Whether performed surgically or not, airway management requires careful assessment of the patient, and proper placement of the airway appliance used is essential.

By Tracy Evans, RN, MPH, ACNP, CEN, CCRN, EMTP; and Michael A. Frakes, RN, BSN, CFRN, CCRN, EMTP

Airway management is the foundation of respiratory care practice. RTs can position themselves as expert consultants regarding airway stabilization and management immediately following intubation or tracheostomy, as well as during interhospital and intrahospital transport.

The decision to establish an artificial airway is made after answering four key questions.1 Is the airway patent? Do oxygenation and ventilation require support? Is the patient able to protect the airway? Will planned therapy require control of the airway? In an emergency situation, the clinician must consider not only the status of the patient, but also expectations for the immediate future. For example, a burn patient may have a patent airway at the time of assessment, but the presence of soot in the nares and on the lips indicates a high likelihood of inhalation injury. Increasing edema could compromise the airway within minutes.

Nonsurgical Airway Management

The first choice for emergent or short-term airway management is the endotracheal tube. In the hands of a skilled clinician, the tube is relatively easy to place in the trachea. There are, however, a number of factors that could complicate endotracheal intubation. Patients with certain conditions are considered likely to be difficult to intubate, and alternative airway procedures should be considered.

While obtaining the patient history, the interviewer should determine whether the patient has dental disease, loose teeth, or oral appliances that could be dislodged during an intubation attempt. It is important to ask whether there are any conditions that could interfere with the mobility of the cervical spine, neck, or mouth, such as prior operations or injuries, arthritis, or temporomandibular joint (TMJ) disease.

Next, a rapid physical examination of the mouth, neck, TMJ, and face will identify anatomical anomalies that could interfere with oral endotracheal intubation. The mouth must open approximately 20 mm for a laryngoscope to be placed properly for visualization, so any condition that limits abduction of the mandible will require an alternative approach to airway management. The size of the tongue should be assessed, and the presence of any foreign bodies or tumors that could impair visualization should be determined. Trauma to the face, jaw, or neck will complicate endotracheal intubation and may require a different approach to airway management.

Esophageal-tracheal tubes were originally designed for prehospital providers who lacked training in advanced airway management techniques. These combination tubes are inserted blindly, without visualization of the posterior pharynx or vocal cords. Some devices, however, also have a role in hospital airway management.2 They consist of a double-lumen tube, with one lumen opening at the distal end of the tube and the other opening in a series of fenestrations that are, when placed properly, in the posterior pharynx. The tube is blindly inserted into the mouth until the rings on the proximal end line up with the front teeth or alveolar ridge. Once the tube is in place, a balloon that fills the anterior pharynx is inflated. This balloon protects the lower airway from any secretions or blood from the mouth and keeps the tube in place. Next, the balloon surrounding the distal tube is inflated, creating a seal similar to the balloon on a traditional endotracheal tube. A manual resuscitation bag is connected to the lumen leading to the pharyngeal fenestrations, and the patient is ventilated. Tube position is confirmed by listening for breath sounds and checking for exhaled carbon dioxide. If no breath sounds are heard and no carbon dioxide is detected, the distal tube is in the trachea. The manual resuscitation bag is moved to the distal lumen and ventilation is resumed, with the same parameters being checked to confirm placement.1,2

While these tubes were designed for personnel not skilled in airway management, they may be chosen for in-hospital use when intubation cannot be accomplished and ventilation is ineffective.

Use of these tubes is one of the adjuncts described in the American Society of Anesthesiologists (ASA) difficult airway algorithm and can sometimes be used to avoid the need for an invasive procedure to control an airway.1,2

Laryngeal Mask Airways

The laryngeal mask airway (LMA) was originally conceived as an alternative to face-mask delivery of anesthetic but has developed into an effective means of airway control. It consists of a tube attached to an inflatable mask that is placed blindly into the posterior pharynx, where it seals the immediate supraglottic area and provides effective ventilation. An appropriately sized LMA can be rapidly inserted in almost any patient, and the use of the LMA in lieu of an endotracheal tube for shorter anesthesia cases in the operating room is becoming widespread. Like the esophageal-tracheal tubes, the LMA is part of the ASA rescue airway algorithm.

Needle cricothyrotomy is a life-saving procedure done when the patient cannot be ventilated. The cricothyroid cartilage is identified and swabbed with an antiseptic, and a 14-gauge catheter is inserted. The needle is withdrawn, and emergency ventilation is done through the catheter. Ideally, oxygen at 50 psi is connected, with delivery for 1 second performed 12 times per minute.1 If high-pressure oxygen delivery is not available, the barrel of a 3-mL syringe can be attached to the proximal end of the catheter. A 7.5-mm to 8-mm endotracheal-tube adapter is inserted into the proximal end of the syringe, where the plunger has been removed; the patient can then be ventilated using a manual resuscitation bag.3 This approach creates a temporary emergency airway. It should be used for no more than approximately 30 minutes, because ventilation is severely limited and hypercapnia results.

Surgical Airway Management

Surgical airway management is a challenge in emergency settings because the need for surgical intervention is low, making it difficult to maintain the skills for a high-risk, low-frequency procedure. It should not be done when mask ventilation or any rescue airway is a reasonable option for airway management.3 Surgical cricothyrotomy is indicated when endotracheal intubation is not an option because of complete upper-airway obstruction or when endotracheal intubation fails, and the patient cannot be ventilated by any other means. It is contraindicated in children younger than 8 years of age, when the larynx is fractured, and when there is such massive edema or hematoma from trauma that safety is affected because anatomical landmarks cannot be identified.

In the rapid four-step method described by Stewart,3 the cricothyroid membrane is identified by palpation below the laryngeal prominence (Adam’s apple). A horizontal stab incision is made with a scalpel, a tracheal hook is used to stabilize the inferior border of the opening, and a size 4 to 5 cuffed tracheostomy tube is inserted into the opening. The patient is then manually ventilated and tube placement is assessed in the usual manner.3 Other authors describe variations on the procedure, but the finished product does not vary.

Tracheotomy is not generally recommended for emergency airway management even with an experienced surgeon performing the procedure. The surgical cricothyrotomy is faster and will provide for adequate oxygenation and ventilation. The cricothyrotomy is sometimes left in place, and it is sometimes replaced by a formal tracheotomy in the operating room. Tracheotomy is one of the procedures most commonly performed on critically ill patients who require long-term mechanical ventilation.3,4

Securing the Tracheotomy Tube

Regardless of the nature of the appliance placed in the airway, maintaining the proper placement of that device is essential. Unintentional misplacement or removal of an endotracheal tube, LMA, esophageal-tracheal tube, or tracheostomy can easily result in hypoventilation, hypoxia, or complications from atelectasis or barotrauma. Airway dislodgement can be rapidly fatal.

Esophageal-tracheal tubes have integrated cloth fasteners. Endotracheal tubes and LMAs are secured with similar techniques, and a cricothyrotomy tube is secured in a manner similar to a tracheostomy tube. The number of methods for securing endotracheal tubes likely approximates the number of practicing respiratory care practitioners. We will not attempt to catalogue each method. However, the common theme is that the method used must be simple to place, must stabilize the tube, and must allow observation of the depth markers on the airway appliance. Adhesive tape, umbilical ties, and IV tubing are frequently utilized. Commercial devices ranging from cloth tapes with hook and loop fasteners to those with sophisticated integrated clamps are also available. As with any situation where a multitude of practice options are of essentially equal utility, the practitioner is advised to master a few techniques, rather than to be minimally proficient in many.

Performing the tracheotomy procedure initially provides the airway opening, but securing the tracheotomy tube properly is critical to maintaining a patent airway before a tract has had time to form. If a tracheotomy tube is coughed or pulled out in the immediate postoperative period, the opening will close and the airway may be lost. Stay sutures are often placed at the end of the procedure; these sutures provide traction to open the wound if the tube is displaced.5 Some authors4 disagree with this practice, stating that these retaining sutures are only beneficial in the operating room under controlled conditions. It is important for the person caring for the postoperative patient to know whether the surgeon used this technique, in case the tube should later become dislodged.

Sutures are also used to tack a tracheal flap to the skin edges to facilitate formation of an opening. In many cases, the flanges of the tracheotomy tube are sutured to the skin to prevent tube expulsion.4,5 It takes at least a week for a permanent tract to form, so the tube should not be removed or changed during this time.

A number of materials can be used to secure the tracheotomy tube. Twill tape is the traditional means of securing the tube, although the specially manufactured hook-and-loop ties are increasingly utilized due to their ease of use and increased patient comfort. For pediatric patients, some caregivers use a stainless-steel beaded chain around the neck.6

Fabric ties must be changed whenever they are soiled or wet to prevent skin maceration; for some patients, this may be more than once a day. Twill tape can unravel at the ends, which can loosen the knots tied in the twill. It can also be irritating to the skin. Hook-and-loop ties degrade over time, particularly when used in home care. It is much easier for one person to change the ties, however, when a hook-and-loop device is used. In addition, since these devices are wide and padded, they are less likely to abrade the skin. Overall, they are simply easier to use.6

The steel beads do not trap moisture, and they are very durable. These ties do not need to be changed as fabric ties would. The tension around the neck is more consistent for the beaded chain than for fabric devices, which depend on the caregiver’s tension adjustment each time a change is made.

The common rule of thumb for applying tracheotomy ties is to be able to slip one finger beneath the tie, securing the tube in a way that is not so tight as to cause pressure sores or to compress structures in the neck, yet is tight enough to prevent movement of the tube.6


Tracy Evans, RN, MPH, ACNP, CEN, CCRN, EMTP, is trauma program manager and director of emergency medical services, Norwalk Hospital, Norwalk, Conn; Michael A. Frakes, RN, BSN, CFRN, CCRN, EMTP, is a senior flight nurse and the practice and research coordinator for LIFE STAR/Hartford Hospital, Hartford, Conn.

1. Blanda M, Gallo UE. Emergency airway management. Emerg Med Clin North Am. 2003;21(1):1-26. Review.
2. Butler KH, Clyne B. Management of the difficult airway: alternative airway techniques and adjuncts. Emerg Med Clin North Am. 2004;21(2):259-289. Review.
3. Stewart CE. Advanced Airway Management. Upper Saddle River, NJ: Pearson Education; 2002:124-149.
4. Walts PA, Murthy SC, DeCamp MM. Techniques of surgical tracheostomy. Clin Chest Med. 2003;24(3):413-422. Review.
5. Morgan CE, Dixon S. eMedicine. Tracheostomy. Available at: http://www.emedicine.com/ent/topic356.ht. Accessed October 9, 2005.
6. Sherman JM, Davis S, Albamonte-Petrick S, Chatburn RL, Fitton C, Green C. Care of the child with a chronic tracheostomy (consensus statement). Am J Respir Crit Care Med. 2000;161(1): 297-308.