6.3 Airway Management Techniques
Key Takeaways
- Climb the airway ladder: positioning and suction, then OPA or NPA, two-person bag-mask, a supraglottic airway, video then direct laryngoscopy with a bougie, then a surgical or needle front-of-neck rescue.
- Waveform end-tidal carbon dioxide is the gold standard for tube confirmation; mist in the tube is condensation, not proof.
- Secure the tube, record depth at the teeth or gums, and reassess after every load, unload, door close, and altitude change.
- A working supraglottic airway that ventilates and shows a waveform should not be pulled in the cabin just to "get a tube."
- Video laryngoscopy wins many predicted difficult views; blood and vomitus can still force a switch to direct laryngoscopy plus aggressive suction.
Once you have assessed and optimized, you still have to manage the airway. Airway management on the August 2026 Certified Flight Registered Nurse (CFRN) outline is a ladder, not a single tool. You climb only as far as the patient needs, and you stop when oxygen is moving and waveform end-tidal carbon dioxide (ETCO2) is present. Full rapid sequence intubation (RSI) pharmacology is Chapter 7; this section is the mechanical ladder, confirmation, and the cabin constraints that break technique.
The airway ladder
Start at the bottom. Do not skip to a blade because a blade feels like real flight nursing.
Positioning, adjuncts, and two-person BVM
Open the airway with ear-to-sternal-notch positioning in the adult and a shoulder roll in the young child. Suction until you see anatomy. Blood and vomitus are why first looks fail—two suctions belong in this rung. An oropharyngeal airway (OPA) is for the unconscious patient without a gag. A nasopharyngeal airway (NPA) can help the semi-conscious patient if there is no midface instability or suspected basilar skull fracture. Bag-valve-mask (BVM) ventilation is a two-person skill: one provider seals with a thenar-eminence grip, the other squeezes slowly. Watch chest rise and the capnograph.
Supraglottic airways, laryngoscopy, and front of neck
An i-gel, laryngeal mask airway (LMA), or King LT is a rescue and a destination when a tracheal tube is not required or not possible. Size it, seat it, and confirm with waveform ETCO2. In a vibrating cabin a working supraglottic airway (SGA) that oxygenates is a success.
When not to pull a working SGA: if the device is ventilating, ETCO2 is present, and you are already loaded or in flight, leave it. Converting in a 24-inch cabin because the program "always intubates" is how you create a can't-intubate-can't-oxygenate (CICO) emergency from a working airway. Convert on the ground, at the receiving bay, or only if the SGA fails.
Video laryngoscopy (VL) is the default first look for many programs because it improves the view in a collar and a tight cabin. Direct laryngoscopy (DL) is not obsolete. Blood, vomitus, and fog wipe a camera; a Macintosh or Miller blade plus a bougie can still find the epiglottis by feel. Have both out. Pass the bougie, feel tracheal clicks or hold-up, then railroad the tube. If the VL screen is a red smear, switch.
If you cannot oxygenate and you cannot intubate, you cut. In adolescents and adults, surgical cricothyrotomy through the cricothyroid membrane is the standard rescue. In small children the membrane is tiny; needle cricothyrotomy with a jet or bag adapter is the usual pediatric rescue until anatomy allows a surgical membrane. Know your program's age cutoff. Board of Certification for Emergency Nursing (BCEN) does not publish a universal age cut.
| Rung | Tool | Stop climbing when |
|---|---|---|
| Position and suction | Ramp, shoulder roll, two suctions | The pharynx is clear and the axis is open |
| Adjuncts | OPA, NPA | The airway stays patent |
| Two-person BVM | Thenar-eminence seal | Chest rise and ETCO2 with a seal |
| SGA | i-gel, LMA, King | Working ventilation; do not pull it in flight |
| Tracheal tube | VL, then DL, with a bougie | Waveform ETCO2 and bilateral rise |
| Front of neck | Surgical cric (adult); needle (small child) | Oxygen moves again |
Confirm, secure, reassess
Waveform ETCO2 is the gold standard. Mist in the tube is condensation, not confirmation. Auscultation dies in rotor wash. A rising pulse oximeter is late. You want a repeating four-phase capnograph, not a single color change on a paper detector.
Secure the tube so a helmet, a stretcher strap, or a single twist cannot pull it. Note depth at the teeth or gums—usual adult starting depths are about 21 cm at the teeth for many women and 23 cm for many men, then confirm clinically. After every load, unload, cabin-door close, and altitude change, reassess:
- Depth mark still where you left it
- Waveform still present
- Chest rise still bilateral
- Cuff still sealing without over-pressure
Write the depth on the tape so the next provider is not guessing in the dark.
Cabin access: helmets, goggles, and belts
A flight helmet, night-vision goggles (NVG), and five-point restraints all steal the head of the bed. Take your own helmet off if it blocks the look. Stow NVGs before you lean in. Seat rails and the aircraft ceiling limit how far you can back up, which is another reason the ladder often stops at a working SGA. Brief the pilot if you need a door opened for a surgical airway. On a scene backboard next to a running aircraft, rotor wash lifts the sheet and the circuit—weight the head, assign one person to the tube, and do not start a look you cannot finish.
- Climb the ladder; do not skip to a blade.
- Two-person BVM before heroics.
- Leave a working SGA in place in flight.
- Confirm with waveform ETCO2, never mist.
- Resecure and recheck after every move.
After placing an endotracheal tube at a noisy landing zone, which confirmation is the gold standard before you accept the airway as tracheal?
An i-gel is ventilating well with a square waveform after a failed first laryngoscopy look. The patient is already loaded. What should you do?
A small child's airway cannot be intubated, and neither a bag-mask nor a supraglottic airway is moving air. What is the usual front-of-neck rescue?