Advanced airway management is the subset of

airway management Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either cl ...

that involves advanced training, skill, and invasiveness. It encompasses various techniques performed to create an open or patent

airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...

– a clear path between a patient's

lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...

s and the outside world. This is accomplished by clearing or preventing obstructions of airways. Obstructions can be caused by many things, including the patient's own

tongue The tongue is a muscular organ (anatomy), organ in the mouth of a typical tetrapod. It manipulates food for mastication and swallowing as part of the digestive system, digestive process, and is the primary organ of taste. The tongue's upper surfa ...

or other anatomical components of the airway,

foreign bodies A foreign body (FB) is any object originating outside the body of an organism. In machinery, it can mean any unwanted intruding object. Most references to foreign bodies involve propulsion through natural orifices into hollow organs. Foreign bo ...

, excessive amounts of

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...

and body fluids, or aspiration of food particles. Unlike

basic airway management Basic airway management are a set of medical procedures performed in order to prevent airway obstruction and thus ensuring an open pathway between a patient's lungs and the outside world. This is accomplished by clearing or preventing obstructions ...

such as head tilt/chin lift or

jaw-thrust maneuver The jaw-thrust maneuver is a first aid and medical procedure used to prevent the tongue from obstructing the upper airways. This maneuver and the head-tilt/chin-lift maneuver are two of the main tools of basic airway management, and they are ...

, advanced airway management relies on the use of

medical equipment A medical device is any device intended to be used for medical purposes. Significant potential for hazards are inherent when using a device for medical purposes and thus medical devices must be proved safe and effective with reasonable assura ...

and advanced training. Certain invasive airway management techniques can be performed "blind" or with visualization of the

glottis The glottis is the opening between the vocal folds (the rima glottidis). The glottis is crucial in producing vowels and voiced consonants. Etymology From Ancient Greek ''γλωττίς'' (glōttís), derived from ''γλῶττα'' (glôtta), va ...

. Visualization of the glottis can be accomplished either directly by using a

laryngoscope Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during ge ...

blade or by utilizing newer video technology options. In roughly increasing order of invasiveness are the use of supraglottic devices such as

oropharyngeal The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its struct ...

(''OPA''),

nasopharyngeal The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its struct ...

(''NPA''), and

laryngeal mask airway A laryngeal mask airway (LMA), also known as laryngeal mask, is a medical device that keeps a patient's airway open during anaesthesia or while they are unconscious. It is a type of supraglottic airway device. They are most commonly used by anae ...

s (''LMA''). Laryngeal mask airways can even be used to deliver

general anesthesia General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...

. These are followed by infraglottic techniques, such as

tracheal intubation Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic catheter, tube into the vertebrate trachea, trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer ce ...

and finally surgical techniques. Advanced airway management is a key component in

cardiopulmonary resuscitation Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...

anaesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), am ...

emergency medicine Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians (often called “ER doctors” in the United States) continuously learn to care for unsche ...

, and

intensive care medicine Intensive care medicine, also called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. It includes pro ...

. The ''A'' in the

ABC ABC are the first three letters of the Latin script known as the alphabet. ABC or abc may also refer to: Arts, entertainment, and media Broadcasting * American Broadcasting Company, a commercial U.S. TV broadcaster ** Disney–ABC Television ...

initialism An acronym is a word or name formed from the initial components of a longer name or phrase. Acronyms are usually formed from the initial letters of words, as in ''NATO'' (''North Atlantic Treaty Organization''), but sometimes use syllables, as ...

mnemonic A mnemonic ( ) device, or memory device, is any learning technique that aids information retention or retrieval (remembering) in the human memory for better understanding. Mnemonics make use of elaborative encoding, retrieval cues, and imag ...

for dealing with critically ill patients stands for airway management. Many airways are straightforward to manage. However, some can be challenging. Such difficulties can be predicted to some extent; a recent Cochrane systematic review examines the sensitivity and specificity of the various bedside tests commonly used to predict difficulty in airway management.

Pharnygeal airways

Pharyngeal airway devices are used in spontaneously breathing patients to move the tongue away from the back of the throat to restore airway patency.

Obstruction Obstruction may refer to: Places * Obstruction Island, in Washington state * Obstruction Islands, east of New Guinea Medicine * Obstructive jaundice * Obstructive sleep apnea * Airway obstruction, a respiratory problem ** Recurrent airway o ...

of the upper airway caused by the tongue most commonly occurs during times of decreased levels of consciousness. Pharyngeal airway devices include nasopharyngeal airways (NPAs) and oropharyngeal airways (OPAs). These devices are the simplest artificial airways.

Oropharyngeal airways

An oropharyngeal airway (OPA) is a rigid tube that is inserted into the mouth through the

oropharynx The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its struct ...

and placed above the tongue to move it away from the back of the throat. They are more commonly used than nasopharyngeal airways (NPAs). OPAs should only be used in profoundly

unresponsive A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound, lacks a normal wake-sleep cycle and does not initiate voluntary actions. Coma patients exhi ...

unconscious Unconscious may refer to: Physiology * Unconsciousness, the lack of consciousness or responsiveness to people and other environmental stimuli Psychology * Unconscious mind, the mind operating well outside the attention of the conscious mind a ...

patients without a

gag reflex The pharyngeal reflex or gag reflex is a reflex muscular contraction of the back of the throat, evoked by touching the roof of the mouth, the back of the tongue, the area around the tonsils, the uvula, and the back of the throat. It, along with othe ...

. Placement of the device may stimulate the gag reflex and cause vomiting, aspiration, and

laryngospasm Laryngospasm is an uncontrolled or involuntary muscular contraction (spasm) of the vocal folds. The condition typically lasts less than 60 seconds, but in cases partial blocking it may last 20 to 30 minutes and hinder inspiration, while exhala ...

. Complications from OPA placement include damage to the teeth and the

lingual nerve The lingual nerve carries sensory innervation from the anterior two-thirds of the tongue. It contains fibres from both the mandibular division of the trigeminal nerve (CN V3 ) and from the facial nerve (CN VII). The fibres from the trigeminal nerv ...

, which may cause changes in taste and sensation of the tongue.

Nasopharyngeal airways

A nasopharyngeal airway (NPA) is a flexible tube that is passed through the nose into the back of the throat. They are the artificial airways of choice in patients who are conscious and have intact gag reflexes because they are less likely to stimulate the gag reflex than oropharyngeal airways (OPAs). NPAs can also be used in other sitations where OPAs cannot, such as in patients with restricted mouth opening or oral trauma. NPAs are generally not recommended if there is suspicion of a fracture to the base of the skull due to the risk of the tube entering the

cranium The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone. However two parts are more prominent: the cranium and the mandible. In humans, the ...

. They are also

contraindicated In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...

in the presence of significant facial trauma.

Epistaxis A nosebleed, also known as epistaxis, is bleeding from the nose. Blood can flow down into the stomach, and cause nausea and vomiting. In more severe cases, blood may come out of both nostrils. Rarely, bleeding may be so significant that low bloo ...

is a complication of NPAs that may result from the use of excessive force during placement.

Extraglottic airways

Extraglottic airway devices (EGDs) create a patent airway without entering the

trachea The trachea, also known as the windpipe, is a Cartilage, cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends ...

. These devices are highly effective for providing oxygenation and

ventilation Ventilation may refer to: * Ventilation (physiology), the movement of air between the environment and the lungs via inhalation and exhalation ** Mechanical ventilation, in medicine, using artificial methods to assist breathing *** Ventilator, a m ...

. They can be used as primary airway devices, such as during

CPR Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore sponta ...

, or as rescue devices in situations where securing an airway using other devices has failed. EGDs are especially good rescue devices for obese patients and patients with significant facial trauma. EGDs do not protect the trachea from obstruction or aspiration. They may be used for several hours until a definitive airway can be secured. Each type of EGD has different features, including the ability to remove air from the stomach (gastric decompression) and perform

. All EGDs can be placed without directly seeing the

(also called "blind" placement). EGDs can be classified into supraglottic airways and retroglottic airways.

Supraglottic airways

Supraglottic airway devices (SGAs) create a seal over the glottic opening to send oxygen directly into the trachea. The SGAs consist entirely of laryngeal masks. Several manufacturers produce these devices, the most well known being the laryngeal mask airway (LMA). Success rates of SGAs in securing airways are similar between the different models, and these devices provide effective ventilation in more than 98% of patients. SGAs can be placed in under 30 seconds, making them advantageous for emergency use. Serious complications are rare and usually result from nerve and soft tissue trauma in the pharynx during placement.

Retroglottic airways

Retroglottic airway devices (RGAs) pass behind the glottis and into the

esophagus The esophagus (American English) or oesophagus (British English; both ), non-technically known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the ...

to create a seal allowing oxygen to be delivered directly to the trachea. The RGAs are designed as laryngeal tubes. Examples of RGAs include the

Combitube The Combitube—also known as the esophageal tracheal airway or esophageal tracheal double-lumen airway—is a blind insertion airway device (BIAD) used in the pre-hospital and emergency setting.Jorge E. Zamora and Tarit K. Saha,Combitube rescue f ...

and The King LT. Studies comparing the effectiveness between the RGAs are lacking. Like SGAs, most complications from RGAs result from trauma to the pharynx during placement.

Tracheal intubation

Tracheal intubation, often simply referred to as

intubation Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Patients are generally anesthetized beforehand. Examples include tracheal intubation, and the balloon tamponade with a Sengstaken-Blakemo ...

, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill or

anesthetized Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), am ...

patients to facilitate

of the lungs, including

mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...

, and to prevent the possibility of

asphyxia Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that can i ...

tion or airway obstruction. The most widely used route is orotracheal, in which an

endotracheal tube A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide. Many different types of tracheal tubes are a ...

is passed through the mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea.

Indications

There are specific indications or guidelines for deciding a more invasive and more secure airway is worth the associated risk:Avva U, Bhimji SS. Airway, Management. pdated 2017 Dec 15 In: StatPearls nternet Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470403/ *

respiratory failure Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...

apnea Apnea, BrE: apnoea, is the temporal cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are ( patency), there ...

or the suspension of breathing * decreased or

altered level of consciousness An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment. A mildly depressed level of consciousn ...

, rapid mental status change,

Glasgow Coma Scale The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These thre ...

score less than 8 (GCS<8). *

major trauma Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Dependin ...

, such as penetrating injury to abdomen or chest * direct airway injury or facial burns * high risk of aspiration

Methods

Classically tracheal intubation has been performed utilizing laryngoscopy to obtain direct visualization of the

vocal cords In humans, vocal cords, also known as vocal folds or voice reeds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speech ...

. There are multiple different laryngoscope blade styles, shapes and lengths from which to choose. Multiple intubation tools are now available with built-in video technology. A

Glidescope Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during ...

utilizes a laryngoscopic blade connected by a cable to a large video screen and requires a slightly different technique than that of a traditional laryngoscope. The McGrath model has a compact design with a smaller screen directly attached to the blade. Studies have shown that video laryngoscopes when compared to classic models resulted in fewer failed intubation attempts, especially in those patients designated as more difficult airways.

Confirming placement

The gold standard for confirming successful placement of an endotracheal tube is direct visualization of the tube passing through the vocal cords. Secondary methods of confirmation include

capnography Capnography is the monitoring of the concentration or partial pressure of carbon dioxide () in the respiratory gases. Its main development has been as a monitoring tool for use during anesthesia and intensive care. It is usually presented as a ...

oxygen saturation Oxygen saturation (symbol SO2) is a relative measure of the concentration of oxygen that is dissolved or carried in a given medium as a proportion of the maximal concentration that can be dissolved in that medium at the given temperature. It ca ...

chest x-ray A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in med ...

, or equal chest rise and breath sounds heard on both sides of the

chest The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...

Surgical airways

Surgical methods for airway management rely on making a surgical incision below the glottis in order to achieve direct access to the

lower respiratory tract The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...

, bypassing the

upper respiratory tract The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...

. Surgical airway management is performed as a last resort in cases where tracheal intubation has failed, is not feasible, or is

. Surgical methods for airway management include

cricothyrotomy A cricothyrotomy (also called cricothyroidotomy) is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or ...

and

tracheostomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the Vertebrate trachea, trache ...

. A cricothyrotomy is a procedure during which an incision is made through the

cricothyroid membrane The cricothyroid ligament (also known as the cricothyroid membrane or cricovocal membrane) is a ligament in the neck. It connects the cricoid cartilage to the thyroid cartilage. It prevents these cartilages from moving too far apart. It is cut dur ...

, allowing an artificial airway to be placed in the trachea. It is the first-line surgical procedure to access an airway in an emergency because it can be performed more quickly than a tracheotomy and is less likely to cause bleeding and damage to thyroid tissue. A cricothyrotomy creates a temporary airway that can be used until a more definitive airway can be secured. A

tracheotomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The ...

is a surgical procedure creating an incision in the front of the neck down to the trachea. A tracheostomy tube can be placed through the opening created by the incision, which allows breathing through the tube rather than the nose and mouth. Although the terms are sometimes used interchangeably, a "tracheotomy" is the surgical procedure creating an incision into the trachea, while "tracheostomy" refers to the opening in the trachea created by the incision. The most common acute complications of a tracheotomy are difficulty speaking or swallowing due to nerve damage, prolonged bleeding at the incision site, and

pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...

. A tracheotomy is rarely indicated in an emergent setting. It more commonly performed in a controlled environment to create an airway that can be used long-term, such as for prolonged

Pediatric considerations

Children are not just small adults. They are unique in far more ways than simply being smaller in size. There are many basic differences in anatomy compared to adults that can affect airway management. For example, children's heads are proportionally larger in relation to their overall body size. This can cause alignment issues that have the potential to make it substantially more difficult to obtain good visualization of the appropriate airway landmarks. The differences in a child's anatomy can also affect equipment choices, such as choosing a straight laryngoscope blade instead of a curved one to achieve better control of a more elastic airway. Making the right equipment choices is so important that a color-coded tape measure (known as

Broselow tape The Broselow Tape, also called the Broselow pediatric emergency tape, is a color-coded length-based tape measure that is used throughout the world for pediatric emergencies. The Broselow Tape relates a child's height as measured by the tape to th ...

) was created to help facilitate rapid and accurate decisions in pediatric emergency situations. Birth complications, congenital syndromes (such as

Down syndrome Down syndrome or Down's syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is usually associated with physical growth delays, mild to moderate intellectual dis ...

) and even recent illness or nasal congestion can affect how airway management is approached in a child. When

, various airway options and even intubation are unsuccessful, this is a terrifying situation known as "cannot ventilate, cannot intubate". Typically this is when a cricothyrotomy would be attempted as mentioned above. However, this tricky procedure is even more difficult in kids due to their extra flexible airways. The chance of accidentally puncturing all the way through the trachea to the esophagus increases substantially. The risk is considered so high that the procedure is contraindicated in children under the age of 5–6 years old.Harless J, Ramalah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci 2014; 4:65–70.

References

{{First aid Medical procedures Airway management