Airway Adjuncts



  • Airway adjuncts are devices used for management of the upper airway
  • Often used as rescue techniques/devices when unable to intubate with standard techniques and difficult to mask ventilate
  • Oral and nasopharyngeal airways:
    • Lift tongue off hypopharynx
    • Combined with positioning aid in airway patency
    • Nasopharyngeal airway may be used when gag reflex intact
    • Oropharyngeal airway placement requires absent gag reflex
  • Extraglottic devices (EGD):
    • Supraglottic (SGD) class (i.e., LMA, PAXpress, CobraPLA, iGel, etc.)
    • These sit above and surround the glottis
    • Retroglottic (RGD) or infraglottic (IGD) class (i.e., Combitube, King tube, Ruch EasyTube, etc.)
    • RGD/IGD ventilate at the hypopharynx and occlude the esophagus
  • Blind insertion technique (specific to device)
  • Less protection from aspiration compared to ET tube
  • High success rates for placement of EGDs


  • 95% success with first method of airway management
  • 98% overall success of intubation
  • 4% of ED airways are difficult


Signs and Symptoms

Physical Exam
  • Predictors of difficult to bag-mask ventilate (MOANS):
    • M – Mask seal (beards/structural abnormality)
    • O – Obese or obstructed
    • A – Advanced age (>55 yr)
    • N – No teeth
    • S – Stiff
  • Predictors of difficult laryngoscopy and intubation (LEMON)
    • L – Look externally:
      • Micrognathia
      • Buck teeth
      • Large tongue
      • Short neck
    • E – Evaluate 3-3-2:
      • Mouth opens <3 fingerbreadths
      • Horizontal length of mandible <3 fingerbreadths
      • Thyromental distance <2 fingerbreadths
    • M – Mallampati score (increasing difficulty):
      • Class I: Soft palate, uvula, fauces, pillars visible
      • Class II: Soft palate, uvula, fauces visible
      • Class III: Soft palate visible
      • Class IV: Hard palate only visible
    • O – Obstruction:
      • Vocal changes/muffled voice
      • Difficulty managing secretions
      • Stridor
    • N – Neck mobility (limited):
  • Predictors of difficult cricothyrotomy (SHORT):
    • S – Surgery or disrupted airway
    • H – Hematoma or infection
    • O – Obese (access problem)
    • R – Radiation
    • T – Tumor
  • Predictors of difficult EGD (RODS):
    • R – Restricted mouth opening
    • O – Obstruction
    • D – Disrupted or distorted airway anatomy
    • S – Stiff lungs or cervical spine

Diagnostic Tests and Interpretation

  • Pulse oximetry should rise or remain at high level with successful airway management
  • Confirming correct placement:
    • Fiberoptic bronchoscopy (gold standard)
    • End tidal capnometry/capnography (>99% reliable)
    • Physical exam (common but unreliable)
    • Chest rise/fall
    • Auscultation of breath sounds with absence of sound over epigastrium
    • Condensation inside the ETT
  • Arterial blood gas is used to guide ventilator settings once airway established

CXR: Useful only in patients following endotracheal intubation to exclude mainstem bronchus intubation or pneumothorax and to adjust the position of the tube
CXR does not rule out esophageal intubation


Pre Hospital

  • Options for patients requiring prehospital airway management vary by region and include:
    • Bag-valve-mask ventilation ± OPA or NPA
    • Orotracheal intubation (±RSI)
    • Nasotracheal intubation
    • EGD placement
    • Surgical airway

Initial Stabilization/Therapy

  • Maintain inline cervical spine immobilization in trauma patients
  • Oxygen (high flow via nonrebreather or BVM)
  • Vascular access (for resuscitation and medication administration) IV or IO

Ed Treatment/Procedures

  • Rapid sequence intubation
  • Prepare:
    • Suction, BVM, ETT, primary airway management modality, rescue airway management modality, medications
  • Preoxygenate:
    • NRB or BVM with 100% FiO2 for 3 min
  • Pretreatment:
    • Minimize adverse responses to airway management
    • Suspected elevated ICP
    • Ischemic heart disease or major vessel dissection/rupture
    • Adults with significant reactive airways disease
    • Children up to 10 yr of age
  • Paralysis with induction:
    • Administration of induction agent
    • Rapid sequential administration of paralytic agent

Paralysis is relatively contraindicated in anticipated difficult airway:
  • Positioning:
    • Head extension
    • Cricoid pressure (Sellick maneuver)
  • Placement of tube
  • Postintubation:
    • Confirm ETT placement
    • Sedation with benzodiazepines, opiates, propofol, or other agents
    • Continued paralysis as needed combined with adequate sedation
  • Failed intubation:
    • Consider other intubation techniques in failed airway algorithm or use of airway adjunct
    • Surgical airway as last resort


  • Induction:
    • Etomidate: 0.3 mg/kg IV
    • Ketamine: 1–2 mg/kg IV or 4–7 mg/kg IM
    • Midazolam: 0.07–0.3 mg/kg IV
    • Propofol: 2–2.5 mg/kg IV
    • Thiopental: 3 mg/kg IV
  • Paralysis:
    • Succinylcholine: 1–1.5 mg/kg (peds: 2 mg/kg) IV, 2.5 mg/kg IM/SC
    • Rocuronium: 1 mg/kg IV (paralyzing dose); 0.1 mg/kg IV (defasciculating dose)
    • Pancuronium: 0.1 mg/kg IV (paralyzing dose); 0.01 mg/kg IV (defasciculating dose)
    • Vecuronium: 0.1 mg/kg IV (paralyzing dose); 0.01 mg/kg IV (defasciculating dose)
  • Reversal:
    • Sugammadex: 16 mg/kg IV for immediate reversal of rocuronium (peds 2 mg/kg IV)
      • Limited data available for pediatric dosing especially infants <2 y/o
    • Flumazenil: 0.2 mg IV q1min up to 1 mg for reversal of benzodiazepine (peds 0.01 mg/kg IV q1min max of 0.05 mg/kg)

Ongoing Care


Admission Criteria
Almost all intubated patients should be admitted to an ICU or OR

Discharge Criteria
Rarely, ED patients who have been intubated may be extubated in the ED and discharged after a period of observation

Pearls and Pitfalls

  • Failure to ventilate is a life-threatening condition
  • Assess every patient for the possibility of difficult mask ventilation or intubation
  • Always formulate a back-up plan in case of a failed attempt
  • Do not fixate on intubation but rather successful ventilation and oxygenation
  • Move to alternate airway management techniques and consider surgical airway if unable to intubate or ventilate despite use of airway adjuncts

Pediatric Considerations
  • Oro- and nasopharyngeal airways are available in infant+ sizes
  • LMAs are available in infant+ sizes
  • Combitube is only designed for patients >48 in in height
  • Nasotracheal intubation is contraindicated in children under 10 yr of age

Additional Reading

  • Brown CA, Sakles JC, Mick N (eds). The Walls Manual of Emergency Airway Management. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2017.
  • Hedayati T, Murphy MF. Airway management. In: Wolfson AB, Cloutier RL, Hendey G, et al., eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
  • Plaud B, Meretoja O, Hofmockel R, et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology. 2009;10:284–294.


David W. Schoenfeld

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