The goals of emergency airway management are maintaining airway patency, assuring oxygenation and ventilation, and preventing aspiration. Tracheal intubation can achieve these goals. Sedation or paralysis after intubation can facilitate diagnostic testing. Extraglottic devices are discussed in detail in the chapter 28, "Noninvasive Airway Management."
Rapid-sequence intubation (RSI) is the sequential administration of an induction agent and neuromuscular blocking agent to facilitate endotracheal intubation. It is the method of choice for emergency airway management.1 RSI allows the highest intubation success rate in properly selected emergency airway cases and is superior to sedation alone. Not all patients targeted for intubation are best managed with RSI; patients deeply comatose and those in cardiac or respiratory arrest will not likely have a response to laryngoscopy and may be intubated without pharmacologic assistance.
Whenever performing endotracheal intubation, anticipate airway difficulties and be facile with alternative airway techniques: bag-mask ventilation, rescue airway devices, and surgical access to the airway.2 In addition, if bag-mask ventilation or rescue device deployment is not likely to succeed or if anatomic alterations exist that will not improve with RSI (edema, mass, bony disruption), do not extinguish intrinsic airway protection and respirations with paralysis.
Develop and discuss an intubation plan, and communicate responsibilities of the care team. Make sure medications are prepared. Have equipment for the difficult or failed airway available. Review proper patient positioning. Discuss the plan for postintubation hypoxia, hypotension, sedation, and ventilation. The use of a checklist may facilitate decision making and error prevention.3
Clinical assessment, pulse oximetry, capnography, and the expected course of the patient all collectively guide decisions regarding the need for tracheal intubation. See the "Difficult Airway" section below for detailed discussion of airway assessment.
Table 29-1 lists all equipment needed at the bedside before beginning intubation.
TABLE 29-1Equipment Needed for Airway Management |Favorite Table|Download (.pdf) TABLE 29-1 Equipment Needed for Airway Management
Oxygen source and tubing
Mask with valve, various sizes and shapes
Oropharyngeal airways—small, medium, large
Nasopharyngeal airways—small, medium, large
Carbon dioxide detector
Endotracheal tubes—various sizes
Laryngoscope blades and handles
Intubating stylet (gum elastic bougie)
Water-soluble lubricant or anesthetic jelly
Alternative or rescue devices: video laryngoscopes, laryngeal mask airway, intubating laryngeal mask airway, Combitube® (Sheridan Catheter Corp., Argyle, NY), King LT® (King Systems, Noblesville, IN)
Surgical cricothyroidotomy kit
Medications for topical airway anesthesia, sedation, and rapid-sequence intubation
Rescue devices and a surgical airway option ideally are placed in a designated difficult airway cart in the ED and include pediatric sizes (see chapter 111, "Intubation and Ventilation in Infants and Children".)