Procedure Manual

Airway Procedures

Basic Airway Adjuncts

Bag-Valve-Mask (BVM):


  • Assisted ventilation for both adults and pediatric patients.


  • Create a good seal between mask and the patients face by using one or two person technique
  • Assure the mask is properly sized for the patient's face

Oropharyngeal Airway (OPA) and Nasopharyngeal Airway (NPA)


  • Assist in maintaining an open airway in patients with inadequate breathing
  • OPA is indicated only in patients with no gag reflex
  • NPA can be used in patients with an intact gag reflex or clenched jaw

Technique (OPA):

  • Choose the correct size OPA by measuring “lip to lobe”.
  • In an adult, insert the OPA upside down until resistance is met, then rotate 180 ° and advance until flange is at the lips
  • For pediatric patients use a tongue depressor to guide the OPA into position right side up

Technique (NPA):

  • Choose the proper size by measuring from nose to lobe
  • Lubricate the NPA and insert into the nostril while pushing the tip of the nose upward.
  • Gently advance until the flange rests against the nostril.
  • Contraindicated if suspected facial fractures or suspected basilar skull fractures (raccoon eyes, battle signs, blood from ear canal)


  • Regurgitation and aspiration of gastric contents

Endotracheal Intubation


  • Respiratory or cardiac arrest
  • Inadequate ventilation with bag valve mask
  • Impending respiratory failure or apnea
  • Hypoxia unresponsive to 100% oxygen, and any of the following:
    • Respiratory rate < 8 breaths per minute
    • Poor ventilatory effort (with hypoxia unresponsive to 100% oxygen)
    • Inability to maintain patent airway
    • Airway obstruction


  • Laryngoscope handle with appropriate size blade.
  • Proper size endotracheal tube (ETT) plus back up ETT 0.5 – 1.0 mm smaller
  • Water soluble lubrication gel, (lubricate distal end of tube at cuff)
  • 10-12 ml syringe
  • Stylet, (insert into ET tube and do not let stylet extend beyond tip of ET tube)
  • ETT securing device
  • Proper size oral pharyngeal airway
  • BVM or automatic ventilator
  • Oxygen source
  • Suction device
  • Stethoscope
  • Digital capnography and oxygen saturation monitors


  • Assure all equipment is readily accessible and functioning
  • Inflate the cuff of the endotracheal tube to check for leaks
  • With the stylet in place, maintain the tube’s natural curve or reshape into “hockey stick” shape
  • If possible adjust the bed height so that the patient’s head is level with the lower portion of your sternum
  • Unless there are contraindications, move the patient into the “sniffing” position by placing a pillow or folded towel under the patient’s occiput
  • Ear should be level with sternal notch

Technique (continued)

  • When intubating an infant, you typically do not need to provide additional head support, because the infant’s large occiput naturally causes the head to assume the sniffing position
  • If the clinical situation allows, pre-oxygenate the patient with a non-rebreather mask or a bag-valve mask for at least 3 minutes prior to intubation
    • This step may minimize the need for BVM ventilation, thus reducing the risk of aspiration
  • While holding the laryngoscope in your left hand, open the patient’s mouth with your right hand
  • Insert the laryngoscope blade to the right of the patient’s tongue and gradually move the blade to the center of the mouth, pushing the tongue to the left
  • Slowly advance the blade along the tongue and locate the epiglottis
    • If using a curved blade, place the blade tip into the vallecula epiglottica
    • If using a straight blade place the blade tip posterior to the epiglottis
  • With the tip of the blade in position, lift the laryngoscope upward and forward at a 45 degree angle to expose the vocal cords
  • Try to achieve the best possible view of the vocal cords before attempting to pass the endotracheal tube
  • To avoid dental injury do not rock the blade against the patient’s teeth as this will do nothing to improve the view
  • While maintaining your view of the vocal cords, insert the endotracheal tube into the right side of the patient’s mouth
  • The tube should not obstruct your view of the vocal cords during this critical part of the procedure
  • Pass the tube through the vocal cords until the balloon disappears into the trachea
  • Advance the tube until the balloon is 3 to 4 cm beyond the vocal cords
    • Typical depth in centimeters is "3 times the tube size" (e.g. 21cm for a 7mm, 24cm for a 8mm tube)
  • Inflate the endotracheal balloon with air and assess for proper placement using capnography
    • If no alveolar waveform is seen on capnography the tube must be removed
  • Secondary assessment of placement should include auscultation over the epigastrium and auscultation of both lungs fields for symmetry
  • If an alveolar waveform is present secure the tube using a commercial tube holder


  • Esophageal intubation (catastrophic if unrecognized)
  • Aspiration of gastric contents
  • Bradycardia
  • Oral trauma
  • Exacerbation of spine injuries

ETCO2 Monitoring using Capnography

Waveform capnography is the most sensitive and specific method available to objectively determine endotracheal tube location after intubation attempts and throughout airway management in the field.

Following intubation, immediately attach capnography line and observe for presence of a four-phase alveolar waveform:

An Alveolar waveform confirms ventilation is occurring. In the intubated patient an alveolar waveform confirms tracheal placement of the tube. In a non-intubated patient, capnography provides continuous monitoring of respirations, and is the most sensitive method for recognizing impending respiratory failure.

A flat line indicates NO VENTILATION is occurring. In the intubated patient this indicates a misplaced esophageal intubation. In the non-intubated patient a flat line indicates respirations have ceased (hypoventilation/apnea).

In states of hypoperfusion, such as severe shock or cardiac arrest, end-tidal carbon dioxide (ETCO2) levels will be very low (< 20 mmHg). In cardiac arrest patients, high quality chest compressions improve perfusion and increase ETCO2 - monitor these levels to maintain optimal CPR and recognize operator fatigue. A sudden rise in the ETCO2 indicates return of spontaneous circulation (ROSC).

End-tidal carbon dioxide (ETCO2) provides valuable information about ventilation, perfusion and the metabolic status of the patient. Normal values fall into a range of 30-45 mmHg.

Elevated ETCO2 levels indicate:

  • Intubated patients
    • Hypoventilation – increase depth and rate of bagging if this occurs
    • Partial airway obstruction – reassess airway and tube if this occurs
  • All patients
    • Bronchoconstriction/CO2 retention such as asthma or COPD (especially if waveform has "shark-fin" appearance)
    • Hypoventilation in spontaneously breathing sedated or unconscious patients – assess for airway management
    • ROSC (sudden rise of ETCO2 during cardiac arrest resuscitation)

Decreased ETCO2 levels indicate:

  • Intubated patients
    • A sudden decline in ETCO2 indicates extubation or obstructed tube – immediately assess patient for each of these complications
    • Hyperventilation – decrease depth and rate of bagging if this occurs
  • All patients
    • Hypoperfusion such as severe sepsis or shock
    • Cardiac arrest or impending cardiac arrest
    • Metabolic acidosis such as diabetic ketoacidosis (DKA) or severe dehydration
    • Hyperventilation as seen in significant dyspnea, pulmonary embolism, or anxiety

Laryngeal Tube Airway


  • Respiratory or other emergencies requiring assisted ventilation


  • Responsive patients with an intact gag reflex
  • Patients with known esophageal disease
  • Patients who have ingested caustic substances


  • Correctly sized airway device (see manufacturer’s recommendations below)
  • Water based lubricant
  • Inflation syringe or KLT900 Cuff pressure Gauge
  • Suction device
  • Bag-Valve-Mask
  • Oxygen
  • Endotracheal tube holder
  • Capnography and oxygen saturation monitors
  • Stethoscope


  • Test cuff by injecting maximum amount of air into the cuff, then deflate for insertion
  • Apply water based lubricant to the beveled distal tip and posterior aspect of tube, being careful not to introduce lubricant into the ventilation ports
  • Pre-oxygenate with BVM
  • Position the head in the sniffing position if no cervical spinal injury is suspected
    • Use the neutral position if cervical spinal injury is considered
  • While holding the King LT with the dominant hand, open the mouth with the non-dominant hand, and apply a chin lift if no cervical spinal injury suspected
  • With the King LT rotated laterally at 45-90 such that the blue orientation line is touching the corner of the mouth, introduce the tip into the mouth and advance behind the base of the tongue
  • As the tube tip passes under the tongue, rotate the tube back to midline (blue orientation line faces chin)
  • Without using excessive force, advance the King LT until the base of the connector aligns with the teeth or gums
  • If using the KLT900 Cuff Pressure Gauge, inflate the cuff to 60cm H2O
  • If using a syringe, inflate the cuff with the minimum volume to seal the airway at the peak ventilatory pressure employed
  • Attach resuscitation bag and deliver a gentle breath while simultaneously withdraw the airway device until ventilation is easy.
  • Confirm proper placement by assessing capnography waveform and by auscultating lungs sounds.
  • Secure the device using a commercial tube holder


  • Regurgitation and aspiration
  • Inadvertent intubation of the trachea

KingLT(S)-D (supraglottic airway) chart

Surgical cricothyrotomy (adult)
Percutaneous cricothyrotomy using the Seldinger technique (adult)
Needle cricothyrotomy with jet ventilation (children < 12 years of age)


  • Inability to secure an airway using nonsurgical methods
  • As a last resort in a “cannot intubate, cannot ventilate” scenario
  • Needle cricothyrotomy is the surgical airway of choice for children less than 12 years old.


  • In true emergencies, there are no absolute contraindications
  • Airway obstruction distal to the cricoid membrane
  • Inability to identify anatomical landmarks
  • Infection at the incision site


  • Cricothyrotomy
    • Cuffed endotracheal tubes (5 and 6mm)
    • Scalpel, No. 11
    • Trousseau dilator
    • Tracheal hook
    • 4 X 4 gauze/sponges
  • Percutaneous cricothyrotomy using Seldinger technique
    • Commercial cricothyrotomy kit
    • Scalpel, No. 11
    • 4 X 4 gauze/sponges
  • Needle cricothyrotomy
    • Over-the-needle catheter, 14 ga, 2 to 2.5 inches in length
    • Syringe, 10 ml
    • Scalpel, No. 11
    • 4 X 4 gauze/sponges
    • Nasal cannula or oxygen tubing with Y-connector

Technique: Cricothyrotomy

  • Position the patient supine, with the neck in a neutral position
  • Clean the patient’s neck using antiseptic swabs
  • Identify the cricothyroid membrane, between the thyroid and cricoid cartilage

  • Using the non-dominant hand, stabilize the trachea
  • Make a 2-3 cm midline vertical incision through the skin from the caudal end of the thyroid cartilage to the cephalic end of the cricoid cartilage

  • Make a 1-2 cm transverse incision through the cricothyroid membrane.

  • Insert the scalpel handle into the incision and rotate 90°. (A hemostat may also be used to open the airway.)
  • If available, use a tracheal hook to lift the caudal end of the opening to allow passage of a cuffed endotracheal tube directly into the trachea (No. 5 or 6)
  • In an urgent scenario, insert the tube into the trachea with the assistance of a hemostat or the handle of the scalpel
  • Inflate the cuff and confirm placement using Capnography (mandatory) and by assessing chest rise and lung sounds
  • Secure the tube

Technique: Percutaneous cricothyrotomy using Seldinger technique

  • Use a commercially available kit that has been authorized by the Medical Director

  • In addition to manufacturer recommended procedures, follow the first 4 steps of the cricothyrotomy technique
  • Direct the needle at a 45° angle caudally while maintaining negative pressure to the syringe
  • Once air is aspirated remove the syringe, leaving the needle in place, and pass the guide wire into the trachea
  • Insert the dilator/airway tube combination over the guide wire
  • Once the airway tube is in place, remove the dilator and guide wire
  • Attach to a ventilation device and secure the device
  • Confirm placement using capnography (mandatory)

Technique: Needle cricothyrotomy

  • Follow the first 4 steps above
  • Attach an over-the-needle catheter (8.5 cm) to a 10mL syringe
  • Use a 16 or 18 gauge needle for a child less than 12
  • Insert the needle in the midline into the cricothyroid membrane, at a 45 angle caudally, while maintaining negative pressure on the syringe

  • A small incision with a No. 11 blade may facilitate passage of the needle
  • Once air is aspirated advance no further and attempt to pass the catheter over the needle
  • If the catheter passes easily, slowly remove the needle and secure the catheter

  • When catheter is secure, insert a size 3mm endotracheal tube adapter into the hub of the needle
  • Attach a BVM on to the ETT adapter and ventilate

  • Needle cricothyrotomy is a temporizing measure only; expedite transport because ventilation will be suboptimal


  • Aspiration
  • Hemorrhage
  • Unrecognized misplacement
  • Thyroid perforation
  • Inadequate ventilation/hypoxia
  • Esophageal or tracheal laceration
  • Mediastinal or subcutaneous emphysema
  • Vocal cord injury

Bougie (Endotracheal Tube Introducer)


The Gum Elastic Bougie is helpful in achieving endotracheal intubation when there is a restricted view of the glottic opening. It is not necessary to use on every patient, but it may be useful when a difficult airway is anticipated. The Bougie is not for "blind" intubation - you should always visualize the tip of the epiglottis, arytenoids, or a partial view of the vocal cords


  • Once the best possible laryngeal view is obtained, pass the bougie into the patient's mouth and through the glottic opening
  • If unable to visualize the vocal cords, advance the bougie anteriorly under the epiglottis and feel for clicks as it slides along the tracheal rings

Source: Knop KJ, Storrow AB, Thurman RJ: Atlas of Emergency Medicine, 3rd Edition:

Source: Knop KJ, Storrow AB, Thurman RJ: Atlas of Emergency Medicine, 3rd Edition:

  • While maintaining the best laryngeal view, slide the endotracheal tube over the bougie, and advance it to the desired depth, while maintaining proximal control of the bougie. This may require two operators.

Source: Knop KJ, Storrow AB, Thurman RJ: Atlas of Emergency Medicine, 3rd Edition:

  • If resistance is encountered while passing the tube, try rotating the bougie and tube 90°.

Source: Knop KJ, Storrow AB, Thurman RJ: Atlas of Emergency Medicine, 3rd Edition:


  • Esophageal intubation
  • Vomiting and aspiration
  • Laryngospasm
  • Bronchospasm
  • Oral trauma
  • Exacerbation spinal injuries

Nasogastric Tube Insertion


  • Airway management using a King LTS-D
  • Unable to ventilate intubated patient due to over distended stomach
  • Prolonged transport for patient felt to be at high risk for aspiration
    • Note for interfacility transfers, the NG tube should be placed by transferring facility


  • Suspected facial fractures or suspected basilar skull fractures (raccoon eyes, battle signs, blood from ear cana)
  • History of alkali ingestion
  • Comatose state with unprotected airway (procedure will induce vomiting)
  • Penetrating cervical injuries in the awake trauma patient


  • 18 Fr nasogastric tube
  • 35 ml syringe
  • Water soluble lubrication gel
  • Tape


  • Medical Control orders required unless being placed using the Gastric Access Lumen on a King LTS-D
  • Mark distance tube should be inserted by measuring from nose to ear lobe to below xiphoid process
  • Lubricate distal 6 - 8" of NG tube and pass into the gastric access lumen of the King LTS-D
  • If placing nasally:
    • Examine nose for septal deviation
    • Use right naris if both nostrils are same size
    • Place patient in semi-fowler's position if condition permits and slightly flex head
    • Insert tube in nostril & gently pass tube into nose along hard palate (floor of nose)
  • Confirm tube placement by aspirating gastric contents and by auscultating epigastrium while injecting 20 -30 ml air through tube (a gurgling sound should be heard via stethoscope)
  • Tape tube in place and maintain suction