Airway management is a critical skill not only for clinical anesthesiologists but also for ICU and ED physicians. The primary objectives of airway management are threefold - to ensure airway patency, provide lung ventilation, and protect the lungs from soiling. Although major airway management complications are rare in the operating room (OR), they can be life-threatening when they occur. 

Airway events are far more frequent in the ICU and ED than in the OR and when doctors with less extensive anesthetic experience perform the procedures. To avoid complications, doctors must be skilled at managing airways. One critical component of effective airway management is evaluating patients for increased risk of complex or failed airways. Another is to ensure providers possess a working knowledge of the various tools and equipment available to provide a positive outcome.

Most Common Types of Airway Management Equipment

Doctors have a wide array of equipment available to support a patient's airway. However, providers must consider multiple factors to determine the appropriate equipment for each case. Knowing the pros and cons of each piece of equipment can help make the best decision. 

Here is an overview of the most common types of airway management equipment and their benefits and drawbacks. 

Airway Maneuvers, Position, and Clearance

When doctors are faced with a patient with an obstructed upper airway, their first method of choice is typically to perform an airway maneuver. 

Head Tilt-Chin Lift Maneuver

For example, the head tilt-chin lift maneuver is performed by first placing one hand on the patient's forehead and the other under the chin. Next, the physician tilts the forehead while lifting the chin forward to extend the neck.

‍Pros:

• The head tilt-chin lift maneuver is the simplest airway maneuver used in resuscitation

Cons:

• Doctors should use extreme caution in patients with suspected neck injuries

Jaw-Thrust Maneuver

A jaw-thrust is usually used if the patient is suspected of having suffered major trauma. This is done by using both hands to apply force behind the ramus of the mandible, displacing the lower jaw forward and upward.

Pros: 

• Improves upper airway patency 
• Since it does not require neck movement, it can be used when there is a risk of c-spine injury (i.e., with patients who are unconscious due to a head injury)

Cons: 

• If there is a risk of pulmonary aspiration, the doctor should place the patient in the recovery position or consider advanced airway management

Adjuvants to Upper Airway Obstruction

Oropharyngeal airway

This equipment is used by inserting the Guedel into the patient's mouth upside down, passing to the back of the throat, and rotating 180 degrees to fit behind the tongue base.

Pros:  

• Can help prevent the tongue and soft tissues of the pharynx from obstructing the airway 
• Oral appliances are available in different sizes for children and adults

Cons:

• Cannot be used in patients with a severe gag reflex or oral trauma. The risk of stimulating this gag reflex, leading to the aspiration of gastric contents, is way too high
• Can also cause trauma to the teeth and the mucous membranes of the oral cavity

Nasopharyngeal airway

Doctors use nasopharyngeal airway (NPA) in patients with an intact gag reflex, trismus, and oral trauma to bypass obstructions in the oral cavity. The procedure is done by lubricating the tip of the NPA, and inserting it into the right nostril aiming perpendicularly to the face down into the pharynx.

Pros:  

• Can be used as an artificial form of airway maintenance when tracheal intubation is not possible, is not recommended, or is outside the practitioner's scope of practice 

Cons: 

• Not for use in patients with a suspected skull fracture
• Can cause trauma to the nostril

Bag-Mask Ventilation

This type of ventilation is a fundamental maneuver in airway management that can be used in children and adults.

Pros:  

• Allows for the temporary oxygenation and ventilation of patients until a more definitive airway can be established 
• Can also be used in cases where endotracheal intubation is not possible
• May be the best option for prehospital airway support in the pediatric population 

Cons: 

• Often used by individuals with little to no training, yielding suboptimal results

Advanced Airway Management

Supraglottic devices

Supraglottic airways include devices that sit adjoining the larynx above the vocal cords. Doctors typically use them as alternatives to endotracheal airways in low-risk anesthetic cases. Examples of supraglottic airways:

• Laryngeal mask airway
• Laryngeal tube
• Esophageal-tracheal
• Endotracheal tube

Pros:

• Can be used in prehospital and cardiac arrest settings to attain a more secure airway without endotracheal intubation

Cons: 

• Do not protect against aspiration. This is a significant downside leading to the lack of a definitive airway
• Possible complications are gastric insufflation, aspiration, laryngospasm, and partial airway obstruction
• Should not be used if there is poor mouth opening, pharyngeal pathology, or obstruction at/below the level of the larynx

Bougie

The bougie, also known as the endotracheal tube introducer (ETI), has become increasingly mainstream in airway management. A gum elastic bougie is a flexible instrument that can be molded into a curved shape. Doctors generally use them when an airway may be challenging to intubate by placing them into the airway under direct/indirect guidance.

Pros:

• Increases first-pass success in obtaining a definitive endotracheal airway
• Offers an enhanced ability to obtain visual confirmation of tracheal placement compared to direct endotracheal tube (ETT) placement without the bougie 
•  Manual in-line stabilization (MILS) decreases the grade of view of the glottis
• Ability to pass it blindly into the trachea when adequate visualization is not possible

Cons: 

• Can cause damage or perforation of the trachea, bronchi, and potentially the esophagus

Check out how QuickSteer™'s ease of use and single-hand operation enables physicians to successfully intubate even the most difficult airways.

Watch this video to see QuickSteer™ in action. 

Want to learn more? Connect with a specialist by calling 763.330.2162 or emailing info@accessairways.com.

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References: 

https://www.ncbi.nlm.nih.gov/books/NBK470403/

https://pubmed.ncbi.nlm.nih.gov/20667150/

https://emedicine.medscape.com/article/80184-overview

https://www.acepnow.com/article/the-bougie-as-an-airway-savior/

https://geekymedics.com/airway-equipment-explained/