Emergency Airway Management

Emergency Airway Management: Assessment, Devices, Ventilation and Safety

Why this matters: Airway failure kills within minutes, yet many emergencies can be prevented by early recognition, positioning, suction, oxygenation and effective bag-mask ventilation. EMT students must know what they can do independently, what requires an advanced provider and how to maintain oxygen delivery during transport and handover.

Scope and safety: Follow your training level, Uganda Clinical Guidelines, local ambulance protocols and medical direction. Intubation and advanced airway procedures should be attempted only by trained, competent providers with a high success rate, backup plans and continuous waveform capnography. Never allow a device attempt to interrupt high-quality CPR or delay basic oxygenation.

Learning outcomes

Recognise threatened, obstructed and failed airways using a structured primary survey.
Perform positioning, manual opening, suction, basic adjuncts and bag-mask ventilation safely.
Select an oropharyngeal, nasopharyngeal or supraglottic device when trained and identify contraindications.
Prepare for advanced airway intervention, failed-airway rescue and post-intubation care without losing oxygenation.
Use pulse oximetry, capnography, chest movement and clinical signs to confirm and monitor ventilation.
Document airway findings, interventions, attempts, confirmation and patient response.

1. Airway anatomy and physiology for EMTs

The upper airway conducts air from the nose and mouth to the larynx. The tongue, soft palate, blood, vomit, swelling, foreign bodies and facial trauma can obstruct it. The larynx protects the trachea during swallowing; the epiglottis and vocal cords are dynamic structures that may swell or spasm. Oxygenation depends on alveolar ventilation, perfusion and inspired oxygen, while ventilation means removal of carbon dioxide. A patient can have acceptable SpO2 briefly while ventilation and CO2 are worsening.

Problem	Mechanism	Clues
Loss of tone	Reduced consciousness allows tongue/soft palate to fall backward.	Snoring, paradoxical chest movement, absent response to voice.
Secretions/vomit/blood	Fluid blocks the oropharynx or is aspirated.	Gurgling, bubbling, coughing, cyanosis and falling SpO2.
Swelling	Anaphylaxis, burns, infection or trauma narrows the airway.	Hoarseness, stridor, drooling, dysphagia, tongue/lip oedema.
Bronchospasm	Lower airway smooth muscle narrows bronchi.	Wheeze, prolonged expiration, increased work of breathing or silent chest.
Foreign body	Food, teeth, blood clot or object occludes airflow.	Sudden cough/stridor, inability to speak, unilateral air entry change.
Ventilatory failure	Fatigue, neuromuscular weakness, CNS depression or chest injury prevents adequate breaths.	Slow/irregular breathing, poor chest rise, rising ETCO2, exhaustion or altered consciousness.

2. Primary airway assessment

Scene and PPE: identify trauma, fire/smoke, chemicals, water, blood and violence. Protect yourself before contact.
Responsiveness: speak, touch and assess response. A patient who can speak clearly has a patent airway at that moment, but may still deteriorate.
Look: chest rise, work of breathing, cyanosis, accessory muscle use, facial burns, blood, vomit, swelling and position.
Listen: snoring, gurgling, stridor, wheeze, silence, hoarse voice and abnormal breath sounds.
Feel: airflow at mouth/nose, tracheal position, facial/neck swelling, subcutaneous emphysema and chest movement.
Check breathing quality: rate, depth, regularity, fatigue, SpO2 and, when available, ETCO2. Agonal gasps are not normal breathing.
Anticipate difficulty: obesity, pregnancy, cervical injury, facial trauma, burns, blood/vomit, limited mouth opening, beard, dentures, paediatric anatomy and previous difficult airway.

“LOOK–LISTEN–FEEL–ACT”: Look for obstruction and chest rise; listen for snoring/gurgling/stridor; feel for air movement; then act with positioning, suction, adjuncts and ventilation.

3. Positioning and manual airway opening

Situation	Position/technique	Reason and caution
No trauma suspected	Head-tilt/chin-lift; align ear with sternal notch where possible.	Lifts the tongue from the posterior pharynx and improves patency.
Possible cervical spine injury	Jaw thrust with manual in-line stabilisation; avoid unnecessary neck movement.	Maintains airway while reducing spinal motion; airway and oxygenation still take priority.
Conscious breathless patient	Allow position of comfort, usually sitting forward.	Reduces work of breathing; do not force supine positioning.
Unconscious but breathing	Recovery position if no contraindication and while monitoring spine/trauma.	Allows drainage and reduces aspiration; reassess frequently.
Pregnancy or obesity	Ramped/shoulder elevation and left uterine displacement where appropriate.	Improves airway alignment and oxygen reserve; get extra help early.

4. Suction and clearing the airway

Use a rigid Yankauer for visible vomit, blood or secretions in the mouth and a soft catheter for deeper gentle suction when trained.
Pre-oxygenate where possible; suction under direct vision, avoiding blind sweeping that can push a foreign body deeper.
Limit each suction attempt to the local protocol, commonly no more than 10–15 seconds in an adult, with re-oxygenation between attempts.
Monitor heart rate, SpO2 and patient response; vigorous suction can trigger hypoxia, bradycardia, laryngospasm or trauma.
Prepare a backup suction source and battery; a blocked catheter or full canister can create a false sense of readiness.

5. Basic airway adjuncts

Adjunct	Indication	Contraindication/risks	Practical check
Oropharyngeal airway (OPA)	Unconscious patient without a gag reflex who needs airway support.	Conscious or semi-conscious patient with gag/cough; can cause vomiting, laryngospasm or trauma.	Choose correct size (mouth corner to angle of jaw), insert with appropriate technique and reassess patency.
Nasopharyngeal airway (NPA)	Reduced consciousness with an intact gag reflex or trismus; supports the nasal passage.	Suspected basilar skull fracture, severe nasal trauma or obstruction; epistaxis risk.	Measure nostril to tragus/angle of jaw, lubricate, insert gently, never force against resistance.
Supraglottic airway (SGA)	Rescue airway for apnoea or inadequate ventilation when trained and authorised.	Intact gag, caustic ingestion, severe airway obstruction below the device, limited mouth opening or local contraindication.	Confirm chest rise, bilateral breath sounds where feasible, waveform capnography and absence of significant leak.

Never use an adjunct as a substitute for observation. A correctly placed OPA/NPA can become obstructed by secretions, displaced by movement or inadequate when swelling progresses. Reassess after every transfer, suction and position change.

6. Bag-mask ventilation (BVM)

BVM is the most important rescue skill when a patient is apnoeic or breathing inadequately. Use a two-person technique whenever possible: one provider maintains a two-handed mask seal and jaw position while the second squeezes the bag and watches the chest.

Choose an appropriate mask that covers the bridge of the nose, mouth and chin without covering the eyes.
Position the head, open the airway and suction visible secretions. Use an adjunct when indicated.
Use the “EC” hand position: thumb and index finger form a C around the mask while the remaining fingers lift the mandible (E).
Deliver the smallest volume that produces visible chest rise; avoid forceful or rapid squeezing.
Use oxygen and a reservoir when available; monitor chest rise, SpO2, pulse and ETCO2.
If the chest does not rise, reposition, reseal, suction, check the valve/tubing, insert an adjunct and consider obstruction or pneumothorax.
Continue reassessment; excessive ventilation increases gastric inflation, regurgitation, aspiration and intrathoracic pressure.

BVM troubleshooting

Problem	Likely causes	Correction
No chest rise	Poor seal, blocked airway, wrong position, closed valve, severe bronchospasm.	Reposition, two-person seal, suction, adjunct, inspect equipment, escalate to advanced airway.
Stomach inflation	Excessive pressure/volume, rapid ventilation, oesophageal insufflation.	Slow smaller breaths, improve airway alignment and consider SGA/intubation by trained provider.
Falling SpO2 despite ventilation	Disconnection, inadequate oxygen source, pneumothorax, pulmonary oedema, severe shunt or wrong placement.	Check equipment and tube/SGA, auscultate, use waveform capnography and seek advanced support.
Sudden resistance	Bite, kink, obstruction, bronchospasm or equipment blockage.	Look inside the mouth, change position/adjunct, suction and treat bronchospasm per protocol.

7. Oxygen therapy and monitoring

Oxygen is a medicine: give it when there is hypoxaemia, respiratory distress, shock, cardiac arrest or another protocol indication, then titrate to the target range. Avoid both untreated hypoxia and unnecessary prolonged hyperoxia. Pulse oximetry is useful but can be inaccurate with motion, poor perfusion, nail products, carbon monoxide exposure or severe anaemia.

Device	Typical use	Safety points
Nasal cannula	Low-flow support for a spontaneously breathing patient with mild hypoxaemia.	Check nares, comfort, flow and actual SpO2 response.
Simple face mask	Moderate oxygen requirement.	Never run at very low flow because rebreathing CO2 can occur.
Non-rebreather mask	High inspired oxygen for severe hypoxaemia while preparing definitive care.	Keep reservoir inflated; it does not provide ventilation to an apnoeic patient.
Bag-mask with reservoir	Apnoea, agonal breathing or inadequate ventilation.	Requires seal, airway opening and controlled breaths; monitor for gastric inflation.
CPAP/NIV	Selected conscious patients with respiratory failure who can protect the airway and cooperate.	Not for vomiting, severe agitation, facial trauma or inability to protect the airway; monitor continuously.

8. Foreign-body airway obstruction

Mild obstruction: encourage effective coughing and observe closely; do not blindly sweep the mouth.
Severe obstruction in a conscious adult/child: call for help and use age-appropriate back blows and abdominal/chest thrusts according to current BLS training.
Becomes unresponsive: lower safely, begin CPR, look for a visible object before breaths and activate advanced help.
Infant: use infant-specific back slaps and chest thrusts; never abdominal thrusts.
After removal: evaluate for residual obstruction, aspiration, rib injury or delayed airway oedema; medical assessment is needed even if the object comes out.

9. Preparing for an advanced airway

Advanced airway placement is a team procedure, not a single person’s rescue attempt. The goal is oxygenation and ventilation with the fewest interruptions and highest first-pass success. Before the attempt, plan for the best device, backup SGA, suction, oxygenation method, waveform capnography, drugs/analgesia if authorised and a failed-airway pathway.

Preparation	Questions to answer
Patient	Why is the airway needed? Can the patient be oxygenated now? Is there aspiration, trauma, swelling, burns, cervical injury or difficult anatomy?
People	Who is the airway operator, assistant, monitor, drug nurse and team leader? Who will call for help?
Equipment	Suction working? BVM and oxygen? Laryngoscope/video device? Tube sizes? SGA? Bougie/stylet? Capnography? Tape/fixation? Backup surgical airway capability?
Plan A–D	Best attempt, optimisation, rescue oxygenation with SGA/BVM, and emergency front-of-neck access by trained experts.
Aftercare	Tube/SGA confirmation, fixation, ventilation plan, analgesia/sedation, gastric decompression if indicated and frequent reassessment.

10. Endotracheal intubation and confirmation

Only trained providers should intubate. A tube in the oesophagus or a displaced tube is immediately life-threatening. Continuous waveform capnography is the most reliable method to confirm and monitor tracheal placement in a perfusing patient, supplemented by chest rise, bilateral breath sounds, absence of gastric sounds, tube depth and clinical response. A single misting sign or initial SpO2 improvement is not enough.

Pre-oxygenate and maintain oxygen delivery between attempts; use apnoeic oxygenation or BVM as trained.
Limit attempts and time; stop early for falling SpO2, bradycardia, poor view or worsening physiology.
After placement, ventilate gently, apply waveform capnography, secure the tube and record depth at the teeth/lips.
Reconfirm after movement, ambulance loading, transfer, deterioration or a sudden change in ETCO2.
If capnography is absent, troubleshoot the circuit and tube immediately while ventilating by BVM and seeking help.

11. Capnography interpretation

ETCO2 pattern	Possible explanation	Action
Persistent flat line after intubation	Oesophageal intubation, disconnection, apnoea, very low pulmonary blood flow or faulty sensor.	Immediately ventilate with BVM, check connections and tube; remove/reposition if placement is not confirmed.
Sudden loss of waveform	Dislodged tube, disconnected circuit, blocked tube or cardiac arrest.	Assess patient and equipment together; begin rescue ventilation and CPR when indicated.
Low/decreasing ETCO2 during CPR	Poor compression quality, low perfusion, prolonged arrest or excessive ventilation.	Improve CPR quality, minimise pauses, check airway and consider reversible causes.
High ETCO2 with prolonged plateau	Hypoventilation, severe bronchospasm, rebreathing or increased CO2 production.	Check rate/volume, circuit, airway pressures and clinical causes; avoid simply hyperventilating.
Sudden rise with ROSC	Improved pulmonary blood flow after return of spontaneous circulation.	Reassess pulse, blood pressure, oxygenation and post-arrest care.

12. Rapid sequence induction (RSI) safety concepts

RSI combines pre-oxygenation, an induction agent and neuromuscular blockade to facilitate intubation. It is a high-risk procedure requiring an experienced airway clinician, a full plan for hypotension and a rescue airway. EMT students should understand the sequence, monitoring and complications even if they do not administer the drugs.

Prepare: monitors, IV/IO access, suction, oxygen, drugs, capnography, backup devices and post-intubation sedation.
Optimise: correct hypoxaemia, hypotension, acidosis and positioning where possible; use a ramped position in obesity/pregnancy.
Pre-oxygenate: maximise oxygen reserve; use BVM or NIV when indicated and safe.
Induce and paralyse: drug choice is clinician-led and patient-specific; anticipate hypotension, apnoea and difficult ventilation.
First-pass attempt: use the best operator/device; stop if oxygenation worsens.
Confirm and secure: waveform capnography, chest assessment, fixation, analgesia/sedation and ventilator/BVM plan.

13. Failed airway and “cannot oxygenate” response

Priority is oxygenation, not repeated laryngoscopy. If intubation fails, return to BVM with two-person seal, insert a supraglottic airway if trained, suction, optimise position and call the most experienced airway clinician. A surgical airway is a last-resort procedure for trained experts when oxygenation cannot be achieved.

Declare the failed attempt and communicate the next plan clearly.
Use a time/attempt limit and protect the patient from repeated trauma.
Maintain oxygenation between attempts; monitor SpO2, ECG, blood pressure and ETCO2.
Consider reversible causes: laryngospasm, bronchospasm, tension pneumothorax, equipment failure, oesophageal placement and severe hypovolaemia.
Document attempts and complications for future airway planning.

14. Special airway situations

Situation	Airway priorities
Trauma/cervical injury	Jaw thrust, manual in-line stabilisation, suction, oxygenation and early expert help. Airway takes priority over perfect spinal immobilisation.
Facial burns/inhalation injury	Look for soot, hoarseness, stridor, facial burns and enclosed-space exposure. Oedema can progress; prepare early advanced airway support.
Maxillofacial bleeding	Position to drain if safe, aggressive suction, two-person BVM and early surgical/anaesthetic help.
Paediatric airway	Large occiput, narrow airway and rapid desaturation; use age/size equipment, gentle ventilation and paediatric protocols.
Pregnancy	Reduced oxygen reserve and aspiration risk; ramp position, left uterine displacement, early help and avoid prolonged apnoea.
Obesity	Ramped position, larger equipment, effective pre-oxygenation and anticipation of difficult mask ventilation.
Neuromuscular weakness	Weak cough and fatigue may precede hypoxaemia; monitor ventilation/ETCO2 and involve critical care early.

15. Airway complications

Aspiration: suction, lateral/recovery positioning when appropriate, oxygen/ventilation and urgent assessment for pneumonitis or pneumonia.
Laryngospasm: remove stimulus, jaw thrust, positive-pressure oxygen and advanced management if persistent.
Bronchospasm: wheeze, high airway pressures and poor chest rise; bronchodilator and escalation according to protocol.
Tube displacement: sudden desaturation, absent waveform or unequal breath sounds; ventilate and confirm immediately.
Right mainstem intubation: unilateral breath sounds and rising pressures; check depth and reposition by the airway clinician.
Pneumothorax: sudden hypoxia, hypotension, unilateral silence and increased resistance; treat as a time-critical reversible cause.
Pressure injury and gastric inflation: avoid excessive ventilation pressure and volume; use a decompression plan when indicated.

16. Clinical scenarios

Scenario 1 — Snoring after overdose: A drowsy patient has slow breathing and loud snoring. Reposition, open the airway, suction if needed, insert an appropriate adjunct, assist ventilation and check glucose/oxygenation. Do not wait for complete apnoea.

Scenario 2 — Facial trauma: Blood and loose teeth fill the mouth after a road crash. Use PPE, suction under direct vision, jaw thrust/manual stabilisation, high-flow oxygen and two-person BVM; call an advanced airway team early.

Scenario 3 — Failed intubation: After one poor view the patient’s SpO2 falls. Stop repeated attempts, ventilate with a two-person mask technique, insert a rescue SGA if trained, use capnography and communicate the failed-airway plan.

Scenario 4 — Sudden ETCO2 loss in transit: A ventilated patient suddenly desaturates and the waveform disappears. Check the patient, tube, circuit, oxygen source and capnography sensor simultaneously; ventilate with BVM and treat dislodgement, obstruction, disconnection or arrest.

Scenario 5 — Burn inhalation: A patient rescued from a smoky room is initially talking but becomes hoarse with soot around the mouth. Monitor closely, give oxygen, prepare early airway support and transfer urgently because swelling can make later intubation impossible.

17. Airway equipment checklist

Category	Minimum readiness check
Oxygen/ventilation	Cylinder pressure, regulator, tubing, reservoir, BVM, masks, PEEP valve if used.
Suction	Power, tubing, canister, Yankauer, soft catheters and backup battery/manual suction.
Basic adjuncts	OPA/NPA range, lubricant, tape, bite block, forceps only if authorised.
Advanced airway	SGA sizes, laryngoscope/video device, blades, tubes, stylet/bougie, syringe, cuff manometer and securing material.
Monitoring	Pulse oximeter, ECG, non-invasive BP, waveform capnography and temperature where available.
Rescue	Backup BVM, spare oxygen, difficult-airway plan, emergency front-of-neck kit for trained teams and PPE.

18. Documentation and handover

Initial airway patency, voice, secretions, obstruction, breathing effort, SpO2/ETCO2 and neurological state.
Position, suction, oxygen device/flow, adjunct size, BVM technique and response.
Advanced airway device, operator, number of attempts, view, tube depth, confirmation method, ETCO2 waveform and fixation.
Ventilation settings or BVM rate/volume, airway pressures, sedation/analgesia and haemodynamic response.
Complications, reassessments after movement and exact handover time/person.

19. Revision questions

Why can a patient have a normal SpO2 while ventilation is failing?
When is an OPA unsafe, and what alternative adjunct may be considered?
List four causes of “no chest rise” during BVM ventilation.
Why is continuous waveform capnography important after intubation?
What is the priority after a failed intubation attempt with falling SpO2?
How does inhalation injury change the airway plan?
What signs suggest right mainstem intubation or tube displacement?
Why should ventilation use the smallest volume that produces visible chest rise?
What equipment must be checked before an advanced airway attempt?
What airway information belongs in a structured handover?

20. Key take-home points

Open, suction, oxygenate and ventilate before attempting advanced procedures.
Two-person BVM, good positioning and continuous reassessment save lives.
Airway devices are not self-monitoring—confirm chest rise, physiology and waveform capnography.
Limit attempts, maintain oxygenation and move early to a rescue plan.
Post-intubation care is an ongoing process: secure, sedate/analgesia as prescribed, ventilate, monitor and recheck after movement.

Selected authoritative resources

For EMT practice: The best airway is the one that delivers oxygen, protects the patient and can be confirmed continuously. Build a plan, keep a rescue option ready and never let a difficult procedure replace basic ventilation.