maximum cuff gripping the ILMA handle with one hand, in a “frying-pan”
volumes. Attach a bag and ventilate the patient while using grip, and providing bag ventilation with the other hand. After
chest rise, breath sounds, and capnography to confirm adequate each adjustment maneuver, assess the quality of bag ventilation
gas exchange. If bagging is easy and ventilation is good, the and mask seal. Easy bag ventilation, good chest rise, and absence
aperture of the ILMA is probably aligned correctly over the of an audible mask leak are indications of good ILMA alignment
vocal cords. with the glottis (Fig. 3.14, step 6).
If optimal ILMA placement is not accomplished initially, To adjust the position of the ILMA, first gently pull the
adjusting maneuvers can be attempted. The purpose of adjusting handle toward you without rotation along the ILMA’s curvature.
maneuvers is to align the aperture of the ILMA with the glottic Next, gently push the handle toward the patient’s feet without
opening. Proper positioning of the ILMA aperture with the rotating it. Finally, try the Chandy maneuver, which consists
Intubating Laryngeal Mask Airway Insertion
1 Completely deflate 2 Place a small amount

the cuff while pushing of water-based
it posteriorly, so that it lubricant onto the
assumes a smooth posterior surface of
wedge shape without the ILMA just before
any wrinkles. insertion.
3 Place the head and neck in a slightly 4 Advance the ILMA

elevated position with minimal extension. straight into the mouth
Open the mouth widely and place the until the curved part
posterior surface of the device against the of the airway tube
hard palate, immediately posterior to the contacts the chin.
upper incisors. Then, rotate the ILMA
into the hypopharynx
until firm resistance is
felt. Release cricoid
pressure during this
step.
Let go of the handle Attach a bag and ventilate the

5 and inflate the cuff. 6 patient. Use chest rise, breath
Initially inflate the cuff sounds, and capnography to
with only half of the confirm adequate gas
maximum volume, exchange. If bagging is easy
and increase inflation and ventilation is good, the
as needed. Do not LMA is probably correctly
overinflate the cuff. aligned over the glottis.
(See product manual
for maximum
volumes.)
7 If adjustment is 8 Next, lift the handle

needed, try the upwards, toward the
Chandy Chandy maneuver. Chandy ceiling above the
Maneuver First, gently rotate Maneuver patient’s feet.
Step 1 the ILMA farther into Step 2
the hypopharynx. This manuever aligns
the mask with the
glottis and may
provide for better
ventilation.
9 If these manuevers 10 Next, slide the ILMA

fail, the epiglottis may back into position
be folded down over while pressing it
the glottis (asterisk). against the posterior
pharynx.
Perform the
“up-down” (Note, the cuff
manuever, by first should remain
rotating the ILMA out inflated during this
* of the hypopharynx maneuver.)
along its curvature
about 5–6 cm.
Figure 3.14 Intubating laryngeal mask airway (ILMA or “Fastrach”; Teleflex) insertion.
of gently rotating the ILMA farther into the hypopharynx and as with the index finger technique. Use the thumb to push the
then lifting the handle toward the ceiling above the patient’s LMA into the mouth along the palate and posterior pharynx.
feet (Fig. 3.14, steps 7 and 8). If these simple maneuvers do Hold the end of the airway tube with the other hand while
not result in adequate ventilation, consider the “up-down removing your thumb from the patient’s mouth.
maneuver” (Fig. 3.14, steps 9 and 10). This technique is used After the LMA is fully inserted, let go of the proximal end
to correct downfolding of the epiglottis, which is common of the airway tube and inflate the cuff enough to achieve a
with insertion of the ILMA and may interfere with ventilation good seal over the glottis (Fig. 3.15, step 7). This may require
or intubation. The up-down maneuver is accomplished by only half the maximum cuff volume. Be careful to not overinflate
rotating the ILMA out of the hypopharynx along its curvature the LMA cuff (see the product packaging for maximal cuff
approximately 5 cm to 6 cm while the cuff remains inflated, volumes). Attach a bag and ventilate the patient, with chest
and then sliding it back into position while pressing it against rise, breath sounds, and capnography used to confirm adequate
the posterior pharynx. Do not use excessive force when placing gas exchange (Fig. 3.15, step 8). If bagging is easy and ventilation
or adjusting the ILMA. is good, the aperture of the LMA is probably aligned correctly
If adjusting maneuvers do not result in adequate ventilation, over the glottic opening. Proper positioning of the LMA
it is likely that the wrong size ILMA has been used. Incorrect aperture with the glottic opening allows optimal ventilation.
ILMA size is more likely to be a problem if the device is too Several tips or techniques should be considered if LMA
small; attempting insertion of a larger ILMA is a reasonable ventilation is inadequate. The best way to ensure proper
first approach. If another ILMA size is not available, external ventilation is to optimize the insertion technique by carefully
anterior neck manipulation or downward pressure may bring following the aforementioned directions. Position the patient’s
the glottis and ILMA cuff into proper alignment. If the size head and neck properly and ensure that the patient is deeply
of the ILMA is not in question, consider completely removing anesthetized or paralyzed. Listen for an audible cuff leak to
and carefully reinserting the device (see Chapter 4 for intubation make sure that a good mask seal has been achieved. Adjust the
through the ILMA and ILMA removal). cuff volume if necessary to improve the mask seal and ensure
optimal ventilation. Simply adding more air to the cuff will
Nonintubating LMAs not necessarily improve the seal of the mask with the glottis.
The following steps describe the use of the LMA Classic Cuff overinflation may cause a leak, but deflation and reposition-
(Teleflex) (or single-use LMA Unique, Teleflex), though these ing may improve the seal.
instructions will be similar for other LMAs that do not have Sometimes adjusting the patient’s head and neck position
a handle similar to the LMA Fastrach (Teleflex) or LMA is easier than trying to change the position of the LMA. Move
Supreme (Teleflex). the patient into a better sniffing position or into the chin-to-
The first step is to select the appropriate size LMA. The chest position to see whether this improves the LMA cuff seal.
LMA is available in a wide range of sizes, from size 1 for If these positions do not help or are not possible, try a jaw-thrust
neonates weighing less than 5 kg to size 6 for adults weighing or a chin-lift maneuver. Apply anterior neck pressure to help
more than 100 kg. The disposable version is available in sizes manipulate the glottis into improved contact with the LMA
1 through 5, but not size 6. After selecting the proper size, mask. This technique can be used in combination with any of
completely deflate the LMA cuff while pushing it posteriorly the maneuvers just discussed.
so that it forms a smooth wedge shape without any wrinkles If mask seal and ventilation are still not optimal after simple
(Fig. 3.15, step 1). Place a small amount of water-based lubricant repositioning maneuvers, withdraw, advance, or rotate the LMA
onto the posterior surface of the LMA just before insertion cuff. Another alternative is to completely remove and reinsert
(Fig. 3.15, step 2). The best patient position for insertion of the LMA while paying careful attention to the details just
the LMA is the sniffing position, with the neck flexed and the described. If unsuccessful, change the size of the LMA. A
head extended. The LMA may be inserted via two different larger LMA will usually improve ventilation even if it is more
techniques, depending on access to the patient. The most difficult to insert. It is much more common to need to increase
common method is the index finger insertion technique. This the LMA size than to decrease it. Finally, consider using the
is accomplished by holding the LMA like a pen, with the index ILMA, placing a King LT, or performing a surgical airway
finger at the junction of the airway tube and the cuff (Fig. when ventilation with the LMA is not adequate.
3.15, step 3). Have an assistant open the patient’s mouth and
insert the LMA with the posterior tip pressed against the hard Aftercare
palate just behind the upper incisors (Fig. 3.15, step 4). Under If the LMA or ILMA will remain in place without tracheal
direct vision, use the index finger to slide the LMA along the intubation, either one can be secured like an ET tube. Removal
hard palate and into the oropharynx (Fig. 3.15, step 5). As of the ILMA after tracheal intubation is easy, but more difficult
the LMA is inserted farther, extend the index finger and push than insertion of the device (see Chapter 4).
the posterior cuff along the soft palate and posterior pharynx.
Exert counterpressure on the back of the patient’s head during Complications
insertion. Continue to push the LMA into the hypopharynx The most important complications associated with using the
until resistance is felt. Use the other hand to hold the proximal LMA are aspiration of gastric contents and hypoxia. The LMA
end of the LMA tube while removing your index finger from does not protect against aspiration and may actually cause
the patient’s mouth (Fig. 3.15, step 6). vomiting if the patient gags during placement of the device.
An alternative method is the thumb insertion technique. In fasted anesthetized patients, the incidence of aspiration is
Use this technique when you have limited access to the patient very low, approximately 2 per 10,000 cases.136 There are many
from behind (see www.lmana.com for details). Hold the LMA descriptive studies and case reports of the use of an LMA for
with your thumb at the junction of the cuff and the airway difficult airways with no mention of significant aspiration.136
tube. Place the mask against the hard palate under direct vision, Although the risk for aspiration is surely higher than 2 per
Laryngeal Mask Airway Insertion
1 2
After selecting the Place a small amount
appropriate size LMA, of water-soluble
completely deflate the lubricant onto the
cuff while pushing it posterior surface of
posteriorly so that it the LMA just before
forms a smooth insertion.
wedge shape without
any wrinkles.
Hold the LMA like a Insert the LMA with

pen, with the index 4 the posterior tip
3 finger at the junction pressed against the
of the airway tube hard palate and into
and the cuff. the oropharynx.
5 Advance the LMA 6 When resistance is

further by extending felt, carefully remove
the index finger and the index finger
pushing the posterior while holding the
cuff along the soft proximal end of the
palate and posterior tube with the other
pharynx. Exert hand.
counterpressure on
the occiput during
insertion.
7 Let go of the airway 8 Attach a bag and

tube and inflate the ventilate while using
cuff with enough air chest rise, breath
to achieve a good sounds, and
seal. This may capnography to
require only half of confirm adequate
the maximum cuff gas exchange.
volume. Do not
overinflate the cuff!
Figure 3.15 Laryngeal mask airway (LMA) insertion. The LMA Unique (Teleflex) is shown in this
sequence.
10,000 when using the LMA in the ED, there is evidence that that functions similar to the esophageal-tracheal Combitube
it provides some protection from passive regurgitation and (see later). Like the Combitube, the LT is designed to isolate
produces less gastric inflation than BMV does.204 the glottic opening between an oropharyngeal cuff and an
esophageal cuff (Review Box 3.4). Unlike the Combitube, the
King LT has only one airway lumen and a simplified cuff
Retroglottic Airway Devices system, so both cuffs can be inflated from a single port. The
King LT literature regarding the King LT is confusing because many
The King LT (King Airway-LTS-D EMS, King Systems, versions of the device have been clinically tested during the
Noblesville, IN; www.kingsystems.com) is a retroglottic device last decade. The latest disposable versions are the LT-D and
Retroglottic Airway Devices

Primary airway in the emergency medical services setting
Distal
Primary airway in cardiac arrest
lumen
Failed rapid-sequence intubation
Difficult bag-mask ventilation Single pilot Proximal
balloon lumen
Difficult intubation
Facial trauma
Obesity
Contraindications
Limited mouth opening
High airway pressure Proximal
Inadequate paralysis or sedation Ventilation cuff
holes Ventilation
Complications Oropharyngeal holes Distal
Inability to ventilate cuff cuff
Aspiration (rare) Esophageal
cuff Gastric
Specifically for the King LT device: suction port
Tracheal placement
The King LTS-D (left) and the Combitube (right).
Tongue edema
Review Box 3.4 Retroglottic airway devices: indications, contraindications, complications, and equipment.
the LTS-D. The LTS-D has an 18-Fr gastric suction port at the uncontrolled prehospital environment. The King LT can
the tip. The modern LTS-D has been available since 2004 and be used in any emergency airway setting for rescue ventila-
is also called the LTS II in some literature.205,206 tion after failed BMV or failed intubation. In cases of failed
The King LT is designed for blind placement and has a intubation with an unexpectedly difficult airway, the King
large proximal cuff and small distal cuff. Unlike the Com- LT may be used to provide adequate ventilation and allow
bitube, the tip of the King LT is designed to be placed in time for other methods of intubation or a controlled surgical
the esophagus only. The shape of the King LT and the size airway.207,218,219
of the tip in previous versions made it unlikely to be placed Because the King LT is a supraglottic airway and is designed
into the trachea.207 However, the latest design of the LTS-D to be placed blindly, it is relatively contraindicated in patients
has a narrower tip and in one study had a 10% incidence of with obstruction of the upper airway by a foreign body, and
tracheal placement.208 Interestingly, most patients with tracheal should not be used in patients with an intact gag reflex.
placement of the LTS-D were still able to be adequately
ventilated.208 Placement of the King LT
Popularity of the LTS-D has grown rapidly in EMS systems, The first step is to choose the proper size King LT. The LTS-D
and it is now widely used by EMS agencies in the United is available only in adolescent and adult sizes in the United
States. Several studies have shown that the LTS-D has a high States. Size 3 is yellow and designed for patients 4 to 5 feet
rate of successful ventilation in the operating room setting.209–211 in height, size 4 is red and designed for patients 5 to 6 feet in
In addition, there are several case reports of the LT being used height, and size 5 is purple and designed for patients taller
as a rescue device for the cannot-intubate/cannot-ventilate than 6 feet. Several pediatric sizes are available in Europe, but
scenario and when placement of an LMA failed.212,213 Some not in the United States. The smallest LT-D available in the
data suggest that the LTS-D may be useful in neonates and United States can be placed in patients weighing as little as
small infants when direct laryngoscopy fails,214 though the 12 kg (approximately 18 months old).
smallest LT-D currently available in the United States is size After determining the appropriate size King LT, check the
2 (patients 12 kg to 25 kg), and the smallest LTS-D is size 3 cuffs and then completely deflate them before placement.
(patients 4 to 5 feet tall). In the EMS setting, the LT-D has a Lubricate the device with a water-based lubricant. The best
high success rate (95%) when used for ventilation of out-of- patient position for insertion of the King LT is the sniffing
hospital cardiac arrest.215 One study found a higher first-attempt position, but it can be placed with the head in the neutral
success rate for paramedics using the King LT in cardiac arrest position if necessary. Hold the LT at the connector with the
compared to ET intubation.216 In addition, Frascone and dominant hand and hold the mouth open by grasping the chin
colleagues found that the rate of successful insertion and with the nondominant hand. Introduce the tip of the device
ventilation with the LTS-D is essentially equivalent to that of into the corner of the mouth while rotating the tube 45 to 90
standard ET intubation in the hands of paramedics.217 degrees so that the blue orientation line on the tube is touching
the corner of the mouth. Pass the tip of the device into the
Indications and Contraindications mouth and under the tongue. As the tip passes under the base
In the ED, the King LT is a good choice as a primary airway in of the tongue, rotate the tube back to the midline so that the
patients who are unresponsive or in cardiac arrest, especially in blue orientation line faces the ceiling. Without exerting force,
Proximal
cuff at base
Distal cuff of tongue
in proximal
esophagus
Figure 3.16 King LTS-D. The device is properly placed posterior to

the larynx, with the distal end in the proximal esophagus. The distal
cuff is inflated in the proximal esophagus and the larger proximal
Figure 3.17 Massive neck, periorbital, and facial edema following
cuff is inflated at the base of the tongue. The proximal portion of
cardiopulmonary resuscitation with a King LT airway in place. The
the tube is at the lip line and the distal aperture (between the cuffs)
exact pathology was not determined but was thought to be a pharyngeal
is aligned with the glottic opening; oxygen flow from the device to
or esophageal perforation.
the glottis is depicted by the white arrows.
advance the King LT until the connector is aligned with the The Combitube (Fig. 3.18) has two parallel lumens, a small
teeth. Inflate the cuffs with the minimum volume necessary distal cuff, and a large proximal cuff. When it is placed blindly
to create a good seal (see the product brochure for maximum the tip will end up in the esophagus in approximately 95% of
cuff volumes). While ventilating with a bag-valve system, gently cases and in the trachea in approximately 5%. The longer
withdraw the King LT until ventilation becomes easy and free lumen or tube is used for ventilation when the tip is in the
flowing. Confirm placement with chest rise, breath sounds, esophagus. It is perforated at the level of the pharynx and
and capnography (Fig. 3.16). occluded at the distal end. The shorter lumen or tube is used
for ventilation when the tip is in the trachea. It is open at the
Complications distal end, like a standard ET tube. The large proximal cuff
It is hard to assess the complication rate of the King LT because or balloon is designed to occlude the pharynx by filling the
the device has been modified several times in the last decade space between the base of the tongue and the soft palate. The
and there is no organized surveillance of out-of-hospital airway small distal cuff serves as a seal in either the esophagus or
devices.220 The current LT-D and LTS-D devices have been the trachea.226–231
available since 2004. The LTS-D is referred to as the LTS II The Combitube provides adequate ventilation in approxi-
in some studies. The most serious complication is tracheal mately 95% of patients when placed by prehospital provid-
placement, which occurred in 10% of cases in one study and ers,226,230,231 and in nearly 100% of patients when placed by
is probably significantly underappreciated and underreported.208 physicians.232 It compares favorably with the ET tube with
Another complication that is not uncommon and certainly respect to ventilation and oxygenation in cardiac arrest situa-
underreported is tongue edema. There is one case report of tions.224,229 In unconscious patients, the Combitube may provide
massive tongue edema occurring 3 hours after placement of protection from aspiration.233
the King LT,221 and mild tongue edema is relatively common Indications and contraindications for the Combitube are
and not reported in the literature. Fig. 3.17 depicts probable similar to the King LT airway. Because the King is easier to
pharyngeal or esophageal perforation, with massive subcutane- use and proven to be an effective and reliable primary and
ous neck and face emphysema following prehospital placement rescue airway device, the Combitube is used less frequently
of a King LT. Because an autopsy was denied, the exact injury than previously.
was never confirmed and may have been related to other
interventions during resuscitation. Placement of the Combitube
There is some concern that the large oropharyngeal balloon The Combitube is available in two sizes. The manufacturer
of the King LT might compress the carotid arteries and be recommends the smaller 37-Fr device for patients from 4 feet
detrimental in patients undergoing CPR, but currently this is to 5 feet 6 inches tall and the larger 41-Fr device for patients
only suggested in animal models222; no high-quality human taller than 5 feet 6 inches. Studies suggest that the smaller
research has been conducted to date, though one small study 37-Fr Combitube can be used safely in patients up to approxi-
that reviewed computed tomography scans of the neck for 17 mately 6 feet tall.234,235 The larger 41-Fr device is appropriate
patients with EGAs in place found no evidence of mechanical for patients taller than 6 feet.
compression of the carotid arteries on image review.223 To insert the Combitube, hold the device in the dominant
hand and gently advance it caudally into the pharynx while
Combitube and EasyTube grasping the tongue and jaw between the thumb and index
The esophageal-tracheal Combitube (Nellcor, Pleasanton, CA; finger of the nondominant hand. Pass the tube blindly along
www.nellcor.com) is a retroglottic airway device designed as the tongue to a depth that places the printed rings on the
a rescue device for difficult and emergency airways and can proximal end of the tube between the patient’s teeth and the
be placed blindly and rapidly.224,225 alveolar ridge.236 If resistance is met in the hypopharynx, remove
Ventilation bag
Ventilation bag attached to shorter
attached to longer (white) airway tube
(blue) airway tube
Tip is in Tip is in
esophagus trachea
A B
Figure 3.18 Combitube. A, Approximately 95% of placements are esophageal, so begin ventilation
through the longer (blue) airway tube. Use chest rise, breath sounds, and capnography to assess for
proper placement. When the distal tip is in the esophagus, ventilation occurs through the vent holes
between the distal and proximal cuffs (white arrows). B, If the tip of the Combitube is in the trachea,
ventilation cannot be accomplished via the long (blue) airway tube. It is essential to recognize this
quickly, and use the short (white) tube for ventilations.
the tube and bend it between the balloons for several seconds common placement error is an improper insertion angle. Use
to facilitate insertion.236 After insertion, fill the pharyngeal a more caudal, longitudinal direction of insertion as opposed
balloon with 100 mL of air and the distal cuff with 10 mL to to an anteroposterior direction of insertion. The Combitube
15 mL of air. The large pharyngeal balloon serves to securely must also be maintained in the true midline position during
seat the Combitube in the oropharynx and creates a closed insertion to avoid blind pockets in the supraglottic area, which
system in the case of esophageal placement. Because approxi- can prevent passage of the tube.231
mately 95% of placements are esophageal, begin ventilation
through the longer (blue) airway tube.231
Use chest rise, good breath sounds, and capnography, without CONCLUSION
gastric inflation, to confirm proper ventilation. Alternatively,
use a Wee-type aspirator device on the shorter (clear) lumen Good basic airway skills and the familiarity with and availability
to confirm that the tip is in the esophagus before ventilation of proven rescue devices are the keys to emergency airway
through the longer (blue) lumen.237 Inability to easily aspirate management. There are many techniques and devices that can
air confirms esophageal placement. Easy aspiration with the be used to manage emergency airways. In difficult situations,
Wee-type device indicates tracheal positioning of the tube and providers will probably have the best success when basic skills
requires changing the ventilation to the shorter (clear) tracheal are performed excellently.
lumen.
REFERENCES ARE AVAILABLE AT www.expertconsult.com.
Complications
Inappropriate balloon inflation and incorrect Combitube
placement can lead to air leaks during ventilation. The most
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S E C T I O N I I

emesis and aspiration limit the use of some techniques, such

BASIC AIRWAY MANAGEMENT TECHNIQUES

B asic airway procedures are often overlooked in favor of

Manual Airway Maneuvers

The technique of subdiaphragmatic abdominal thrusts to

Figure 3.3 A-E, Heimlich maneuvers (see text).

and aggressive positive pressure ventilation has failed, practi-

Oropharyngeal and Nasopharyngeal Airways

Oropharyngeal Airway Insertion

For oropharyngeal Open the patient’s

When the airway is Alternatively, open

NASOPHARYNGEAL AIRWAY INSERTION

For nasopharyngeal Generously

Advance the airway Advance the airway

Figure 3.5 Oropharyngeal and nasopharyngeal airway insertion.

Figure 3.7 A standard flow meter can measure flow up to 15 L/min,

The best two-handed method is to hold the mask in place

A better two-handed Use the long fingers

sible to ventilate and oxygenate with a face mask, especially

Laryngeal Mask Airways

Laryngeal Mask Airway Insertion

Contraindications Intubating LMA

Complications LMA unique

Intubating Laryngeal Mask Airway Insertion

1 Completely deflate 2 Place a small amount

3 Place the head and neck in a slightly 4 Advance the ILMA

Let go of the handle Attach a bag and ventilate the

7 If adjustment is 8 Next, lift the handle

9 If these manuevers 10 Next, slide the ILMA

Laryngeal Mask Airway Insertion

Hold the LMA like a Insert the LMA with

5 Advance the LMA 6 When resistance is

7 Let go of the airway 8 Attach a bag and

Retroglottic Airway Devices

Figure 3.16 King LTS-D. The device is properly placed posterior to

REFERENCES 24. Kobayashi M, Ayuse T, Hoshino Y, et al: Effect of head elevation on

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