Article title: Airway Adventures! Can you master this disaster? Fix this Airway! by Tom Trimble, RN CEN from Emergency Nursing World  htpL//

What this article assumes: The reader is a healthcare professional with the responsibility of carrying out or assisting with airway management in emergency situations and has certification in ACLS/PALS, and experience with Rapid Sequence Drug-Assisted Intubation and related tasks.

What this article will do: Help the emergency nurse to anticipate and be prepared for difficult and adverse events, to assess the possibilities, and to be more familiar with less commonly used techniques that may be appropriate for such events.

N.B.: This article is posted as a discussion of advanced practice airway management strategies for difficult and dangerously dynamic airway situations with high probability of adverse outcomes and in which experts may reasonably disagree or have preference for a different approach based on their experience, training, skill and confidence level. It does not comprehensively discuss all aspects of airway management or of care of the patient with an artificial airway. The purpose of the article is to promote thinking and planning for such situations before they occur. Our DISCLAIMER completely and specifically applies to all portions of this article.

Ooops! Where did it go?:    You are bagging a patient whose trachea is intubated. In shifting the patient for placement of an X-Ray plate
 for the CXR, the 15mm endotracheal tube connector falls off the tube to the floor and vanishes under the furniture. So there you are with an intubated patient and a breathing bag that no longer attaches! What do you do?
  • Designate someone to find the connector, or to pull one off of a spare endotracheal tube.
  • A "traditional" solution might be to give an oral breath to the tube as needed; however, this might be distasteful and unsanitary.
    G Hutchison
    The grand plan BMJ  1994:484 <>
  • The patient could be mask ventilated over the open tube end. Depending on how much tube is protruding, one may need to choose a high contour mask, fold the tube without kinking under the mask, or quickly snip the tube shorter with trauma shears (avoiding the inflation line).
    Heath, MR CEMACH report: oesophageal intubation Br J Anaesth. 2005 Sep;95(3):426. PMID: 16076928
  • If there is no spare of the same size, from which to take a connector, have someone open a smaller tube (e.g., 6.0 mm tube, if the patient’s tube is an 8.0 mm) and insert the end within the patient’s tube until secure and air-tight. Your ventilation device can now be connected to the 15 mm connector of the smaller tube. Tighten that connection.
  • Make the best possible fit within or to the valve with the endotracheal tube, tape or seal with Tegaderm® to minimize leaks, and fully support with hand. Do this only until the problem can be fixed; the emergency must be resolved quickly.
  • When a correct connector is found, be sure that it is clean and dry (an alcohol wipe helps). Seat it firmly and fully within the endotracheal tube with a slight twist to help lock the connection. Take care to support the endotracheal tube while doing so and not transmit distal motion to it that may displace the tube making go down into the mainstem bronchus  causing one lung ventilation leading to collapse of the unventilated lung and possible barotrauma of the over-ventilated lung.


15mm (outside diameter) adapting connector
from endotracheal tube
15mm endotracheal tube connector
firmly seated into tube
15mm endotracheal tube connector & tube,
22mm connector of BVM mask,
Laerdal Patient Valve showing 15/22mm connection,
valves, and flexible connection
15/22mm connections of BVM & Anesthesia Bag
with masks

Lost Resuscitation Mask: You are mask ventilating a patient. In the crowded activity at the head of the bead, the mask falls off and bounces-rolls underneath furniture where it can't quickly be retrieved. Imprudently, no one has stocked a spare mask ready to hand; replacements are in a dispensing machine in another room. What are you going to do?

  • Place the BVM's 22 mm connector into the mouth lips or lips and teeth. Use your "mask" hand to lift the jaw, hold the lips against the connector to prevent air leak with the web and sides of the thumb and forefinger as you pinch off the nostrils with those two fingers.

  • Use an alternative airway such as the Modified Nasal Trumpet.

  • Attach an endotracheal tube to the BVM's 15 mm connector (the inside port) and insert the endotracheal tube into the patient's pharynx and use the same mouth-closing nose-pinching maneuver to ventilate.


ETT Taped to Chin/ Lost Tie: Very often on television, due to dramatic and photographic requirements, one will see that the endotracheal tube, if taped, simply has a piece of plastic tape wrapped once around the tube and then stuck to the lower jaw. This is unreliable and unsafe in emergency patients and should not be done. Fastening only to the mandible is unwise as it is a movable object; this makes it more likely that the endotracheal tube will move up or down within the trachea or even be accidentally extubated. The Advanced Cardiac Life Support recommendation is to prefer a commercial endotracheal tube holder device (as they have been tested) in preference to improvised or local customary practice in taping. Consensus opinion is that when endotracheal tubes are taped, it should be with:

  • inelastic cloth adhesive tape, that

  • goes entirely around the head,

  • typically is split at the ends so that four ends are available to encircle the tube or to fasten partly to the upper lip and yet fully enclose the tube,

  • without dentition or a prominent alveolar ridge to support the tube in position, an accessory piece of tape may need to support the tube from the nose above to keep the tube from migrating downwards

  • should be double-faced posteriorly (so that the tape doesn't stick to the hair), and

  • is applied to clean, dry skin,

  • preferably  with Compound Tincture of Benzoin applied to increase adherence and protect the skin, and

  • with very tender or fragile skin (infants, elderly) consideration be given to using protective barriers such as Skin Blanket™ or Stomahesive™

  • Note should always be made of the length of endotracheal at a definable immovable landmark such as the upper teeth or, in edentulous patients,  the alveolar ridge from which upper teeth would normally appear; the "lip line" may do in a pinch, but it is less clear as to which part of the lip, and whether it is retracted or dehydrated.

  • Should the tube become "loose", it should be seized and held immediately with the heel of the holding hand resting firmly on the patient's zygoma, while immediately assessing adequacy of ventilations and accuracy of placement of the tube. Auscultation of breath sounds should be done, and every test confirming endotracheal placement done until the tube is unequivocally determined to be within the trachea at a safe depth. The cause of failure (leading to the near-loss of the tube) should be considered, and very secure and accurate fastening should be done. Reconsider adequacy of sedation and paralysis if patient movement was the cause. Consider X-Ray confirmation of position, and whether the patient needs fiberoptic endoscopy to check for injury.

  • In extreme cases, the poorly secured tube has been aspirated deep within the trachea/bronchus or esophagus (depending on placement), and is a major undertaking to retrieve without further harm and potential airway loss.

  • The mid-tracheal position of the endotracheal tube will change with flexion or extension of the neck, thus care must be taken with any patient transfer or movement (gurney to CT scanner table, for example). Many EMS systems will automatically apply a "hard" cervical collar, long spine board, and head supports, to intubated patients without trauma simply to help safeguard against accidental extubation, facilitate CPR, and ease transfers.

  • Remember, during transfers, to allow "slack" for the breathing bag connection and room for the airway/bag person to move and protect the endotracheal tube. Verify accurate position of tube and adequacy of ventilation after every move. The gurney should not be moved faster than the pace of the airway/bag person can safely maintain ventilation without pulling on the tube.  Always, have a face mask that fits the patient with you, in case of extubation.
    Re-intubation of the accidentally extubated patient is always more hazardous.


Be Careful where you cut!: If trimming or cutting near the endotracheal tube, be careful to isolate and identify what you cut before you do so.

   If the little cuff balloon inflation line is cut accidentally, you will immediately lose the seal of the cuff within the trachea: you will have an airway leak with loss of pressure and volume to inflate the lungs, and you will lose the protection of the cuff which, if inflated, helps act as a barrier to prevent aspiration of secretions. Further, there is no way to connect a syringe to the severed line to reinflate it.

   If you do not keep "Blunt Needles" on hand for this possibility,  you will have to insert the largest intravenous cannula that you can fit into the stump of the inflation line. Place a needleless cap onto the cannula. Affix a syringe and reinflate the balloon. Secure all connections with tape. If this is not entirely adequate, obtain the best inflation possible, and clamp the stump of the line with a non-crushing clamp. If a satisfactory repair is not possible, than the patient will need to be re-intubated, either by direct laryngoscopy or over an airway exchange catheter.


Which way do you want it shortened?:  Endotracheal tubes of Oro-Nasal style typically are about 30 cm length, longer than needed for orotracheal intubation in persons of normal stature. Some intubators may desire a shortening of the tube prior to placement. When cutting a tube, be careful to cut the proximal end (which would protrude from the mouth) rather than cutting off the distal end with its balloon cuff and beveled-end with Murphy-eye, and to avoid cutting below the level of the inflation line as it leaves the tube; either error prevents use of that tube which must then be thrown away.

When is a 100% O2 Non-Rebreathing Mask Not 100%?: There is a general assumption that a "non-rebreathing face mask" connected to oxygen at 15 liters per minute is delivering 100%. Yet, patients may feel that their need is not being met.

  • When might this be so? Patients may have a high oxygen requirement due to large areas of non-functioning lung tissue causing a ventilation-perfusion mismatch; cardiac shunts may cause admixture of oxygenated and non-oxygenated blood causing poor delivery to tissues; hypermetabolic-hyperdynamic states may increase oxygen consumption.

  • What's the error in the assumption? It's assumed the patient is at rest, has a reasonable ability to take up oxygen, and that the entire minute volume is supplied by the mask. 15 LPM is also not necessarily the maximum available or needed flow rate. The masks are also loose compared with a well applied close fitting anesthesia mask, and dilution can occur from poor fit or through mask holes.
         Boumphrey SM, Morris EA, Kinsella SM.100% inspired oxygen from a Hudson mask-a realistic goal? Resuscitation. 2003 Apr;57(1):69-72. PMID: 12668302

  • What's Minute Volume?   Respiratory Rate X Volume of Breath = Minute Volume.

  • How can I tell if it's not enough? Observe the patient's respiratory rate, depth of breathing, apparent work of breathing (as demonstrated by amount of respiratory excursion of chest, use of accessory muscles, tripod position, pulsus paradoxus, etc.), apparent comfort and oxygen saturation at rest and during activity, presence of autonomic signs e.g., tachycardia, diaphoresis, pallor or cyanosis. An example would be a pre-transplant pulmonary hypertension patient with a resting minute volume requirement of 93 LPM of 100% oxygen to maintain a 98-100% saturation, but who desaturates with activity.

  • Is there a way to confirm this? Ask your respiratory care practitioner to check the patient and consider spirometry (A "Wright's Meter" will do) or flow-volume loop testing (depending on the clinical situation). Arterial Blood Gas testing may be useful.

  • How can I deliver more flow? Be sure of your flowmeter (and source gas). The usual meter is graduated from 0-15 LPM, but often can deliver above this to 40 LPM or near flush rates. Some pediatric low flow meters have an expanded scale from 0-5 LPM and are limited to 8 LPM. Very high flow meters may be graduated to 70 LPM.

  • Without that high flow meter, what can I do? Use double flow meters at flush rate on a "Wye" connection connected to large volume nebulizers (Special high flow nebulizers are available also.) with mist tubing connected by a Y or T connection going to an aerosol mask for the patient with mist tubing extensions (aka horns or whiskers) in the exhalation ports to minimize dilution by room air during inhalation.

  • How do I oxygenate him during pre-intubation? Use an Anesthesia Bag: the closely fitted mask, a rapid flow rate, and the 2-3 Liter reservoir bag, will assure the best possible oxygenation.


Torn ETT Cuff: Avoid damage to the inflatable cuff of the endotracheal tube by fully deflating the cuff against the tube before it is passed. It should be navigated with direct vision past snaggled-teeth or buck teeth, orthodontic braces and wire, or metal piercings. Use only water-soluble surgical lubricants. Be attentive to inflation volume to avoid over-inflation.

     Detection during use may be noted by leak during ventilations; falling airway pressures on the ventilator; audible leak - failure to seal of the cuff - at the neck (auscultate) despite adding air; poor capnographic waveform; softness of the pilot line's balloon which fails to remain improved despite adding air; increased tautness of the balloon does not occur despite careful over-inflation of the cuff.

    When any tube is removed because of fault, set it aside for examination rather than discarding it in the trash. We were able to demonstrate an invisible leak by injecting air to the cuff while it was immersed in a cup of water thus seeing the resultant bubble stream.

    Once the cuff is blown, the tube must be replaced. Exchanging the tube might be done by

  1. extubation-reintubation.

  2. over an airway exchange catheter or bougie.

  3. or the airway could be protected by placing a Laryngeal Mask Airway (LMA) over the original endotracheal tube (with 15mm connector removed) so as to protect the lower airway; then removing the tube (that is to be replaced) over a catheter so that the replacement endotracheal tube may then be slid down over the catheter.

  4. Alternatively, the replacement ETT could be inserted through the LMA upon a fiberoptic bronchoscope so as to visualize and navigate below.


Prolapsed Cuff:  Although less frequent with modern disposable PVC endotracheal tubes that have integral high-volume low-pressure cuffs than in the days of reusable rubber tubes with glued-on cuffs or tracheostomy cannulae with glued cuffs, it is still possible to have an over-filled cuff, or a "blown" cuff displace distally and obstruct the flow of gasses through the tube.

   If there is sudden obstruction of the tube, not otherwise explained (e.g., by biting, secretions, or major bronchospasm), consider immediate passage of a suction catheter or "red robinson" catheter through and beyond the tube to check for blockage. If the catheter fails to pass or suctioning secretions does not clear the airway, then the cuff may have failed and the tube must be removed immediately.

   "Fall back to basics" to face mask ventilation, or supraglottic airway such as a laryngeal mask, until the patient can be safely reintubated.


Divide and Be Conquered: An ambulance crew assuming care of a patient whose initial resuscitation was begun by fire first responders, prepared to ventilate, and noting no oropharyngeal airway in place, asked if one had been placed, were told "No" and inserted an oral airway. Mask ventilation was satisfactory, but subsequent ED attempts at endotracheal intubation were impeded. A lateral neck X-Ray showed a metallic airway of an old-fashioned pattern impacted in the hypopharyngeal and glottal area. Intubation was accomplished upon removal of the offending airway with the Magill's Forceps.

    The metal-wire style airway, once commonly provided by resuscitator manufacturers, was flangeless making it difficult to maintain it above the lips and between the teeth; it was customary to attach a string by which it might be fished out, which was not present. It had fallen within the pharynx where it could not easily be seen or felt.

    Abandoning use of obsolete equipment is needed, and was done. However, the essential take-home point is to maintain unity of focus upon the airway. The person who answered "No", was not the person who had placed it. Whenever possible, when tasks must change, have the "Airway  person", if competent, remain at that task and monitor changes. Whenever tasks are divided or reassigned, be wary that division of attention is likely to occur, also.

Oropharyngeal airways, flangeless, metal wire
with strings

Magill's Forceps are used to manipulate the tube or objects in the airway without the hand blocking the view

Divide and Be Conquered II: A patient was brought to a hospital ED by Fire Paramedics with their rescue airway device, a Combitube, in place for ventilation after failed endotracheal intubation. In this system, Combitubes are rarely used, and not by the hospital unless one is brought to them. There was disconnection upon transfer from gurney to gurney.

     A clear communication was asked and replied as to which port was being ventilated "#1" [Blue; pharyngeal outlet] or "#2" [White; distal tip -the gastric end, or if the Combitube has been placed within the trachea {occurs <5% of insertions}, it becomes the "tracheal" port]. Two hospital staff heard "#2" --the white port. Ventilation began, generating gastric distention, then "a fountain of barf" as vomiting ensued from the white port. Ventilation was switched to the "#1" [Blue port], gastric decompression and clean-up followed.

    The person replying as to "which port?" was not the original airway manager inserting the Combitube or ventilating the patient. However unintentional the misspoken reply, clarity was not supported by the change of personnel. It is our opinion, that communication should be directly from Airway Manager to Airway Manager; that substitutions should not, if possible, occur en route; and that especially when there have been difficult or unusual airway events, the Airway Manager must remain with the patient and to report and confer directly with the subsequent Airway Manager so that all details may be known, queried, transcribed, and investigated. Singularity of focus upon the airway enhances patient safety.

    When revision of the airway plan will be needed, or conversion to another method of airway control, it is best to have all details of what previously occurred before undertaking change. Forewarned is forearmed. This will allow consideration of airway trauma {edema, bleeding, perforation, subcutaneous emphysema, fractured cartilages, etc.} and best control during intubation or surgical access.


Head Suspended In The Air: Older, stiffer necks and those beset by arthritis, ankylosing spondylitis, rheumatoid arthritis, previous fusion of the cervical spine, or bodies deformed by kyphosis, scoliosis, gibbus or "dowager's hump", lack normal mobility and may have locked joints.

  • Inspect the patient's head, neck, and shoulders from the side looking for gaps in support. The stiffness may be sufficient that the unsupported head and neck is off the bed.

  • Support these areas by filling in "hollows" with padding or towels to prevent injury.

  • Consider neck injury if there has been trauma, even minor.

  • Anticipate potential "Difficult Airway - Difficult Intubation", especially poor visualization of the glottis or difficulty inserting the tube.
    Mask Ventilation  or laryngeal mask ventilation may remain satisfactory.

  • Avoid sedation and paralysis if there is potential for soft tissue airway collapse.

  • Consider potential need for an alternative airway, such as a Laryngeal Mask Airway, Esophageal Tracheal Combi-Tube, Illuminated Stylet or TrachLight, or Fiberoptic Bronchoscope.

  • Bony changes in the thorax and weakness of thoracic muscles may constitute restrictive lung disease predisposing to respiratory insufficiency and pneumonias. Such patients may be difficult to wean from the ventilator.

  • Physical movements should be gentle, well-supported, and well-coordinated to avoid injury to demineralized, osteoporotic, and degenerative bone/joint disease.

Illustration by kind permission of LUMEN
-Loyola University Medical Education Network

Get your teeth into it: Well-fitting dentures should be left in place to support facial contours during mask ventilation. Loose-fitting or damaged dentures may need removal to prevent injury or aspiration.

  • The "SealEasy" mask manufactured by Respironics, nicknamed "The Blob", is excellent for mask ventilation when the face has uneven contours.

  • A Modified Nasal Trumpet is an excellent way of supporting ventilation in the edentulous patient prior to intubation.

  • An alternative for the edentulous patient with sunken cheeks, is the use of an oral airway, good jaw support, and possibly stuffing the cheeks with fluffed or rolled gauze. A damp linen surgical towel may be wrapped around the mask to provide a better mask seal, and the cheeks can be pulled upwards into the mask's cuff.

  • Remove dentures to provide more room for laryngoscopy and endotracheal intubation. Keep them handy in case mask ventilation must be resumed.

  • Secure removed dentures in a labeled denture cup (and listed on a belongings list), as they are easily lost within the bed or may fall to the floor and be broken.


Cricoid versus Thyroid: In an emergency department, airway management mandates the assumption of a "full stomach" with the potential for regurgitation, vomiting, and possible aspiration into the lungs. The mainstay in prevention is the use of "Rapid Sequence Intubation" to provide optimum intubating conditions, least insufflation of the stomach, and minimizing passive regurgitation by occluding the esophagus with Sellick's Maneuver of Cricoid Pressure.
     Resuscitation. 2004 Apr;61(1):5-7. Resuscitation great. Brian Sellick, cricoid pressure and the Sellick Manoeuvre. Baskett PJ, Baskett TF. PMID: 15081175 -- 
     Lancet. 1961 Aug 19;2:404-6. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. SELLICK BA. PMID: 13749923

   Sometimes this pressure improves or worsens the laryngeal view for the intubator; excessive pressure can even obstruct ventilation or block passage of the tube.
The intubator may ask for a change of hand position, pressure, or to let go entirely. One must be pragmatic and use the manipulation that permits rapid visualization and intubation.
     Levitan RM, Kinkle WC, Levin WJ, Everett WW.
     Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.
     Ann Emerg Med. 2006 Jun;47(6):548-55. PMID: 16713784

   The "BURP Maneuver" of Backwards Upwards Rightwards Pressure may considerably improve visualization, but is correctly applied to the thyroid cartilage of the upper Adam's Apple and not the cricoid cartilage. It reverses the distorting forces of the laryngoscope's lift, and "tips" downwards, again, an otherwise upwards angled un-held thyroid cartilage which would have lifted the glottis so as to contribute to the difficult view of the notorious "Anterior Larynx."
     Knill RL Difficult laryngoscopy made easy with a "BURP". Can J Anaesth. 1993 Mar;40(3):279-82. PMID: 8467551


POCPOM: There are several instances in which the intubator is hampered by a crowded oral cavity: patients with cervical spine precautions (wherein, neutral neck position and a rescue cervical collar interfere with line-of-vision and the opening of the jaw); small mouth or limited mouth opening due to arthritis, jaw trauma, TMJ problems, buck teeth; angioedema, tongue swelling,

   An effective way of assisting the intubator in gaining enough room to see and pass the tube is to "Pull Out Cheek - Push On Maxilla".

   John McDonald, MD of REACH Air Ambulance so described and taught this technique. The assistant  providing either Sellick's Maneuver of Cricoid Pressure (to minimize aspiration), or Knill's BURP Maneuver (to improve the laryngoscopic view) can use the other hand to simultaneously pull the cheek down and outwards (to provide additional space) and press against the maxilla (to stabilize the head and neck from rotation).

Illustration by kind permission of Gary McCalla, MD
REACH Air Ambulance Medical Director

Nasotracheal Intubation Epistaxis: Epistaxis during nasotracheal intubation can be minimized or prevented by:

  • Inspection of the nostril's passage, with direct light if possible,  lifting and flattening of the nose tip to see the septum and turbinates (avoid deviations, polyps, fractures) to check feasibility and the probable size of tube that will pass.

  • Gentle persuasion and explanation to the awake patient during all preparation and actions to obtain best cooperation.

  • Topical decongestants and vasoconstrictors: sprayed, atomized, or nebulized cocaine; oxymetazoline or phenylephrine with lidocaine for anesthesia; or 2% Lidocaine Jelly squirted into nostril by syringe (gets the lubricant there before the tube arrives).

  • Serial dilatation of nasal passage by successively larger diameter nasopharyngeal airways every two minutes until an adequate size endotracheal tube can be passed (~6.0-7.0 mm internal diameter in the average adult).

  • Immersing the endotracheal tube into very warm water, while preparations are being made, to soften the PVC plastic before use.

  • If possible, use the tapered and inclined side of the wedge-like tip of the tube against the septum, so that the open portion of the tip will ultimately lie in the midline of the airway. This will help it to glide through tight spaces and minimize likelihood of soft tissue obstructing the tip.

  • Gentleness advancing the tube with thought for the anatomy and respect for the tissues.

  • Remember that cervical spine injury must be cleared before manipulation of the neck or other safeguards taken to prevent worsening of injury (alternative airway methods that ensure stabilization throughout the procedure).

  • In the breathing patient, listen carefully at the tube connector for best airflow manipulating the head elevation, neck flexion, and flexion loop control with an Endotrol® tube (Malinckrodt)® and passing the tube at the moment of inspiration by the patient as the vocal cords are abducted.

Pop--Whoosh: You are bag ventilating the patient. You hear a loud "pop", hear a whooshing hissing sound, and notice the bag valve mask resuscitator doesn't refill quite as quickly. What has happened? The oxygen supply line has popped apart. Either the flow rate was too high for the resistance of the small bore connection tubing, or if things were otherwise going well, then someone has stood upon the tubing occluding it and causing the resultant overpressure to separate the tubing at the point of least resistance.

   Keep bagging. This is the chief merit of the self-refilling bag valve mask resuscitator; it will continue to function without a compressed gas supply (all that is needed is a non-toxic respirable atmosphere). If the patient has been pre-oxygenated or ventilated with oxygen for several minutes (washing out the nitrogen stores in the patients lung and tissues), there will be a brief reservoir period of reserve oxygen in the patient. Have someone reconnect and adjust the oxygen flow as soon as possible.


Overshoot to Mainstem Bronchus: A common error by the intubator is to insert the endotracheal tube too far past the vocal cords with the tube going into the Right Mainstem Bronchus, as it is more nearly in line with the trachea and is larger than the Left Mainstem Bronchus. This results in one lung ventilation and the possibility of barotrauma from the volume intended for two lungs being delivered to one. The unventilated lung will become progressively atelectatic and collapse. Unoxygenated blood from the left lung will mix with the output of the right lowering the amount of oxygen delivered to tissues.

  • The first clue in detecting this is to observe the length of tube outside the airway and checking the depth markings (~22 cm - 24 cm for oral; ~25 - 27 cm for nasal tubes in adults).

  • Next, observe the symmetry of chest wall expansion.

  • Third, auscultate the left axilla first, then the right axilla (comparing equality of breath sounds), then the stomach for gastric bubbling indicating esophageal intubation.

  • Oximetry and capnography should be present, but will not show immediate change if one lung ventilation occurs.

  • Tube depth may need to be adjusted.

  • If concerned about the depth of the tube and adequacy, always consider seriously whether esophageal placement has occurred. Use every objective test available, as well as clinical findings, until you can confirm unequivocally that the tube is in the trachea and the right depth and adequate ventilation is occurring. "If in doubt, take it out."


Pushing tube distally: Once an endotracheal tube is correctly placed, it is still possible to inadvertently push the tube closer to the carina or mainstem bronchus.

Hold the tube firmly with the heel of the holding hand resting against the malar area (if stable) or the wrist across the forehead until the tube is securely fastened. Beware of shifting the tube up or down.

During transport, if the BVM is connected directly to the tube without a flexible connection, it is possible for alternating pressure and tension to loosen and move the tube.

Frequently check the depth of the tube and the adequacy of ventilation.

If a ventilator circuit is on, be sure that the weight of the circuit, heat-moisture exchanger, capnography sensor, etc., are properly supported so as not to weigh down the breathing tube either displacing it or kinking it with a flop-over.

Even with the tube secured at the intended depth, flexion or extension of the head and neck may migrate the tube end up or down.


Flopped-Over ETT: The patient is intubated and breathing spontaneously; you found bagging to assist breathing to be easy; the patient is now transferred to the ventilator . . . Suddenly, the patient seems to be working harder, the heart rate is accelerating, the chest and abdomen seem to be "see-sawing" asynchronously, there is no coughing or bronchospasm, alarms are shrilly squealing for over-pressure.

  1. Scan the patient visually and his breathing circuit air-path to the machine.

  2. The patient is not biting his tube.

  3. In addition to the end-tidal CO2 detector in-line, there is now an HME (Heat Moisture Exchanger) which is used as an "artificial nose" or condenser humidifier for the gas flow to the patient, the breathing circuit is not supported by an arm nor taped to the bed. This is a fair amount of unsupported weight on the endotracheal tube and it has flopped over bending and kinking the tube causing additional resistance and obstruction that has increased the work of breathing.

  4. Lift and support the apparatus attached to the endotracheal tube . . . as you do so, the partial obstruction clears and the patient's breathing eases.

  5. Put towels under the apparatus or attach the ventilator's support arm.

  6. Tape the circuit tubing to the bed rail so that its weight will not pull down on the tube.

  7. Oro-nasal tubes used in oral intubations are usually over-long. They are not capable of resisting excessive force that might collapse them.


Lost IV: "Losing" the IV during resuscitation or rapid sequence intubation makes the situation immediately more dangerous. It is good practice to verify the adequacy and security of the IV before beginning; even better, to establish a second access if at all possible. Frequent inspection, and constant attention during medication administration to ensure that it is effectively and safely delivered is essential.

   Likewise, I believe that it is best practice to avoid using mere saline locks during periods of acute activity and that it is preferable to administer medications through a running IV line so as to be constantly aware of flow and be able to support blood pressure. Be aware that Succinylcholine can be given intramuscularly at twice the dose: Adults: 2 mg/kg; Infants: 4 mg/kg (due to rapid metabolism).

Be wary of these situations:

  • IV not flowing due to kinked cannula or tubing,  lack of flow not discerned due  to over-full drip chamber, multiple drugs given into tubing without effect on patient and admixture within tubing, flow corrected and all drugs hit patient suddenly as a bolus with compounded uncontrolled effects.

  • No Actual Infusion as field External Jugular IV not easily visualized due to patient position and original IV tubing disconnected  by another nurse from extension tubing to attach critical infusion, thus wasting drugs thought to be given. Avoid multiple drug/infusion nurses.

  • Back-up of critical infusion into field-started original gravity bag due to lack of anti-backflow valve in Paramedic's IV tubing (different brand) when used to piggy-back the infusion into only available IV access. Verify tubing design, flow, and delivery; substitute familiar and compatible tubing as soon as possible, obtain additional IV access as  soon as  possible in critical patients. If a critical infusion must be piggy-backed into a Y-site of tubing without an anti-backflow check  valve, place an occluding clamp immediately above the Y-site.

  • Precipitation within tubing of incompatible drugs when caution not taken to ensure adequate flushing in between.

  • "Positional" IV causing intermittent or delayed effect due to non-delivery of drug. Ensure line is positioned for verifiable flow and then restrained or splinted in that position. Even plaster-roll splinting may be necessary  to achieve this.

  • IV "infiltrated" with fluids and drugs extravasated. Verify adequacy of infusion before, during, and after each drug infusion.

  • Frequent non-invasive blood pressure measurements on same limb as IV interfering with drug delivery and potentially may lead to damage to IV site.

  • The tourniquet left on after starting the IV now being infused.

  • Slow infusion due to shorter staff not raising bag high enough for fast flow due to high bed position during intubation. Lower bed to increase relative height of bags.

  • Infusion pump tubing limiting height to which pole can be raised for gravity infusions. Save some piggy-back set "drop hooks" to use on the pumped bag's tubing so that the pole can be raised to full height for the gravity infusion to run rapidly. You could also suspend the lower bag from a knotted tourniquet loop, twill tape or string, tape the bag to the pole, or cut a length of discarded IV or oxygen tubing to make a suspension loop.

  • Gurney's IV pole is too short for rapid infusions and gets in the way  of the airway manager. Use a foot-end IV pole or rolling pole to take the drug nurse's work area away from the crowd at the head of the bed. 

  • Make it run faster. Use squeeze-ball transfusion tubing or pressure infusion bags to increase infusion rate. Even a 24 gauge cannula can deliver bolus fluid for a patient hypotensive after nitrates by lowering the bed along with the Trendelenberg's position, raising the bag and applying pressure to it.

  • Secure it right the first time. Emergently placed IV inadequately secured, loosened by subsequent movements, poorly adherent due to diaphoresis, IV line easily snags on staff movement and equipment and is pulled out. Dire circumstances require extra care to ensure IV is securely fastened and stress-relief taped to avoid pulling out. Skin must be clean and dry for good adhesion; if diaphoresis continues and line can't immediately be sutured in, then bandage it in with cloth, carefully, until the situation is under control.


Lack of CPAP A-Bag: A child sedated for wound repair becomes hypoxic with falling pulse oximetry SPO2, despite oxygen by nasal cannula. Attempts to "bag him up" with the BVM fail, as the SPO2 keeps falling, and the patient shows an obstructed breathing pattern. The situation resolves when an anesthesiologist uses an anesthesia bag with flow rate sufficient to create CPAP (Constant Positive Airway Pressure), and a strong Triple Airway Maneuver. Subsequent analysis and additional history indicates unreported preexisting obstructive sleep apnea, and other features suggesting possible airway difficulty.

   There are difficult mask ventilation situations where the BVM is not ideal. When there are circumstances of narrowed or obstructed air passages due to soft tissue obstruction, e.g., patients with sleep apnea, morbid obesity, upper airway abscess or masses, or severe pulmonary edema, ―a constant positive airway pressure helps hold open the airway in the same manner that air separates the walls of an air mattress or raft. The BVM is binary: it only produces positive pressure insufflations; airway pressure than drops to zero at end-expiration. If the patient "works" violently to overcome the obstruction, high negative pressures are generated leading to further collapse and even pulmonary edema. The Anesthesia Bag , and the skill to use it, are useful and versatile to deal with such situations.

“Provision for the ‘worst case scenario’ of persistent upper airway obstruction should be made even with patients with mild OSA and a breathing circuit capable of delivering CPAP should always be available when the presence of OSA is known or suspected.”

   While the self inflating Bag Valve Mask Manual Resuscitator is the mainstay of emergency resuscitation, that is so primarily because it will continue to operate on "room air" (if not in an oxygen deficient or toxic atmosphere) if there is no compressed oxygen supply available.

   (Historical Note: The BVM was originally invented by Dr. Henning Rubin after a polio epidemic in Copenhagen, Denmark, in which hospitals nearly ran out of oxygen for ventilators due to a trucking strike. It gained interest by the military for field resuscitation in contaminated environments due to nerve gas wherein mouth-to-mouth ventilation would be contraindicated and manual artificial respiration would be ineffective. As the prospect of effective CPR developed, ventilation bags moved from the province of anesthesiology into other other emergency fields.)
     Resuscitation. 2005 Mar;64(3):251-2. Images in Resuscitation: Henning Ruben and the self inflating bag. Baskett P. PMID: 15733750


Connected to "Air" Flowmeter: If the patient's pulse oximetry fails to rise sufficiently, always recheck your delivery system. In the haste of resuscitation, it is not uncommon for oxygen supply tubing to not have been connected to an oxygen supply, the portable oxygen tank to have run out, the flowmeter to have not been turned on or is at a slow rate, or even to have been connected to the "wrong" flowmeter such as the compressed air supply so that the bag is being refilled with medical-grade "room air".

   Trace the supply line to the source; check the source. At one institution, the typical green and yellow nipple adapters have been replaced with clear  to compel attention to which gas the flowmeter actually provides. Conversely, it is now more difficult to see from the doorway of the room if the adapters are present, and if they fall, they  are harder to find.

   A skillful airway/bag person uses all his senses and is attuned to situational awareness: i.e., noticing the "not hearing" of gas flow, awareness of how quickly and readily the self-refilling bag refills is consistent with gas supply, noticing that the oxygen reservoir doesn't have sounds of oxygen overflow if it is  of tubing type, or is not moving adequately if a bag reservoir, or lack of valve actuation if using a refill valve. Ventilation with room air is better than no ventilation at all, but oxygenation with 100% oxygen while doing so is better yet!


Wired Jaw: Whenever a patient is present, whose jaws have been wired or rubber-banded together as part of their maxillofacial repair, a wire-cutting instrument must be continuously present, so that emergency access to the oral airway is possible. Of course, a strong working source of suction should always be present.

  Use of a modified nasopharyngeal airway, mask or nasotracheal intubation are potential emergency actions. However, vomiting in the presence of wired jaws could be disastrous. Traditional locations to tape the cutters are the wall or head of the bead, the chart, or the patient's gown.
It is good to have a "standard" location (preferably, one that goes where the patient goes) and bold signage to indicate their location and purpose.

     Hughes, C., Johnson, C. & Irvine, G. (2001)
     A technique to reduce airway risk in patients undergoing maxillofacial surgery.
     Anaesthesia 56 (11), 1116-1130 
     PubMedID: 11708341   doi: 10.1046/j.1365-2044.2001.02331-22.x

suggests using a digital camera after surgery to illustrate the patient's banding and indicators of where to cut, and subsequent airway management measures that can be visibly posted where the patient is.
{The emergency call number might well be added, too.}

  Medical Wire Cutters Beattie, C
The modified nasal trumpet maneuver.
Anesth Analg. 2002 Feb;94(2):467-9,
PMID: 11812720

Trismus/ Bitten Tube: Trismus, the inability to open the mouth normally, can be due to seizure, anoxia, muscle spasm, tetanus and other infections, trauma, radiation injury, or inflammatory conditions of the TMJ, and can significantly impede the management of the airway.

  1. Initial management is a well fitting mask, taking care to ensure that the lips are parted to allow ventilation between and around the teeth as well as the nose.

  2. Nasal airways may temporize.

  3. Neuromuscular blockade and deepening the induction sedative may cause relaxation if due to tetanic contraction of muscles, but cannot alter damaged tissue, e.g., scars and contractures, locked joints., etc.

  4. Laryngeal mask airways can often pass if there is 20 mm of inter-dental opening.

  5. Nasotracheal intubation can be tried, perhaps with fiberoptic assistance. If possible, use a nasal decongestant and vasoconstrictor first, lubricate generously, be careful and gentle so as to avoid epistaxis that may worsen the problem.

  6. If the patient is orally intubated but is inadequately sedated and paralyzed, or undergoes spasm or seizure, the tube can be occluded by bite pressure or even severed if a bite block is not in place or the patient is not immediately  paralyzed of anesthesia deepened. A gauze roll or plastic bite stick may be used to prevent complete occlusion of the tube.

"Bite Stick" for seizures, trismus

"Bite-Proof Bite Block™" to protect ET Tube



Endotracheal Tube Attachment Device
Hollister Endotracheal Tube Attachment Device






Thomas Endotracheal Tube Holder

Precision Medical® ET Tube Holder
with Bite Block incorporated


Rapid Push of Drugs: Remember to carefully observe the needed duration of injection for medications, and allow time for effect to occur before repeating. There is a natural tendency to speed things up, but "squirting" in the morphine, lidocaine, or sedative may drop the pressure rapidly. Give the drugs over the appropriate interval into a running IV line so as to verify absorption and flushing between medications.


Why is the Blood Pressure going down?  <Preload -->  <Cardiac Output -->  <SBP: Shortly after Rapid Sequence Intubation and ventilation, the patient's blood pressure falls rapidly. Here are possibilities to review:

  • Preexisting uncorrected hypovolemia. Whether acute hemorrhage from trauma, or the insidious prolonged lack of intake due to progression of respiratory distress or enfeeblement, hypovolemia may cause exaggerated effect of the "Rapid Sequence Intubation" drugs upon the circulatory system. A bolus infusion of crystalloid before RSI may forestall this. Judicious selection of RSI agents (e.g., Etomidate, instead of Thiopental or Methohexital) may mitigate hypotension. Small incremental "push" doses of Phenylephrine or Ephedrine may temporize pressure while restoring euvolemia.

  • Hyperbagging is probably the commonest cause of low blood pressure in the freshly intubated patient. Positive Pressure Ventilation is a reversal of the normal intrathoracic pressure dynamics. A large or frequent positive pressure breath "pushes away" the normal low pressure refill of the heart diminishing the preload and therefore the cardiac output contribution to blood pressure. Remember that the endotracheal tube lessens the airway deadspace (smaller volume now indicated compared with mask); and that paralysis has lessened the work needed to raise the chest, and of metabolic demand; rapid rate of insufflation is commonly due to staff anxiety, this tends to overblow the patient causing pH changes, and lessens the expiratory time interval between breaths. Inadequate expiratory time causes stacking of breaths increasing auto-peep which drops preload and increases potential for barotrauma.

  • Esophageal or Endobronchial Misplaced Endotracheal Tube: Faulty tube placement can lead to hypoxia, hypercarbia, and acidosis worsening cardiac and renal performance. With undetected one-lung ventilation there is potential for systemic changes due to the shunt effect of the ventilation-perfusion mismatch (i.e., one lung's blood is oxygenated, the other is not, but both are mixed as returned to the heart, thus oxygen saturation of the hemoglobin delivered to needy tissues is less than desired), Ventilating one lung with the volume and pressure intended for two lungs is further likely to rupture the lung creating pneumothorax with tension, which may shift the heart and great vessels causes a kink restricting flow and output.

  • Pneumothorax: If the chest wall is pierced; the lung nicked by an errant needle; the lung ruptured at a  weak spot by disease; or by over pressure of the system.

  • Myocardial Infarction is a potential complication of critical patients, due to the stresses of the critical state or trauma, persistent hypotension, acidosis, complications of drug effect, etc.

Hyposedation: After the Rapid Sequence Intubation is "over" and care moves on to other phases, it is important to have, before the physicians leave the room, an ongoing plan for sedation, analgesia, and paralysis for management of the patient until transfer to the patient's ultimate destination. It will be necessary to avoid agitation and maintain homeostasis. Patients who are inadequately sedated and paralyzed are a danger to themselves, their artificial airway, and to others.

   "Road trips" for diagnostic studies are specially concerning to ensure safety and adequate scans without motion artifact in a setting with fewer immediate resources in absence of an appropriate physician or Monitored Anesthesia Care. It is also useful to keep soft wrist restraints in place for fewer surprises.


Extubation by self during Transport: Transport is rife with opportunities for accidental extubation.
  1. There is stimulus to the patient
  2. whose sedation may be waning,
  3. motion,
  4. transition to other beds or tables with restraints unfastened,
  5. snags of lines or tubings,
  6. less familiar environments,
  7. distraction by other responsibilities and needs of other procedural specialists.
  • Always have a mask with you that fits the patient and alternative airways.
  • Have your emergency equipment, monitors, portable suction.
  • Have someone with you who can manage the worst possible scenario, or know whom to call for stat backup.
  • Know your plan A, B, & C.


"No Slack" needs "Flexible" Connection: Commonly, immediately after placement of the endotracheal tube, the BVM (bag valve mask resuscitator) is connected directly to the tube's connector, ventilation is performed and checked, and the tube secured.

   If manual ventilation is prolonged or transportation is necessary, often the airway/bag person is still attempting to hover the bag over the patient without dislodging the tube. This is even more difficult during transportation, especially if those helping to move the patient are rushing and not focusing on the needs of the person with the bag. It is more likely that an accidental extubation or malposition of the airway can occur. Using a short flexible connecting  tubing can make things safer, more convenient, and comfortable to perform.


Pushing Mask "Down": The most common error and pitfall of mask ventilation is to press the mask down onto the face. Doing so without simultaneously lifting and supporting the jaw, opening the mouth, and -in the absence of cervical injury - extending the head, leads to the retropulsion (pushing backwards) of airway tissues increasing the airway resistance to gas flows through a narrowed or collapsed airway and possible diversion of insufflations to the stomach. Optimizing mask ventilation is an essential airway management skill.


Expiratory Time: A frequent problem in stressful situations is "hyper-bagging" the patient with large volumes and rapid rate. Too little time between inflations prevents adequate emptying of the previous breath given. This can lead to "stacking" of breaths and increased "auto-peep"  (positive end expiratory pressure) causing altered cardiac preload and a potential for barotrauma of the lungs.

   Positive pressure ventilation is a reversal of the normal intrathoracic pressure changes; significant decrease of preload, cardiac output, and blood pressure can occur worsening the patient's situation. Gentle easy inflations just sufficient to raise the chest, a slow rate with inspiration:expiration ratio equal or greater than 1:2 is desired.


D-O-P-E- = Dislodged, Obstructed, Pneumothorax, Equipment: When difficulties occur during artificial ventilation, the cause must be vigorously sought and immediately corrected. A useful mnemonic for doing so when an artificial airway is in use, taught in life support courses, is "dope".

  • D = Dislodgement  (The tube has shifted in position and is not ventilating the correct area)

  • O = Obstruction (Flow through the tube is blocked by kinking, secretions, tissue, mucus plugs, equipment problems, etc.)

  • P = Pneumothorax (Barotrauma from excess ventilation, exacerbation of closed lung injury, other iatrogenesis such as nicking lung during central line insertion leads to worsened ventilation and decreased cardiac output)

  • E = Equipment (Malfunctioning of equipment may lead to inability to oxygenate or ventilate. Assume equipment problems if performing oddly or no physiologic causes found.)


NGT/OGT placed into trachea: Having a cuffed endotracheal tube in place is not a sure guarantee that the gastric tube that you are passing will take the other path and go directly into the esophagus and stomach. The presence of a tube interferes with easy passage and makes it easy for another smaller tube to pass alongside of it. Some things that will help with successful passage are:

  • Use as large a tube as is feasible. It's less likely to move alongside, but it is stiffer and might move dislodge things. Be careful.

  • If a nasogastric tube keeps coiling in the pharynx and mouth, or has difficulty "making the turn" from the nose downwards, it might be possible to direct it by passing it through a nasopharyngeal airway already placed. A soft NPA might also protect the nose from trauma and epistaxis by the stiffer plastic gastric tube if the patient has coagulation problems. Lubricate generously, and insert with gentle carefulness respecting the tissues. Splitting the NPA with scissors before its insertion, may make removal of it from around the nasogastric tube easier.

  • If there is no probability of cervical spine injury, then rotation of the head and neck towards one of the shoulders may make it less likely that the tube tip will strike and be blocked by the arytenoid cartilages or other glottal structures.

  • Move the larynx laterally; this has been shown by fiberoptic inspection to significantly increase success in passing the tube without having it impact and be blocked by glottal structures.
         Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubated patients: fiberoptic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology. 1999 Jul;91(1):137-43.  PMID: 10422939


Dental Fragments: It's good practice to quickly check the state of dentition before intubating the patient, and to avoid laryngoscope pressure against the teeth. If a tooth is thereafter missing or fragmented. Careful search to retrieve it should be made. Chest X-Ray may be needed to localize it. If it cannot be reached with Magill's or Bayonet forceps, then bronchoscopy  may be needed.


Bulb Burn: A common failing of intubators is to put the laryngoscope down while leaving the blade extended and the bulb on.

   Good practice is to press the blade against the bed so as to fold it and turn off the bulb simultaneously. This conserves battery and bulb life, bulb brightness, and prevents overheating. Prolonged time with the bulb on heats the bulb sufficiently that touching it has caused uncomfortable "hot" moments for staff. It is also known for reuse of the laryngoscope with a hot bulb to cause injury to the patient. 
     Koh TH, Coleman R. Oropharyngeal burn in a newborn baby: new complication of light-bulb laryngoscopes. Anesthesiology. 2000 Jan;92(1):277-9. No abstract available. PMID: 10638930


Bulb OFF: If laryngoscopes and their bulbs are not carefully inspected before use, it is not uncommon that a bulb may be loose and not light or may be burned out. Carefully tightening (without over-tightening which might destroy the gasket or the bulb base) will usually solve the problem. If it recurs, or does not remain alight when wiggled or during vigorous shaking of the laryngoscope, the bulb should be replaced and/or another blade obtained for immediate use.

   It is not good to have the light go out while visualizing the vocal cords or passing the tube! Worse still, is if "someone" has replaced the bulb incorrectly, with a small laryngoscope bulb in a blade calling for a large laryngoscope bulb; it may seem to work but be unreliable, and most dangerously, to fall out into the airway during laryngoscopy!

Should a bulb fall out, another working laryngoscope must be immediately available to inspect for the missing bulb and retrieve it and to correct the original airway management problem. Magill's forceps, or Bayonet forceps, should be ready to hand to attempt grasping the bulb. Bulbs that cannot be found visually must be vigorously sought with neck and chest X-Rays. Bronchoscopy may be needed to retrieve the bulb.


Drowning the patient with mist tubing on T-Tube: Many patients with artificial airways (endotracheal tube, tracheostomy cannula), but who are breathing on their own with adequate respiratory ability, may need the benefit of an aerosol mist system that brings air/oxygen to them from a nebulizer that delivers "particulate water" micro-droplets on the gas stream so as to loosen secretions and plugs by replacing the natural humidification of the nose that has been bypassed. This is done through large-bore corrugated tubing.

   The droplets will, through turbulence and cooling, drop-out and condense into water drops within the tubing. If not drained, they will rattle in the tubing. A drainage collection bag should be interposed in the tubing at the lowest point (should be hung below the patient on a lower rail of the bed). If the drainage bag is omitted, or the patient changes position (turning on his side) so that the tubing runs "downhill" to the patient and it is connected by T-Tube directly to the airway for blow-by, condensation can roll into the patient's airway and drown him, or cause a coughing fit, bronchospasm, and aspiration. A tracheostomy collar is less likely to do this, but splashing into the cannula might still occur.


Why is this Patient Talking?: As sedation lightens, you notice the patient starting to move and wake up. He is breathing on his own. You notice that his neck and jaw are moving with movements similar to swallowing. Just as you wonder if he is moving the tube, he starts talking to you!

What does this mean
The tube is no longer between the vocal cords (phonation would be impossible).

Is there an alternative explanation
? The tube may not have been placed in the trachea. It may may have been placed in or dislodged to the pharynx. Oxygenation and ventilation may occur, especially if the patient is breathing spontaneously; there would not, however, have been adequate protection against aspiration. Some "corking" effect might have occurred if the inflated cuff was on top of the cords or blocking the glottis. Gastric insufflation may also have occurred.

  Remove the tube. Reassess the need for airway protection and intubation. Provide oxygen and check pulse oximetry.

  If the patient still needs to be reintubated, upon confirmation of endotracheal placement, ensure adequate sedation, neuromuscular blockade, and soft restraints to prevent self-extubation by the patient.


Vomiting per ETT: A cardiac patient is deteriorating rapidly, is cardioverted from ventricular tachycardia, intubated for airway protection, again has ventricular tachycardia becoming ventricular fibrillation, and is shocked again. CPR continues, followed quickly by vomiting from the endotracheal tube. What has happened?

   There has been an unrecognized esophageal intubation. Projectile vomiting from an endotracheal tube can only mean the tube is in the esophagus. Ventilation of the stomach instead of the lungs has contributed to the patient's hypoxic deterioration and is the cause of the vomiting.

   With every intubation, it is imperative to use several tests to confirm endotracheal placement of the tube, including objective tests; the "gold standard" is continuous waveform capnography. It is important for all practitioners concerned with airway management and resuscitation to have clear understanding of endotracheal confirmation. It is good if several practitioners simultaneously and independently confirm tube placement and agree that it is accurate.


Stomach Rupture: Rupture of the stomach's lesser curvature is also known to occur with excessive ventilation in the presence of a poor natural airway or unrecognized esophageal placement of an endotracheal tube. This disaster leads to tension pneumoperitoneum and further embarrassment of circulation, shock` and peritonitis which the patient may not survive, in addition to the original insult and airway problem.
     Check PubMed for articles on Gastric Rupture in resuscitation, CPR, or intubation.


Mask-Tegaderm Over Stoma: If a patient with an open stoma needs respiratory support, the stoma will either be a leak if ventilated by face mask from above, or an opportunity through which to ventilate the patient by a soft-cuffed mask or through which to pass a cuffed tube by which to isolate the lower airway and ventilate the patient.

   If the contour of the neck is irregular (from surgery or radiation) and mask fit is poor, or the upper airway (mouth and nose) are too great a leak, or the tracheostomy is healing and nearly closed (difficult to ventilate or cannulate, but still a leak) ,one may feel more confident performing conventional face mask ventilation. The stoma can be occluded for this by covering it with a Tegaderm®/Op-Site® type dressing. Be careful to confirm adequate ventilation by face mask by checking for adequate chest excursion and auscultation of breath sounds.


Empty Tanks: Don't get short during a transport. Check the transport oxygen tank before you leave to be sure that it is full.

   If there is high likelihood of delay, potential code situation, or a high minute-volume requirement, do not hesitate to take another tank as spare.
Be sure during stops in the scanner, etc., to conserve your tank supply by changing over to wall supplies of piped oxygen whenever possible.


Trash & Replacement?: Whenever possible, during a slack moment, clear out the debris and trash that accumulates in the patient's bed and adjacent care area.
Especially after patient movement, bits of plastic caps and other debris are likely to get under the patient's body.
Clutter gets in the way, confuses care, and if thrown on the floor can cause a slip and fall.
Begin replacement of used equipment and supplies to maintain instant readiness of the room.


Plan A, Plan B, Plan C: Whenever beginning the definitive management of a potentially "difficult airway", airway managers and nurses should explicitly understand, coordinate, integrate, and prepare for the sequence of steps that will be used at each critical juncture, with optimized conditions and efforts, smoothing transition between phases. In other words, there should be no "what do we do, now?" or "that didn't work, --find me the bougie!" There should be a fully prepared smooth flow into the next step.

Plan A should be the initial definitive effort after optimizing oxygen saturation, best positioning of the patient, IVs running, all tools working and at hand; --what you expect to happen if the procedure succeeds.

Plan B is what is to be done next at failure of Plan A; i.e., either recover the airway and ventilation by the original method (bag mask with oral or nasal airway) or a "rescue airway" such as a Laryngeal Mask Airway or Combitube device {fall back & regroup is always the default option}; or if the patient is still well-saturated and controlled, advancing to the next technique to accomplish the objective: use of an introducer, special laryngoscope blade or technique, fiberoptic stylet or bronchoscope, etc.

Plan C might be either what comes after Plan B, if the patient is stable: or what to do if the situation turns to "crisis" and the airway is lost or cannot be accomplished in any other manner. This may be a surgical airway (cricothyrotomy, or tracheotomy), jet ventilation for rescue, or subsisting on a rescue supraglottic airway until a tube can be passed through it. Consider "Double-Prepping": i.e., a fiberoptic stylet or Glidescope, for Plan A or Plan B, but the neck is already examined, landmarks identified and marked, and the skin prepared with povidone and surgical airway equipment is at hand. If operating room or anesthesia back-up is available, Plan C may be to "Stop at Plan B" and take the patient to where there are more resources and people before the patient has deteriorated or had so many attempts made that conditions have been worsened.

"Patients don't die of failure to intubate, they die of failure to stop trying to intubate”
                                                       Attributed to Jonathan L. Benumof, MD

"A surgical airway is better than an arrested patient with a nice-looking neck."
                                               D. John Doyle, MD PhD FRCPC


The "Crike Spike": Cricothyrotomy can be lifesaving relief of airway obstruction. There is no best approach for all circumstances. The wisest course is prudent preparation and securing the airway in advance of desperation. Anecdotal reports of a successful field improvised device have been heard for several years, but have not previously been studied.

     Improvised cricothyrotomy provides reliable airway access in an unembalmed human cadaver model.
     Platts-Mills TF, Lewin MR, Wells J, Bickler P.
     Wilderness Environ Med. 2006 Summer;17(2):81-6.
     PMID: 16805143

  The authors have tested and validated that a high-flow intravenous drip chamber and spike can be rapidly made and inserted into the trachea with successful ventilation. The device provides a larger airway and is more rigid than an intravenous cannula that might kink, and readily attaches to the 15mm inside diameter of a bag-valve breathing bag or ventilatory circuit.

  Using a low-pressure low-velocity source (bag) to ventilate may require manual occlusion of the victim's mouth and nose during inflation to prevent the inflation from "taking the path of least resistance" out of the patient, but ventilation was otherwise easy.

Note: Conventional practice with a high pressure "jet ventilator" for bronchoscopy or rescue ventilation in hospital settings is to keep an open oro-nasal and upper airway to allow the rapid flow to entrain room air and to allow ready exhalation that will prevent air-trapping and blow-back secretions. This is in contradistinction to the volume-limited nature of the low-flow low-pressure bag. An adequate expiratory airway must always be assured, regardless of ventilation method.

"Crike Spike" IV Drip Chamber cut and inserted into 15mm adaptor for flexible connection to Bag-Valve resuscitator

"Crike Spike" IV Drip Chamber cut and inserted into 15mm adaptor elbow for
anesthesia bag; Bag-Valve device can
be used

Sanders Jet Ventilator connected to 50
psi oxygen line. Black knob regulates
downstream pressure, lever triggers 
ventilation (manually cycled), gauge
shows downstream pressure, clear
tubing & metal tip (dust-capped with plastic blunt cannula and needle cover) connect to cannula or small-bore access. Used with open upper airway to prevent barotrauma
The Armpit Trick: The scene of a "Difficult Airway", whether in the hospital or in the field, can be chaotic and tumultuous. "Assistants" may not be as "helpful" as they intend. Objects in use tend to 'remain in motion" and to be easily lost or misplaced. The Airway Manager should carefully choose and prepare the intended endotracheal tube with shaping of the angulation, lubrication, stylet inserted, and inflating syringe (with air in it) attached to the inflation line of the ET tube. Any necessary back-up ETT (smaller size, or special type) which might also be needed should be similarly prepared. The Airway Manager should tuck the tube(s) in the opened package under the left armpit while performing Direct Laryngoscopy. With the tube(s) easily kept in the armpit during laryngoscopy, the right hand is free to manipulate the head, jaw, or larynx to improve the view, the assistants can be directed in their tasks, and the tube is ready-to-hand, when needed, without having been lost, dropped or altered.

A Matter of Gravity: Consider a patient, with impacted obstruction of the esophagus by a meat bolus, who is to undergo sedated endoscopic removal in your emergency department. He is fasted and otherwise
prepared for sedation. The gastroenterology consultants are filling your room with additional carts, monitors, and equipment.

  Propofol sedation is provided by the Attending Emergency Physician. Access to the head of the bed is limited by the crowding. All is well until the grasping and biting of the forceps upon the bolus stimulates vomiting of
bloody residue from the stomach. The patient is sitting, (appropriate for endoscopy and for minimal secretions) with an unprotected airway. However, your patient is sedated thereby altering airway reflexes that ordinarily
help guard the lower airway, and is spewing vomit which by gravity may fall towards the glottis, and has the presence of large stimulating instruments in his pharynx and esophagus. He is in great danger. 

  The scope is removed, the patient lowered to supine, and suctioning is done; however, the patient still vomits. What to do? Recall that the natural angle of the trachea is 20°-25° downwards from horizontal, therefore any regurgitation into the pharynx will track down and soil the lower airway past an areflexic glottis. 

  Cluttered equipment and personnel inhibit access to side pedals on the gurney for elevating the bed height and lowering the hydraulic jack at the head to create a Trendelenberg’s Position which would favor gravity
drainage. Know your equipment! Grasping the footbar of the bedframe on this gurney and lifting straight up causes immediate emergency Trendelenberg’s Position. As one moves toward the head, steepening of the
head-down position is done by stepping on the hydraulic release of the ordinary leveling mechanism. More suctioning is done, and additional Propofol is given to deepen sedation and for its anti-emetic effect.

  The patient’s desaturation and ventilation are controlled by a two-handed mask-hold and bag ventilation. When stabilized, the procedure is successfully resumed and concluded, and the patient, upon follow-up, does
not develop aspiration pneumonitis.  

  Whenever there is copious emesis or bleeding in the presence of an unprotected airway, the use of gravity drainage to minimize aspiration will be of great benefit. When the situation is under control and the airway
protected, one should resume a normal supine or head-up operating position. Untoward effects of prolonged Trendelenberg’s Position would be: embarrassed respiration from the weight of viscera upon the
diaphragm, increased intracranial pressured and vascular congestion of the head, neck, and torso. 

  Consideration of appropriate venue, available support, and potential need for prophylactic endotracheal intubation is incumbent on the physicians organizing the procedure.

"Altered" Mental Status: Paramedics radioed in their short estimated arrival time with a patient described as "combative" from stroke endured during sleep (last seen well going to bed) and efforts to start an I.V. underway. Upon arrival, the patient was non-verbal, restless and agitated, with a slight right facial droop, all extremities were moving with apparently equal strength. An oxygen non-rebreathing mask had slipped from the face and was dangling around the neck. The spouse was giving loud loving encouragement to the patient telling him "You've had a stroke . . . you're at the hospital and they will help you!" There was fleeting mention of "asthma" in Past History and "Lasix."

   What was odd was that "he didn't look like a stroke", i.e., didn't have focal weakness, nor were his movements random or athetoid. His skin was quite cool and clammy to touch, and his face pale and gray on the edge of frank cyanosis. He had rapid breathing with great labor and some gasps. Despite an intermittent reading of SPO2=95%, he was moved immediately to a resuscitation room where all usual initial efforts were done.

   Breath sounds were equal in all fields, not gurgly or crackly, but greatly diminished nearly to the point of a "silent chest." A nebulizer treatment of albuterol and ipratropium was begun with a "Mask and Horns" to provide the best concentration of medicine for a patient in distress. Within minutes of beginning the first nebulizer, the patient "looked better" with progressively decreasing distress and rapid improvement of skin color, perfusion, and mental status. Halfway through the neb, he was able to smile, speak a few words, and relax; his symptoms were fully reversed and he was recovered at the end of the treatment. The remainder of his stay was uneventful and he was discharged home.

   A mentor once told me, that "The Four H's"  needed to be excluded first as causes of otherwise unexplained agitation or restlessness in confused or unconscious persons: Hypoxemia, Hypoglycemia, Hypovolemia, and High Bladder (acute urinary retention). Blood sugar had been checked; there was no hypovolemia or "High Bladder", but excessive attention in the field had been focused upon the muteness and combativeness; rather than the spotty 95% reading which had not been correlated with the effort needed to achieve it, and therefore missed the hypoxemia that was the true cause of his problems.

  The patient had severe bronchospasm and severe "air hunger" until his bronchospasm was relieved. This had made him agitated, unable to speak, and the mild  droop or nasolabial flattening was a latent residuum of a previous stroke made prominent by his hypoxia.


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