Airway assessment and management is one of the most critical interventions that emergency physicians perform. Intubation is not always necessary, however, and rushing into invasive airway management before initial resuscitation can be problematic.
Perform a rapid clinical airway assessment which includes noting the patient's level of responsiveness, skin color, respiratory rate, and depth of respirations. Obtain oxygen saturation and capnography unless the patient is in impending or actual cardiac arrest. The goal is to determine if the patient is maintaining and protecting their airway and meeting critical oxygenation and ventilation goals. Nothing should be placed in the pharynx to assess gag reflex. Emergent and immediate decisions on airway management may proceed before obtaining blood gases and x-rays.
IMPENDING/ACTUAL CARDIAC ARREST
Open the airway and initiate low-volume ventilation unless following cardiocerebral resuscitation protocols. The primary focus of initial cardiopulmonary resuscitation is on establishing quality chest compressions and evaluating for a shockable rhythm. Once these priorities are addressed, the airway can be further managed with an extraglottic device or endotracheal intubation.
Position patient to open the airway, drain secretions and maximize oxygenation and ventilation, while maintaining cervical stabilization precautions if indicated. Place conscious patients in a sitting position, if possible, and unconscious patients on their side unless they require urgent invasive procedures. Patients who are unable to maintain an open airway should have one or two properly sized nasal trumpets placed if they are not anticoagulated or at risk for mid-face fractures; an oral airway may be used instead of, or in addition to, the nasal airways if no gag reflex present. Provide supplemental oxygen if the room air saturation is below 94% with the goal of increasing saturation to above 94%; high flow oxygen should be avoided when possible.
NONINVASIVE POSITIVE PRESSURE VENTILATION
If ventilation is adequate but oxygenation is poor, consider immediate initiation of noninvasive ventilation. Noninvasive positive pressure ventilation (NIPPV) may be used as a temporizing measure while other treatments are initiated (e.g., nitrates in acute cardiogenic pulmonary edema), for pre-oxygenation prior to intubation in any medical condition, or as an alternative to invasive airway management in some cases, such as in patients with DNR or DNI status. NIPPV for emergency situations is commonly delivered via a full-face mask using either continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) using a ventilator, stand-alone reusable device, or a disposable device (CPAP only). CPAP provides the same amount of pressure support during inspiration and positive end-expiratory pressure (PEEP) during exhalation—usually 5 to 10 mmHg—while BPAP allows for increasing pressure support up to 15 mm Hg without overwhelming the patient with expiratory resistance, which may remain at 5 to 10 mm Hg. There are no studies showing a significant advantage to one system over another.