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AIRWAY MANAGEMENT / MAINTENANCE

I. Ensuring maintenance of an adequate airway is of primary importance for all patients

transported by San Antonio AirLIFE. Criteria for advanced airway procedures may
include:
A. Acute respiratory failure, obvious respiratory distress
B. Oxygen saturations < 92% on 100% oxygen
C. Glasgow coma score 8 in trauma patients suspected of head injury
D. Significant oral / facial burns or edema of the neck, face and / or oral
mucosa
E. Significant smoke or toxic inhalation associated with carbonaceous
sputum or impending respiratory compromise
F. Obtunded patients with poor airway reflex (AVPU score of P or U)
G. Infants with cyanotic CHD who are ductal dependent, have right to left
shunting or who have had a Blalock shunt or other central shunts will have
SpO2 saturations of 70 – 85% and should not routinely be intubated unless
also suffering from significant respiratory distress or metabolic /
respiratory acidosis. Consult Medical Control if necessary
H. Newborn receiving Prostin – consider intubation prior to transport if any
events of apnea have been witnessed

II. Treatment
A. Perform assessment and determine Mallampati Classification (Class I –
IV) of airway, assess jaw mobility and thyroid-mentum distance.
B. Provide C-Spine stabilization for suspected trauma patients.
C. Pre-oxygenate with oxygen via non-rebreather or bag valve mask device
to enhance oxygenation and induce nitrogen washout. Spontaneously
breathing patients, with adequate Minute Volume, should be administered
oxygen via non-rebreather mask for a minimum of 2 – 3 minutes prior to
intubation attempts. Patients requiring BVM ventilations should be
ventilated for a minimum of 2 minutes prior to intubation attempts.
D. Sedation / Pre-medication
1. Consider analgesic / sedation / hypnotic administration
with fentanyl, Versed, or etomidate as per guideline.
Extreme caution is required for sedation of patients who are
hemodynamically unstable (i.e. cardiogenic or
hypovolemic shock). Sedatives may cause or worsen
hypotension. Fentanyl and etomidate cause less adverse
hemodynamic effects than other medications utilized for
pharmacology-assisted intubation (PAI) carried by San
Antonio AirLIFE (i.e. Versed, Valium). Patients who are
completely obtunded and who are hemodynamically
compromised may be intubated without medications.

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2. Pre-medicate pediatric patients (≤8 y/o) with Atropine
0.02mg/kg IVP (minimum dose of 0.1mg) and a maximum
dose of 0.5mg.
E. Pharmacological Agents for Airway Procedures

1. Consider etomidate per guideline for all patients but

especially those with Class III or Class IV Mallampati
airways in lieu of paralytics.

2. Consider the non-depolarizing paralytics Zemuron

(rocuronium) or Norcuron (vecuronium) with sedation as
per guideline. EXTREME CAUTION with Mallampati
Class III airways. Paralytics have a relative
contraindication for use in Mallampati Class IV airways
until the trachea has been intubated.
F. Intubation Procedure

1. Provide cricoid pressure (Sellick’s Maneuver) following

administration of pharmacological agents above.

2. Intubation may be performed by either the oral or nasaltracheal

route. (*Nasal intubation requires the patient to be
spontaneously breathing.*)

3. Select appropriate laryngoscope blade. Lubricate stylette

prior to placing it in tube and lubricate tube prior to
intubation.

4. A Bougie may be utilized in place of a stylette.

Confirmation of Bougie placement should be verified by
the presence of tracheal clicking (vibration caused by the
device rubbing over the cricoid rings.

5. Note Cormac – Lehane Airway Classification (Grade I –

IV) during laryngoscopy.

6. Intubate the trachea with cuffed ETT. Ensure pilot balloon

is below the level of the vocal cords.

7. Surgical cricothyroidotomy may be performed if patient

condition mandates (i.e. severely distorted airway anatomy,
kyphosis, entrapment, can’t intubate – can’t ventilate
situations, etc.)

G. Confirm Intubation

1. Visualize ETT passing through and below level of vocal

cords.

2. Auscultate breath sounds. Compare bilaterally.

3. Ensure no ventilation sounds over epigastric region.

4. Apply ETCO2 Detector (Quantitative (Color-metric) or

Qualitative (continuous waveform monitoring)) and ensure
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presence of ETCO2. Absence of ETCO2 indicates

incorrect tube placement or severe, deadly, hypo-perfusion
states.

5. If there is any doubt regarding tube placement, it should be

removed and BLS ventilation procedures initiated.
H. Unsuccessful Endotracheal Intubation Attempt(s)

1. Ventilate patient with BVM utilizing oral-airways and

nasal-pharyngeal-airways as necessary. Re-attempt
procedure. After two unsuccessful intubation attempts by
an individual, they should relinquish next attempts to their
partner. Consider switching size and type of laryngoscope
blade.

2. Consider use of External Laryngeal Manipulation (ELM).

ELM of the laryngeal structure such as 1) increased
Sellick’s Maneuver, 2) Backwards-Upward-Rightward-
Pressure (BURP) may enhance visualization of airway
structures.

3. If not utilized during prior attempts, endotracheal

intubation should be attempted via Bougie assist.
4. Consider use of the Laryngeal Mask Airway (LMA). The
LMA is a low-pressure ventilation device and attempts to
provide too much positive pressure ventilation may
interrupt seal of laryngeal mask rendering it less effective.

I. Can’t Intubate / Can’t Ventilate Situations

1. Consider use of the Laryngeal Mask Airway (LMA). The

LMA is a low-pressure ventilation device and attempts to
provide too much positive pressure ventilation may
interrupt seal of laryngeal mask rendering it less effective.

OR
2. Perform insertion of an oral-pharyngeal airway (OPA) and
bilateral nasal-pharyngeal airways (NPA). Provide
aggressive mask seal while lifting mandible. Apply
Sellick’s Maneuver while performing BVM ventilations.
OR
3. Consider Surgical Cricothyroidotomy for patient’s ≥10
y/o.
4. Consider Needle Cricothyroidotomy for patient’s ≤10 y/o.
J. Securing Airway Adjunct
1. Secure device with tape, commercial tube-restraint, tube tamer,
twill tape, or other appropriate device.
K. Post Intubation Management
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1. Consider analgesic, anxiolytic, or paralytic administration for

optimal airway control as needed.
2. The ventilator should be considered for inter-facility flights or
flights > 15 minutes in duration. The initial tidal volume (Vt)
will be 6 – 10 mL/kg (ideal body weight). Respiratory rate
(RR) should be set to administer a Minute Volume (MV) of 6 –
10 L/min. (Vt x RR = MV)
3. Ventilator Management for infants/children:
4. Volume and rate to maintain normal ETCO2.
5. FiO2 – Adjust to maintain acceptable SpO2 saturations for
disease condition.

L. When transferring care of the patient to the receiving facility, placement of

the ETT should be checked and verified prior to relinquishing care of the
airway by the AirLIFE Medical Crew. Continuous ETCO2 monitoring
shall be performed throughout transport and until delivery of the patient to
the receiving bed at the receiving institution. Confirmation of ETT
placement upon relinquishment of care should be documented in the

AirLIFE patient care record.

Reviewed/Revised: 10/98, 4/2001, 6/2002, 01/04, 03/05, 03/07, 02/09