EMT-Basic Exam: The Basics of Advanced Airway - Advanced Airway Management of Adults

Advanced Airway
This guide discusses the advanced airway techniques that EMT-Basics may need to employ in the field. It’s important to note that not every EMS system allows EMT-Basics to perform these maneuvers. You should consult your supervisor for more information on the types of procedures that EMT-Basics may perform in the field.

For this reason, the NREMT cognitive exam does not include a specific percentage of questions that address advanced airway techniques. However, because you may take an exam that differs from the NREMT cognitive exam, it is important to review the topics in this guide carefully as you may see questions regarding these techniques on state or municipal examinations. 

Advanced Airway Management of Adults
This guide provides an overview of advanced airway techniques for adults, children, and infants. Some of these techniques can look painful to the patient’s family members. Ensure them of the importance of these life-saving techniques and ask them to leave the scene if they become too distressed.

Tip: Contact medical direction for the proper protocol before performing any of the following advanced airway management techniques.

1. Orotracheal Intubation
Just as you reviewed earlier, the EMT-Basic must ensure that the patient’s airway remains open and clear at all times. A blocked airway can quickly result in death if left untreated. Without adequate oxygen, brain death can occur in as little as 6 minutes.
The most effective way to maintain the airway is to insert a tube directly into the patient’s trachea (windpipe) that allows the EMT-Basic to ventilate the patient using a bag-valve mask (BVM), oxygen-powered breathing device, pocket mask, or other ventilation device. This tube, called an endotracheal tube, creates a tight seal between the ventilation device and the trachea. It allows the EMT-Basic to control the amount of air delivered to the patient’s lungs and prevents gastric distention, a condition that forces air into the stomach during ventilation. The trapped air in the stomach pushes against the diaphragm, making ventilation difficult. If too much air becomes trapped in the stomach, it can force undigested food and gastric juice back up the esophagus in a process called passive regurgitation. This is a serious danger to the airway.
EMT-Basics can minimize the risk of gastric distention in adults by using the Sellick maneuver when inserting the endotracheal tube during orotracheal intubation.

The Sellick maneuver was developed to decrease the risk of passive regurgitation in the operating room. It’s used in prehospital settings to reduce gastric distention and prevent regurgitation during ventilation. It should only be used on unresponsive patients who do not have a gag reflex. To perform the Sellick maneuver, place pressure on the cricoid ring to collapse the esophagus. Maintain this pressure until the patient’s airway is protected. One disadvantage of this maneuver is the need for an additional EMT-Basic during artificial ventilation. One EMT-Basic must maintain the pressure on the cricoid ring while the other performs ventilation.

Cricoid ring.

Tip: Do not attempt to perform the Sellick maneuver if you’re unsure of the proper location of the cricoid ring. If you apply pressure to another area, you may comprise or damage the airway.
Orotracheal intubation is the most effective way to ventilate a patient who is apneic (not breathing) and has no gag reflex. This process helps minimize the risk of aspiration, delivers oxygen to the lungs, provides complete control of the airway, and allows the trachea and bronchi to be suctioned.

While you should always refer to your medical direction physician for the proper protocol, the EMT-Basic should consider using orotracheal intubation in prehospital settings when
- You can’t ventilate a patient who is apneic.
- The patient is unresponsive to painful stimuli.
- The patient has no gag reflex.
- The patient can’t protect his or her airway.

a. Endotracheal Tube Insertion
Before you begin insertion of the endotracheal tube, you should follow the proper body substance isolation (BSI) precautions. Wear a mask, eyewear, and gloves to protect yourself and the patient.
The endotracheal tube is a hollow, open tube that attaches to a bag-valve mask. The other end, which is placed into the patient’s airway, is beveled. There’s a small hole on this side of the tube called a Murphy’s eye, which prevents the tube from becoming obstructed. There’s also an inflatable cuff on the tube that creates an airtight seal against the trachea. This seal ensures that air is delivered to the lungs and not the stomach, preventing gastric distention. Before inserting the endotracheal tube, you should ensure that the cuff doesn’t have any leaks.
Endotracheal tubes are available in different sizes. You should select the correct size for the patient or use the 7.5 mm tube, which is considered the standard size for most adults. This flexible tube is sometimes difficult to control when inserting it into the airway. Inserting a stylet, a pliable piece of metal, inside the tube can assist with insertion.

To insert the endotracheal tube in the trachea, the glottic opening, the space between the vocal cords and the trachea, must be in plain view. You should use a lighted device called a laryngoscope to locate the glottic opening. A laryngoscope has two types of blades: a straight blade called a Miller and a curved blade called a MacIntosh. When inserted into the patient’s mouth, the laryngoscope uses these blades to reveal the airway. The Miller blade lifts the epiglottis out of the way to reveal the glottic opening. The MacIntosh blade is inserted into the vallecula, a depression at the back of the throat, to reveal the airway. Either blade may be used on an adult, but a Miller blade should always be used on children and infants.

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Laryngoscope.

After the laryngoscope is inserted into the patient’s throat, select an endotracheal tube and use the stylet to aid with its insertion. After the endotracheal tube is in position, inflate the cuff to create an airtight seal and remove the laryngoscope blade. Secure the tube and place a bite block or oral airway in the patient’s mouth to prevent the patient from biting down on the tube.

Tip: Remember, the patient is not receiving oxygen during intubation. Taking more than 30 seconds to intubate puts the patient’s life at risk.

After the endotracheal tube is inserted, the EMT-Basic should ventilate the patient and listen for breath sounds over the epigastrium (area over the stomach) and the bases of the lungs to ensure that the tube has been inserted properly. If a tube is improperly placed, the patient’s lungs will not be ventilated, and the patient will rapidly deteriorate. If you hear gurgling over the epigastrium or cannot hear breath sounds, the tube must be removed. The patient should be ventilated with a BVM and simple airway adjunct prior to any further attempts at intubation. If breath sounds are heard in only one lung, it is likely that the tube has been advanced too far, into one of the mainstem bronchi. If this happens, the tube should be withdrawn in 1-2 cm increments and the tube position should be reassessed.
You may decide to use an end tidal carbon dioxide detector to evaluate tube placement. This device changes color when carbon dioxide is detected. Another method you can use is pulse oximetry, which monitors the patient’s oxygen levels. However, you should know that neither of these methods is accurate or effective in pulseless patients. Once you establish that the tube is in the correct place, continue to monitor the patient so the tube doesn’t move or become extubated, or removed.

Tip: If you are unsure if the endotracheal tube has been placed correctly, remove it immediately and try again after ensuring the patient is reoxygenated.

Sometimes complications can arise while inserting an endotracheal tube. Improper techniques can damage the patient’s teeth, lips, tongue, or airway. When inserting an endotracheal tube, it’s important to know the distance from the front teeth to the different parts of the airway in an adult:
- 15 cm from front teeth to vocal cords
- 20 cm from front teeth to sternal notch (area between clavicles and sternum)
- 22 cm from front teeth to tip of properly positioned endotracheal tube
- 25 cm from front teeth to carina (point where the trachea divides into two stems)

Taking longer than 30 seconds to intubate deprives your patient of oxygen. Vomiting, hypoxia, and unstable heart rate may occur if intubation and ventilation do not take place quickly. If you’re unable to correctly place the endotracheal tube after two tries, you should not make a third attempt. Continue ventilation with an adjunct and transport the patient to the hospital immediately.

2. Esophageal Tracheal Combitubes
In some cases, you won’t be able to insert an endotracheal tube. Trauma patients and patients who have bleeding in the airway are often difficult to intubate. In these cases, an esophageal tracheal Combitube is another option used to manage the airway. An esophageal tracheal Combitube is used on adults with no gag reflex. This tube is used on patients over 16 years of age who are taller than 5 feet. Smaller Combitubes are available for patients under 5 feet. The Combitube is also used when there is no way to visualize the airway because it’s inserted blindly and then advanced into either the trachea or the esophagus. It should not be used on patients who have esophageal conditions, such as cancer, because it can cause bleeding.
 

An esophageal tracheal Combitube has two ventilation ports—one designed to be inserted into the trachea and one designed to be inserted into the esophagus. When inserting the Combitube into the esophagus, the first port is used and air escapes from the far end through small holes. When inserting the Combitube into the trachea, the second port is used for ventilation and functions in much the same way as the first port. The Combitube has two cuffs to seal the airway.
To insert an esophageal tracheal Combitube, lubricate the tube and insert it into the patient’s mouth while lifting the tongue and jaw. Ventilate the patient through the blue tube and listen over the epigastrium while observing the rise and fall of the chest. If you don’t hear gurgling but do hear breath sounds, the tube is in the esophagus. Continue to ventilate through the blue tube and inflate the two cuffs. If you hear gurgling and don’t hear breath sounds, then ventilate through the white tube while listening over the epigastrium. Note the rise and fall of the chest. If you don’t hear gurgling, the tube is in the trachea. Continue to ventilate through the white tube.
Incorrectly identifying tube placement and ventilating through the wrong port can be fatal to the patient. The EMT-Basic should ensure that he or she identifies the correct placement of the Combitube to prevent complications.
Sometimes suctioning may be required to remove liquid and other materials from the airway. Once the patient is intubated, you can suction the trachea using the techniques you have studied.

Related Topics You Should Review:
- Using the Sellick maneuver
- Cricoid ring location
- Operating a laryngoscope
- Suctioning techniques