My Rules for Getting the Airway

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There are all these fancy terms out there in respect to airway. There’s apnoeic oxygenation, delayed sequence intubation, the vortex etc….. Let me tell you something, you already know. This stuff has been around in one form or another for a while, but we have discovered its application to emergency medicine only recently.

After giving an advanced airway workshop to doctors and nurses a week or so ago, I thought you may benefit from some of the approaches to the airway, that were taught.

What I want to do is control the airway. I dont ever want to cut the neck and I want to use every possible trick I know to make it easier. I have been teaching airway for many years, have put thousands of doctors through the Advanced Airway Workshop and am really proud of the skills that I have learnt from people much smarter than me and then adapted them so they can be utilised in the most practical way and then taught them. Regardless of how long I’ve been doing this, I suffer some lower abdominal discomfort if I’m about to do a tube on someone that doesnt look that easy.

I recently had to intubate someone and they were a Grade IV Cormack-Lehane scale tube, ie., this was not going to be a pleasant experience, but the rules I teach, I use and in it went. This stuff works.

So here are some of the rules I use.

How Do I Prepare?

I don’t care if I’m doing a sedation, or if I’m about to do an intubation, I check my equipment and take out what I’m about to use, which is:

  • a size 3 curved blade.
  • a 7.5 endotracheal tube (ETT)(everyone gets a 7.5).
  • a stylette always and I bend it to the shape I want. You can see here that that is at about 35 degrees. Why bend it? Remember that the trachea lies anteriorly and if you go in and only see epiglotis but no cords, you can still curve the tube under the epiglottis and direct it forward so it is in the right place, the trachea.
  • an oropharyngeal airway- mostly to use as a bite block, for when I’ve tubed.

I also prepare for apnoeic oxygenation. Now this isn’t of much use in an arrest situation, but in sedation for procedures, it keeps those sats up there for the whole process. Alternatively, if you’re intubating, it can buy you a fair bit of time. This is all about nasal prongs on the patient. Oxygenate using your normal teachniques, but when the patient is asleep, crank up the oxygen to 15L/min via the nasal prongs. Remember they need to be asleep when you turn this up, as it can be very uncomfortable.

Now, not all patients have great saturations. Some a sicker than others and have low sats. Know that if your patient has 92% saturations with oxygen on, before you try to intubate, that you will have a hard day at the office. That patient’s PaO2 is probably less than 60mmHg and will drop quickly when you try to intubate.

You may need to be more aggressive with pre-oxygenation and use BiPAP or CPAP or even a PEEP valve on you bag-valve-mask apparatus. I cetainly will also add apnoeic oxygenation to these patients.

When the patient is unwell it will also determine your approach to the drugs used. For example the use of rocuronium is supposedly better than sux in sepsis as it decreases the oxygen demand on the patient thought to be due to fasciculations and thus the patient doesnt desaturate as quickly.

The new catch phrase however, is Delayed Sequence Intubation. This effectively is procedural sedation that sedates the patient with Ketamine, so that you may be able to improve the oxygen status before proceeding to intubation.

Unless it’s a trauma scenario, head up of about 20 degrees also helps.

What do I do to Get the Tube In?

The first thing I do is not worry about getting the tube in. The most important thing for me is to oxygenate and ventilate. Sure we have to secure the airway, but oxygenation and ventilation are the key.

In an arrest, I do not intubate(unless I have a video laryngoscope), until there is return of spontaneous circulation.

In all other cases, if I can bag-valve-mask- and please remember that this is a technique that needs practice, then I relax. Only when I cannot intubate, then not oxygenate or ventilate do my thoughts go to surgical airway. However I stop and think about a laryngeal mask.

The first thing I do is not worry about getting the tube in. The most important thing for me is to oxygenate and ventilate. Sure we have to secure the airway, but oxygenation and ventilation are the key.

In an arrest, I do not intubate(unless I have a video laryngoscope), until there is return of spontaneous circulation.

In all other cases, if I can bag-valve-mask- and please remember that this is a technique that needs practice, then I relax. Only when I cannot intubate, then not oxygenate or ventilate do my thoughts go to surgical airway. However I stop and think about laryngeal mask.

If you’re in a situation where there aren’t a lot of helpers with you ie., you are in a rural setting with limited resources, a laryngeal mask can be a very important device. You can insert, inflate and then attach to a ventilator if you wish.

The figure on the right shows an intubating laryngeal mask, which can be used to pass a specially reinforced ETT.

However,, if you are in a situation where you have tried to intubate…and cannot, then find you cannot ventilate or oxygenate, don’t go straigh to a surgical airway. This of the laryngeal mask. It may just open that airway enough for you to ventilate the patient.

Predicting The Difficult Airway

Predicting the potentially difficult airway is very important in emergency intubations. Remember that this is an emergency situation and the reason you initially wanted to intubate will not have gone away.

I think the benefit of being able to predict, is all about getting you  ready for what you know will be difficult and to consider the alternative approaches.. Watch the quick video on the 3:3:2 rule above.

My 3 Rules for Intubation

I recently wrote a blog on the 3 essential things required for intubation.

  1. Always use apnoeic oxygenation. Done, we’ve discussed this and you can read more on it by clicking the link above.
  2. Position the Patient for success. If there is no issue with potential spinal injury, then the patient position can be changed to improve the view you have. The optimal position for laryngoscopy was found to be neck flexion of 35° and face plane extension of 15°. This translates to placing the patient in position such that the external meatus and the sternal notch are aligned in a straight line
  3. The EPIGLOTTIS is the key landmark. Stop looking for the vocal cords. Move the laryngoscope down towards the base of the tongue until you see the epiglottis. Put the tip of the laryngoscope blade in that space between the base of the tongue and the epiglottis. Then pull in the direction of the handle and the cords should fall into view. Then using the ETT with the stylette in it, you have the best chance of getting that tube in.

How do I Know When I have a Failed Airway?

We have to have some kind of definition. It is usually accepted that when you cannot intubate following 3 attemps or cannot ventilate to saturations above 90%, this is a failed airway.

Everyone needs to have a difficult airway protocol. Have you thought about what might be yours? The time to consider it, is not when the tube isnt going in, it’s now.

Mine is try to intubate, if cant, change something, ie., the blade, or introduce a pillow under the head. If cant intubate for a 3rd time this is a failed intubation. I will then see if there is anyone more experienced thatn be. I may in fact do this earlier. The reality of another pair of hands is, that if they are not as experience as you, a different pair of hands sometimes changes the outcome.


I hope this has helped and hope to put you under pressure at an airway workshop coming soon. I will also be covering these in a morning session on the second day of EMCORE 2015.

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator


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