Key Takeaways
- Oropharyngeal airways (OPAs) are for unconscious patients only; insert upside down and rotate 180 degrees in adults
- Nasopharyngeal airways (NPAs) can be used in conscious or semi-conscious patients; contraindicated in basilar skull fracture
- Endotracheal tubes (ETTs) are sized 7.0-8.0 mm ID for adults; cuff pressure maintained at 20-30 cmH2O
- Confirm ET tube placement with ETCO2 capnography (gold standard), auscultation, and chest X-ray
- Laryngeal mask airways (LMAs) are supraglottic devices used as rescue airways when intubation fails
- Tracheostomy care includes inner cannula cleaning every 4-8 hours, stoma care, cuff management, and suctioning
- The difficult airway algorithm includes preparation, optimized positioning, video laryngoscopy, supraglottic device, and surgical airway as last resort
- Suctioning: pre-oxygenate with 100% O2, limit suction passes to 10-15 seconds, and use appropriate catheter size (half the ET tube ID)
Airway Management Devices & Procedures
Airway management is a core competency for respiratory therapists and a heavily tested topic on the TMC exam. This section covers the devices and techniques used to establish and maintain a patent airway, from basic adjuncts to advanced airway management.
Basic Airway Adjuncts
Oropharyngeal Airway (OPA):
- Purpose: Prevents tongue from obstructing the oropharynx in unconscious patients
- Contraindications: Conscious or semi-conscious patients (may trigger gag reflex and vomiting)
- Sizing: Measure from corner of mouth to angle of the jaw (or earlobe)
- Insertion in adults: Insert upside down (concavity facing palate), advance to hard palate, rotate 180 degrees
- Insertion in children: Insert right-side up using a tongue depressor to depress the tongue
Nasopharyngeal Airway (NPA):
- Purpose: Maintains airway patency; tolerated by conscious and semi-conscious patients
- Contraindications: Basilar skull fracture, severe coagulopathy, nasal obstruction
- Sizing: Measure from tip of nose to earlobe; diameter = diameter of the patient's little finger
- Insertion: Lubricate with water-soluble lubricant, insert along the floor of the nasal cavity (not upward)
- Advantage: Can be used when OPA is not tolerated (patients with intact gag reflex)
Endotracheal Intubation
| Parameter | Adult | Pediatric |
|---|---|---|
| ETT Size | 7.0-8.0 mm ID (male: 8.0, female: 7.0-7.5) | Uncuffed: (age/4) + 4; Cuffed: (age/4) + 3.5 |
| Insertion depth | 21-23 cm at the teeth (tip 3-5 cm above carina) | (age/2) + 12 cm at the teeth |
| Laryngoscope blade | Macintosh (curved) #3-4 or Miller (straight) #2-3 | Miller (straight) preferred in infants |
| Cuff pressure | 20-30 cmH2O | Same if cuffed tube used |
Indications for intubation:
- Inability to maintain or protect the airway
- Respiratory failure despite non-invasive interventions
- GCS ≤ 8 (severe neurological impairment)
- Anticipated airway compromise (burns, anaphylaxis, expanding hematoma)
- Need for prolonged mechanical ventilation
Confirming ET Tube Placement (in order of reliability):
| Method | Reliability | Details |
|---|---|---|
| ETCO2 capnography | Gold standard | Continuous waveform; should detect CO2 within 6 breaths |
| Chest X-ray | Definitive | Confirms depth; tip 3-5 cm above carina |
| Bilateral breath sounds | Supportive | Auscultate over both lungs and epigastrium |
| Chest rise | Supportive | Symmetric bilateral chest rise with ventilation |
| SpO2 maintenance | Supportive | Stable or improving oxygen saturation |
| Condensation in tube | Least reliable | Moisture in tube during exhalation (can also occur with esophageal placement) |
Supraglottic Airways (Rescue Devices)
Laryngeal Mask Airway (LMA):
- Sits over the laryngeal inlet; does not pass through the vocal cords
- Used when intubation fails or as a bridge to definitive airway
- Does NOT fully protect against aspiration
- Easier to place than ETT; higher success rate for non-expert users
Combitube / King Airway:
- Dual-lumen (Combitube) or single-lumen (King) rescue devices
- Designed for blind insertion; does not require laryngoscopy
- Used in emergency situations when intubation is not possible
Suctioning
| Parameter | Guideline |
|---|---|
| Pre-oxygenation | 100% O2 for at least 30 seconds before suctioning |
| Suction catheter size | Catheter OD should be less than half the ETT ID |
| Suction duration | No more than 10-15 seconds per pass |
| Suction pressure | Adults: -100 to -150 mmHg; Children: -80 to -100 mmHg; Infants: -60 to -80 mmHg |
| Technique | Insert without suction, apply suction while withdrawing with rotating motion |
| Closed vs. open | Closed (in-line) preferred for ventilated patients to maintain PEEP |
An OPA is contraindicated in which of the following patients?
What is the GOLD STANDARD for confirming endotracheal tube placement?
A respiratory therapist is preparing to suction a patient through a 7.0 mm ID endotracheal tube. What is the maximum catheter outer diameter that should be used?
Place the steps for endotracheal suctioning in the correct order.
Arrange the items in the correct order
Endotracheal tube cuff pressure should be maintained at what level?
A nasopharyngeal airway (NPA) is CONTRAINDICATED in which clinical scenario?
When inserting an oropharyngeal airway (OPA) in an adult patient, the correct technique is to:
A Mallampati Class IV score indicates:
An LMA (Laryngeal Mask Airway) differs from an endotracheal tube in that the LMA: