Airway Emergency: Start With The Basics of Airway Management

We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway emergency: the dreaded “can’t intubate-can’t ventilate” airway emergency scenario.

As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.

One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition.

Airway Emergency: The Case

The patient was a 50 yo, 5’ 10”, 110 kg male suffering from respiratory failure from sepsis. The intensivist was preparing to intubate  and had asked me, as the anesthesiologist on the code team that day, to come over to the ICU to provide an extra pair of hands in case the intubation proved difficult. However, as I entered the ICU it was clear that the situation had clearly changed for the worse. The intensivist had tried and failed the intubation and had then been unable to ventilate. He was just setting up for an emergent cricothyrotomy. The oxygen saturation was 50. A nurse was unsuccessfully attempting to ventilate the unresponsive patient.

I had brought a glidescope with me and I rushed to the head of the bed, intending to attempt another intubation to establish an airway. However, the first thing I saw was that the nurse, in her anxiety, was pushing the face mask down over the face and in the process, forced the chin down over the neck. The whole head was bent steeply downward.

I quickly took over the airway, tilted the head back into the sniffing position and inserted an oral airway. I grabbed both jaw angles and pulled upward. The patient had a large round face and a thick neck which made keeping the mask seal challenging with one hand. I instead made the seal with both hands and asked the nurse to squeeze the bag. We were immediately able to ventilate and the saturation rose over the next minute into the mid 90s. Everyone in the room took a deep breath. I was then able to intubate using the Glidescope. Disaster was averted.

In this particular airway emergency, the lesson learned was to always start with the basics of airway management. Links are provided below to previous blog articles with greater detail on each topic. I recommend reading to the end for the big picture and then returning to the links for more in depth discussions.

Don’t Be Afraid To Ask For Help In An Airway Emergency

Our intensivist called for assistance early.  Rarely will you be in a situation where you are the only person trained in intubation. Never hesitate to ask for help. That help can be getting equipment ready, aid in holding the head or neck in position, or asking someone else to intubate.

The faster that help can arrive, the better off you (and your patient) are. Ask early and apologize later if you don’t need the help. If I’m anticipating a potentially difficult intubation I will often ask a colleague to stand by as an extra pair of hands. I also make sure I have back up equipment like bougies, supraglottic airways, and videolaryngoscopy.

Can’t Intubate

A common error if you’re having trouble intubating is to keep trying the same thing over and over again. Change your blade from a curved MAC to a straight Miller blade or the reverse. Alter the patient’s head position, try cricoid pressure, have someone else try. Sometimes it’s your technique that’s making the intubation difficult.

Bear in mind, however, that the more laryngoscopies you perform, the more likelihood there is of increasing laryngeal edema or bleeding. This can worsen the airway and ultimately make ventilation difficult. Unless you quickly see evidence of impending success, it’s often better to switch to an alternative method of intubation like videolaryngoscopy when you can.

Of course, if the intubation is elective, such as for elective surgery, then you can always abort the intubation attempt and awaken the patient to perform an awake intubation.

Can’t Ventilate

This is a true emergency. Without the ability to ventilate, you have only minutes until life-threatening complications occur, including brain damage and death. You must always be prepared for loss of the airway because it can occur unexpectantly.

First, Open the Airway

The most common cause of airway obstruction is the collapse of tongue and soft tissue at the back of the throat over the larynx. Tilting the head and pulling the jaw upward lifts this tissue off the larynx and opens the airway.

Illustration showing steps of opening an airway: Tilting the head and pulling the jaw upward lifts this tissue off the larynx and opens the airway.

A common cause of airway obstruction is the collapse of tongue and soft tissue at the back of the throat over the larynx. Tilting the head and pulling the jaw upward lifts this tissue off the larynx and opens the airway.

Use the head tilt, chin lift maneuver or the triple airway maneuver. Even if you’re using cervical spine precautions (and keeping the head in a neutral position with the neck) you should still pull the jaw upward.These maneuvers lift the tongue, epiglottis and soft tissue upward and off the glottic opening.

The triple airway maneuver tilts the head, lifts the chin, and thrusts the jaw.

The triple airway maneuver tilts the head, lifts the chin, and thrusts the jaw.

Insert An Oral or Nasal Airway

Insert an nasal or an oral airway to treat airway obstruction. Nasal airways are better tolerated by semi-conscious patients. Oral airways are often used in unconscious patients to avoid the potential risk of nose bleed.

Illustration showing proper technique for inserting a nasal airway

Always insert a nasal airway parallel to the floor of the nose.

Illustration showing one technique to insert an oral airway in an airway emergency

You can use a tongue blade to pull the tongue forward and then slide the oral airway in over the tongue to keep the tongue off the larynx.

Oral and nasal airways are not mutually exclusive. If I’m having a really hard time ventilating a patient I will insert both an oral and a nasal airway. They work by different mechanisms and their function ca be additive. If the patient regains consciousness, and a gag reflex, to the extent that they are no longer tolerating the oral airway then you may have to remove it. Having a nasal airway in place helps maintain an airway that may still be somewhat precarious.

Pull The Face Into The Mask,
Never Push The Mask Onto The Face

A big mistake with ventilation is trying to seal the mask by pushing the mask down onto the face, as in this case. This maneuver invariably forces the chin downward, piling the soft tissue around the back of the tongue over the larynx and worsening airway obstruction.

illustration showing that the first step to a applying a ventilation mask starts with opening the airway.

The first step to a good mask seal is opening the airway. (All illustrations from Anyone Can Intubate 5th Ed., C. written MD)

To ventilate, start with a good mask seal. Always pull the face up into the mask by grasping the mandibular bone (not the soft tissue) and lifting the face into the mask to produce the seal. The face becomes sandwiched between your fingers pulling up and your thumb and forefinger sealing the mask against the face.

Illustration of applying the top of the mask to the bridge of the nose to obtain a good mask seal while make ventilating a patient

Apply the top of the mask to the bridge of the nose, where leaks often occur.

Illustration of applying the top of the mask to the bridge of the nose to obtain a good mask seal while make ventilating a patient

Apply the top of the mask to the bridge of the nose, where leaks often occur.

Illustration showing pulling the face into the mask, using the cheek tissue on either side to help make the seal while makes ventilating a patient

Pull the face into the mask, using the cheek tissue on either side to help make the seal.

Illustration showing final mask position with the lower lip and mouth inside the mask while makes ventilating a patient

Seat the mask over the chin, making sure the lower lip is inside the mask.

Illustration showing Thumb and forefinger positions to obtain an effective mask seal when ventilation in an airway emergency

Note the finger positions. Thumb and forefinger press mask against the face and form a “C” shape. Remaining fingers grip mandible and form an “E”.

Note the positions of the fingers. Thumb and forefinger press mask against the face and form a “C” shape. Remaining fingers grip mandible and form an “E”. You are literally pulling the face into the face with your fingers while your thumb is applying counter pressure. This push pull action also holds the head in extension and holds the airway open.

Illustration showing how to pull the patient's face into the mask to seal.

Don’t just push the mask down, pull the patient’s face into the mask to seal.

Use Two Person Ventilation When It’s Hard To Ventilate

Use good ventilation technique, based on your knowledge of basic physiology, to ventilate effectively, as previously discussed in this blog article.

If difficulty persists, use both your hands to seal the mask. Have a helper squeeze the bag for you. Place thumbs on top of the mask, index fingers on the bottom, bunching the soft tissue of the cheeks under the mask. Pull the jaw upward with your remaining fingers by spreading them along the jaw line, underneath the angle of the mandible. Pull up forcefully, squeezing the patient’s face between the mask and your hands. Hold just the bone. Pushing on the soft tissue under the jaw can force it into the airway and worsen obstruction.

Illustration showing the technique of using both your hand to seal a mask and having an assistant squeeze the bag as a way to ventilate effectively during airway emergencies

Using both your hand to seal a mask is very efficient in long difficult ventilations. You must communicate carefully with the assistant squeezing the bag to ensure good ventilation.

Use of both hands makes it easier to shift the mandible forward and pull the obstructing tissue up and off the larynx. Move your fingers as needed to perfect your seal. You may still sometimes need a helper to stop leaks

When someone else is squeezing the bag, it’s especially important to verify adequate ventilation — since you can no longer feel the compliance of the bag yourself. Watch the chest rise, see the air condense on the mask (if mask is clear plastic), and have someone listen for breath sounds. Make sure your helper communicates any signs of obstruction or lack of seal immediately. This technique is a team effort.

Follow this link to a video on how to open an airway, insert an oral or nasal airway and apply a mask to ventilate. Ventilation using both one hand and two hands with an assistant is also demonstrated.  

Rescue With a Supraglottic Airway!

If the goal is urgent ventilation, remember that intubation is only one way to ventilate.  A supraglottic airway like the Laryngeal Mask Airway is a superb rescue airway. If you can ventilate though an LMA you will have time to consider what further steps need to be taken to secure the airway, or to wake up the patient.

In you still can’t ventilate, you must consider surgical options such as a jet ventilator or cricothyrotomy to quickly reestablish oxygenation. The intensivist was just beginning this step when I arrived on the scene.

Illustration showing one version of a Failed Airway Algorithm

A Failed Airway Algorithm

Crisis Management

In the stress and chaos of an emergency, it’s a common human failing that the brain can freeze in unfamiliar circumstances. Forgetting key steps and even techniques is common. That’s one of the main reasons why we perform Critical Event Training. It’s also the reason we all have to rectify with ACLS, PALS, BLS every 2 years. It’s easy to forget the basics if you don’t use them all the time.

The more familiar we are with a scenario, the more likely we will immediately perform the steps that are needed to resolve it, especially if those crises are rare in real life. In addition, Crisis Check Lists are increasingly being used to specifically help ensure that providers use all possible options during rare critical events such as cardiac arrests, pulmonary emboli, dysrhythmias, hypoxia, and others. If your hospital doesn’t have Crisis checklists consider obtaining them.  One such aide can be downloaded here.

Teamwork is also extremely important. Your team members must feel comfortable with making suggestions, pointing out potential problems, and keeping each other informed on what steps have been taken and which are needed. The value of treating patients as a team is that you can leverage the power of multiple brains in the room to solve the problem. You are much more powerful and likely to succeed as a group rather than trying to act alone.

Frequent practice, learning about how to treat those rare emergencies, and improving your ability to function as a team is important before you actually find yourself in a critical event.

May The Force Be With You

Christine Whitten MD

Author, Anyone Can Intubate 5th Edition
Pediatric Airway Management: A Step-By-Step Guide

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten      Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

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4 thoughts on “Airway Emergency: Start With The Basics of Airway Management”

  1. Dr. Whitten: Just stumbled on this site, which has a lot of great info. I’m editor of Anesthesiology News, and we have an annual special issue on Airway Management. I’m wondering if you might want to write a review for that issue (it is published every August). If interested, please contact my email… thanks… James Prudden, Anesthesiology News

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