2.2 Airway Management Devices & Procedures

Airway Management Devices & Procedures

Establishing and protecting an airway is core RT work and one of the densest topics on the TMC Examination. Device selection follows a clear logic: match the adjunct to the patient's level of consciousness, escalate to a definitive airway when the patient cannot protect or maintain ventilation, and keep a rescue device ready when intubation is anticipated to be difficult.

Basic Airway Adjuncts

Oropharyngeal airway (OPA): Holds the tongue off the posterior pharynx in the unconscious patient without a gag reflex. It is contraindicated in conscious or semi-conscious patients because it provokes gagging and vomiting. Size it from the corner of the mouth to the angle of the jaw. In adults, insert it inverted (concave side toward the palate), advance to the hard palate, then rotate 180 degrees. In children, insert it right-side up with a tongue depressor to avoid pushing the tongue back.

Nasopharyngeal airway (NPA): Tolerated by patients with an intact gag reflex, making it the choice when an OPA cannot be used (for example, a semi-conscious overdose with trismus). Size it from the nare to the earlobe; diameter should approximate the patient's little finger. Lubricate and pass along the floor of the nasal cavity. It is contraindicated in suspected basilar skull fracture (raccoon eyes, Battle sign, cerebrospinal fluid rhinorrhea/otorrhea) because of the risk of intracranial passage.

Endotracheal Intubation

Indications for intubation: failure to protect or maintain the airway, refractory respiratory failure despite noninvasive support, Glasgow Coma Scale 8 or below, anticipated airway loss (airway burns, anaphylaxis, expanding neck hematoma), and the need for prolonged mechanical ventilation.

Confirming placement (most-to-least reliable):

Cuff Pressure — A High-Yield Number

Keep cuff pressure at 20-30 cmH2O. Tracheal mucosal capillary perfusion pressure is roughly 30-35 cmH2O, so pressures above 30 compress those capillaries and cause ischemia, leading over time to mucosal necrosis, tracheal stenosis, and tracheoesophageal fistula. Pressures below 20 break the seal and permit micro-aspiration of subglottic secretions, a driver of ventilator-associated pneumonia. Measure with a manometer (minimal-leak or minimal-occluding-volume techniques) at least each shift.

Supraglottic Rescue Airways

• Laryngeal mask airway (LMA): Seats over the laryngeal inlet without passing the cords. Faster and higher-success for non-experts, but it does not fully protect against aspiration. Used when intubation fails or as a bridge to a definitive airway.
• Combitube (dual-lumen) / King LT (single-lumen): Blind-insertion devices requiring no laryngoscopy, used in emergencies when intubation is not possible.

Suctioning

Sizing math: For a 7.0 mm ID tube, half the ID is 3.5 mm, so the catheter outer diameter should not exceed ~3.5 mm (about a 10-12 French catheter). An oversized catheter occludes the airway and the resulting high negative pressure can collapse alveoli, causing suction-induced atelectasis and hypoxemia.

Suction hazards to anticipate: transient hypoxemia (mitigated by pre-oxygenation and short passes), bradycardia or other dysrhythmias from vagal stimulation of the carina, mucosal trauma and bleeding, raised intracranial pressure in neuro patients, and bronchospasm. If the heart rate falls sharply or SpO2 drops during suctioning, stop, withdraw the catheter, and re-oxygenate before any further attempt.

Suction on a clinical indication — visible or audible secretions, a sawtooth flow-volume loop, rising peak pressures on volume ventilation, or falling tidal volume on pressure ventilation — rather than on a fixed schedule, because routine deep suctioning adds risk without benefit.

Tracheostomy Care

A tracheostomy tube creates a long-term surgical airway below the larynx. Routine RT care includes cleaning or replacing the inner cannula every 4-8 hours and as needed, stoma care to prevent skin breakdown and infection, securing the tube to avoid accidental decannulation, monitoring cuff pressure with the same 20-30 cmH2O target as an ETT, and humidifying inspired gas because the upper airway is bypassed.

Two emergencies must be recognized instantly: accidental decannulation within the first several days, before a tract has matured, can be life-threatening because blind reinsertion may create a false passage — ventilate over the stoma or orally and call for help; and a mucus plug or tube obstruction presents as rising pressures, falling tidal volumes, and distress, managed by suctioning, removing the inner cannula, and if needed changing the tube.

The Difficult Airway Algorithm

When intubation is anticipated to be hard or a first attempt fails, follow a stepwise plan rather than repeating the same failing attempt. The structure is: prepare (assemble equipment, suction, drugs, and the team), optimize (sniffing position, external laryngeal manipulation, the best blade, a bougie), mask-ventilate to maintain oxygenation between attempts, escalate to video laryngoscopy, then to a supraglottic rescue device (LMA or King), and finally to a surgical airway (cricothyrotomy) when the patient cannot be intubated and cannot be oxygenated.

Limit attempts, since repeated traumatic tries convert a difficult airway into a bloody, edematous, impossible one. The cricoid cartilage is the surgical landmark you located in section 2.1 — anatomy and procedure converge here.