EMT and Paramedic Airway Skills Overview!

Don’t Forget the Basics of your EMT and Paramedic airway skills! Today, we'll go over basic and advanced airway with important reminders and rules! Whether you're an EMT-b or a Critical Care Paramedic, today should have something juicy for everyone!

Airway Adjuncts - Airway 101

MedicTests.com Airway 101

  • Many new and seasoned EMS providers, especially Paramedics, overlook the simple oral (OPA) and nasal (NPA). In practical use, both are approved methods to help provide a patent airway; at least temporarily until complete airway control is obtained.
  • The names; oral airway (OPA) and nasal airway (NPA) are misleading, implying that they are actual airways; however, neither one will provide a secure patent airway, and their use still requires a head-tilt/chin-lift or modified jaw-thrust.
  • Insertion of either will provide better passage of ventilation and exhalation, but neither will help lift the tongue, as this can only be accomplished with manual opening techniques.
  • If inserting a OPA indicates a general lack of a gag reflex, it should raise multiple red flags regarding the patient's overall respiratory system. If the patient cannot protect his airway, then his ability to provide his own effective ventilations is very doubtful.

Note: Using an OPA or NPA without manual opening techniques is no more useful than ventilating an unopened airway without the device.

Using an Oropharyngeal Airway (OPA)

An OPA is indicated in the following circumstances:

  • Unconsciousness
  • No gag reflex
  • Apneic patients receiving ventilatory assistance via BVM

An OPA is contraindicated in the following circumstances:

  • Conscious patient
  • An active gag reflex

Steps to insert OPA

  1. Measure the OPA from the earlobe or the angle of the jaw to the corner of the patient’s mouth.
  2. Open the patients’ mouth with the cross-finger technique. Insert the OPA with the tip pointing to the roof of the mouth.
    Never place your fingers in the patients mouth without a bite stick in place to prevent being bitten.
  3. Rotate the OPA 180 degrees, the flange will rest against the lips/teeth; positioning the end in the pharynx.

Using a Nasopharyngeal Airway (NPA)

An NPA is indicated for use under the following circumstances:

  • A semiconscious or unconscious patient with a gag reflex
  • Patients who otherwise will not tolerate an OPA

An NPA is not indicated for use under the following circumstances:

  • A patient with a severe head injury with blood draining from the nose.
  • A history of fractured nasal bones/nasal surgery or deviated septum

Steps of insertion of an NPA:

  1. Measure the NPA from the tip of the patients nose to the earlobe.
  2. NPA's like OPA's come in different sizes and choosing the appropriate size for the patient is all important.
  3. Always lubricate the NPA prior to insertion with a water salable lubricant.
  4. Inserting the NPA:
  5. Place the NPA in the larger nostril
  6. Make sure the curve of the device follows the curve of the nose.


Tips to Remember!

  • If the right nostril was used the bevel should face the wall of flesh that divides the nose down the middle called the "septum."
  • If the left nostril was used insert the NPA with the tip pointing upward until resistance is met then rotate 180 degrees into position.
  • When completely inserted, the flange rests against the nostril while the other end of the NPA opens into the back of the windpipe.

Check out this video on the proper placement of the oral or nasal airway!


Using a Combitube

The Combitube allows for either esophageal or tracheal insertion. It’s a plastic tube with 2 separate chambers or lumens. One tube resembles an ET with an open distal end. The other tube is blocked by the obturator at the distal end. Both tubes use a low pressure cuff to seal either the trachea or esophagus, depending on the placement. When inflated, the large pharyngeal balloon fills the space between the base of the tongue and the soft palate, anchoring the tube into place. The Combitube usually finds itself in the esophagus because of the shape of the tube and the structure of the pharynx.


Combitube (size: standard small Adult) intubation may be performed only on those patients who meet ALL of the following criteria:

  • Are unconscious and without purposeful movement.
  • Do not have a gag reflex.
  • Unable to perform endotracheal intubation.
  • Apneic or have a respiratory rate of <6.
  • Appear to be at least 4. 5’ tall.


Combitubes must NOT be used on patients who meet any one of the following criteria:

  • Have a positive gag reflex.
  • Have known esophageal injury, surgery, or disease (e.g., tumor, varices).
  • Have a foreign body airway obstruction (FBAO).
  • Have a history of laryngectomy with stoma.
  • Are known narcotic overdoses, with ALS less than 10 minutes away.
  • Any circumstance where airway edema is suspected or could develop.
  • Ingestion of a caustic substance.
  • Allergic / anaphylactic reaction.


  • Combitube
  • 100 + cc syringe for inflation of pharyngeal cuff
  • 20 cc syringe for inflation of distal cuff
  • Water soluble lubricant
  • Stethoscope
  • Portable suction device


Insertion Procedure

  1. Inflate each cuff and check for leaks, apply emesis diverter to tube # 2.
  2. Apply water-soluble lubricant to distal end of tube.
  3. Hyperoxygenate patient.
  4. Place patient’s head in a neutral position.
  5. Grab lower jaw and lift upward.
  6. Insert tube; advance until teeth / gums are between black rings on tube.
    Note: Alternately, you can omit steps 5 & 6 and use a Laryngoscope and visualize placement of the tube into the esophagus.
  7. Inflate pharyngeal cuff (Port # 1 blue pilot balloon) with 85 cc of air (do not hold tube during inflation).
  8. Inflate distal cuff (Port # 2 white pilot balloon) with 15 cc of air.
  9. Ventilate through TUBE # 1.
  10. Assess ventilation:
  • Rise and fall of the chest
  • Bilateral lung sounds
  • Confirm placement with CO2 detector
  • Gastric auscultation

If CHEST RISE is present and GASTRIC SOUNDS are absent:

  • Secure tube.
  • Verify placement.
  • Continue ventilation


  • Remove the emesis diverter and ventilate on TUBE #2
  •  Assess ventilation as above


  • Deflate both cuffs.
  • Pull the tub back approximately 2 cm.
  • Reinflate cuffs and recheck tube placement.
  • If you are unable to confirm placement via either tube discontinue and return to a BLS airway.

Tips to Remember!

  • The Combitube will enter the esophagus 85% of the time, so ventilation with tube # 1 is ordinary.
  • If ventilation is through tube # 2 then the tube is in the trachea and tube # 2 may be used for medication administration and suctioning, just as if it were an ordinary ET tube.
  • Removal of the tube should be accomplished with the patient on their side and suction immediately available.
  • If resistance is met when advancing the tube, the attempt should be discontinued.
  • Don't FORCE it! If resistance is met on intubation attempts, the tube should be removed and BVM continued.

Now check out this video on proper placement of a Combitube!


Intubation 101

Intubation Overview:

Intubation means : to place a tube in a patient’s trachea to control the airway and allow for ventilation. Sometimes, this is easier said than done. It’s simple enough in concept, but requires us to displace the individual anatomy that stands between the oral opening and the trachea. Part of this challenge is the largest obstacle in the airway; the tongue. We need to move it out of the visual field to be able to see the laryngeal structures. Usually when you encounter that huge floppy tongue, there’s a big floppy epiglottis attached to the base of it. If you don’t see it right away, look in the pool of pizza, beans and beer, oozing out of the airway, lying in the back of the oral pharynx, you’ll find it!

The common ET tube is a flexible tube that is open at both ends. The proximal end has a standard 15mm adapter to attach to oxygen deliver systems for positive-pressure ventilations. The distal end is beveled to aid insertion in to the patients’ trachea. The adult sizes are from 5 – 10 mm and has a balloon cuff that closes off the remaining tracheal opening to prevent aspiration. The cuff has a small tube so that the medic can inflate the cuff with 10 cc air via syringe after proper tube insertion. A properly placed tube with the cuff sealed properly gives a controlled airway environment for EMS.The markings on the tube are in millimeters. The length of the tube from the distal end is indicated in cm at several levels. Recommended sizes for adult male are 7-8 mm and 6-7 mm for adult females. Infant and pediatric tubes are available with and without cuffs. Cuffed tubes are indicated for children over the age of 8 years old. Children under 8 have a circular narrowing at the level of the cricoid cartilage.  This serves as a natural cuff. Cuffed tubes may be indicated in children that require high ventilatory pressure (i.e., status asthmaticus, acute respiratory distress syndrome) Remember; suction is our friend!

Intubation Tips for Success

1. Lubrication is Key!

On Occasion, the endotracheal tube may become "caught up" along a floppy, dry epiglottis. Because it is difficult to predict when this may happen, pre-lubricate the tube tip with a thin layer of water-soluble lubricant. This lubricant can also minimize the degree of surface trauma to the trachea and tracheal rings as the tube passes through the vocal cords.

2. Choke up on the bat!

Delicate force is necessary to lift the tongue and pharyngeal soft tissue anteriorly in order to visualize the vocal cords during intubation. Patients with extra neck soft tissue or a large tongue may need significant force applied to obtain an unobstructed view.

3. Maximize your site line!

Direct posterior cricoid pressure does not consistently provide an optimal view of the vocal cords. It is controversial whether the BURP maneuver (backward-upward-rightward pressure) applied to the cricoid cartilage improves or worsens visualization. BURP as well as, cricoid pressure should be used with extreme caution and only if local protocol allows it.

4. Minimize exertion and avoid shaking!

Grasp the laryngoscope handle as close to the blade as possible, this gives you the greatest control and strength. Lift; never ever bend your wrist, doing so will cause you to put undue pressure on the teeth and possibly break them!

 Indications for tracheal intubation include:

  • Inability of EMS to properly ventilate the patient by traditional means (i.e., via BVM, mouth-to-mask)
  • Patient can’t control his own airway (i.e., unconscious, coma, cardiac arrest)
  • Prolonged ventilation is anticipated

Intubation advantages:

  • The trachea is isolated ; preventing aspiration of stomach contents in to the lower airways
  • Ventilation and improved oxygenation is easier and more effective
  • Suctioning is easier
  • Gastric distention is eliminated during ventilation
  • A quick route for certain emergency meds (i.e., narcan, atropine, vasopressin,epinephrine, lidocaine; {NAVEL})

Intubation Procedure

  1. Place patient in correct position.
  2. Hyperoxygenate patient with BVM ventilations with adequate tidal volume and rate for 1-3 mins with 100% oxygen, avoid  hyperventilation .
  3. Apply cricoid pressure as needed to prevent passive regurgitation if protocol allows it.
  4. Instruct partner to place patient on cardiac and pulse oximetry monitors.
  5. Select a proper ETT for the patient.
  6. Insert stylet into ETT making sure it doesn’t’ exit the distal end.
  7. Select proper sized blade and visualize landmarks (Epiglottis, posterior notch, vocal cords).
  8. Suction as needed.
  9. After direct visualization insertion into the trachea
  10. Insert ETT 2-3 cm past the cords under direct visualization.
  11. Attempts should be limited to a fall in HR or SpO2 or 30 seconds per attempt.
  12. Hyperoxygenate between attempts with BVM 100% O2.
  13. Remove stylet, inflate cuff and bag ventilate.
  14. Confirm position with at least three of the following methods (one method needs to be mechanical):
  • Direct endotracheal visualization
  • Esophageal intubation detector
  • Absence of epigastric sounds
  • Presence of bilateral breath sounds
  • Equal chest rise
  • Misting or fogging in the ETT
  • CO2 detection device
  • Secure the tube. (Consider cervical collar to prevent extubation).
  • Reassessment tube placement after each patient movement (may be done with CO2 detection device).
  • If any doubt about proper placement, use direct visualization to confirm.

Special Considerations:

  • The goal is to always ventilate the patient.
  • Do not sacrifice good ventilation with repeated attempts at intubation.
  • Make 2 attempts at intubation and move to next procedure as defined in Airway Management Protocol .
  • Do not delay transport with repeated unsuccessful intubation attempts.

Now check out this AMAZING intubation video!

Rapid Sequence Intubation

The primary indication of the use of RSI is the need for immediate control of a patient’s airway when it cannot be controlled by other means and intubation and airway control is imperative. RSI should not be used routinely and should be implemented only when the patient cannot be intubated because of clenched jaw, persistent seizures, combativeness in a conscious patient with an intact gag reflex, etc.
Rapid Sequence Intubation uses several different medications. These may include: neuromuscular blockers, defasciculating agents, sedatives, and premedication agents such as Lidocaine and Atropine that are administered in specific situations.
Following an organized and simple step-by-step process will help organize and facilitate a smooth and rapid procedure. Prior to initiating the procedure select the appropriate agents for premedication and paralysis based on the patient’s presenting condition, calculate the doses and prepare medications for the proper sequence of administration of neuromuscular blockers. This procedure will reflect the use of a defasciculating (a non-depolarizing agent used to prevent painful muscle contractions and twitching) agent and succinylcholine as the paralyzing agent. Know your local operating guidelines, as there are several methods and different medications that can be used for RSI.

"If safe to do so, an attempt at nasal intubation should be tried prior to choosing to use RSI"

Procedure for Rapid Sequence Intubation (RSI)

Medictests.com RSI

1. Prepare, Preoxygenate

It is essential that your partner is knowledgeable about the RSI procedure. In order to prevent complications and insure a smooth process with minimal difficulty make sure everyone understands what is about to be done. Adequate preoxygenation with 100% O2 delivered by a BVM, suctioning, cervical-spine stabilization and application of cricoid pressure are essential skills everyone needs to be proficient with. Ensure that a baseline neurological assessment has been completed prior to paralysis, especially in the head injured patient. A baseline neurological examination must include at minimum: initial survey information, disability exam (AVPU), pupils, extremity movement, and a Glasgow Coma Score.

2.  Premedication

Primarily Atropine and Lidocaine are used depending on the clinical situation. The dosages and recommended clinical guidelines are described below:

  • Atropine: Atropine’s parasympatholytic / anticholinergic effects help prevent bradycardia due to acetylcholine and succinylcholine stimulation of muscarinic receptors of the heart. Atropine does not affect nicotinic receptors, so it will not interfere with neuromuscular blockade. Administer the adult dose of : 0.6-0.8 mg rapid IV push or pediatric dose: 0.02 mg/kg rapid IVP before succinylcholine, if indicated. Atropine is administered when there is preexisting bradycardia, or in children less than one year of age. Atropine must always be administered prior to a repeat dose of succinylcholine.
  • Lidocaine: Given to suppress the cough reflex and reduce the risk of increased intracranial pressure. Administer it before intubating patients with the potential for increased intracranial pressure. The dose is 1.5 mg/kg IV push. Some guidelines recommend 1 mg/kg.

3.  Sedation

Sedation is mandatory!
It is essential to adequately sedate the patient because Paralytics have absolutely no effect on consciousness or pain perception. Administering adequate sedation is ethically correct and physiologically it reduces panic, helps to reduce intracranial pressure and induces amnesia. The sedative of choice is diazepam (Valium) or midazolam (Versed). Valium will outlast most paralytics but Versed has a faster onset of action. Sedation must be in adequate doses to maintain sedation of the patient post-intubation. Always administer benzodiazepine agents at a minimum of 60 seconds before paralyzing the patient.

  • Valium: adult: 5-10 mg IV; peds: 0.1 mg/kg IV
  • Versed: adult dose only: 2-5 mg IV push

4.  Cricoid pressure

Sellick’s maneuver improves visualization of glottis and occludes the esophagus to inhibit aspiration of gastric contents. It must be maintained until placement of the ET tube is confirmed and the cuff inflated. (Check local protocol)

5. Paralyze

Give a small dose of a non-depolarizing paralytic agent to prevent fasciculations caused by succinylcholine that are painful and potentially a cause of increased intracranial pressure. A common approach is:

  • Administer vecuronium at 1/10th the paralyzing dose to prevent fasciculations. The defasciculating dose of vecuronium is 0.01 mg/kg IV push. We do not recommend using vecuronium as the initial paralyzing agent because it is long-acting (can last up to 45-90 minutes). If the patient is unable to be intubated, you will need to perform a surgical airway procedure. We encourage prehospital guidelines that use only short-acting agents in the field for initial paralysis. Not only is it better for the patient but it is good risk-management as well.

Once the patient has received the defasciculating dose of vecuronium:

  • Succinylcholine will be administered to achieve paralysis. The paralyzing dose of succinylcholine is 1.5 mg/kg rapid IV Push (same dose and volume as Lidocaine). Paralysis is confirmed when the patient’s jaw becomes slack, or they become flaccid, or the vocal cords release their spasm. Agent choice is based on your local guidelines.

6. Post-paralysis

  • Once paralysis is confirmed – Intubation is crucial! But, if the patient can’t be intubated by direct laryngoscopy or an alternative procedure such as the intubating laryngeal mask airway (ILMA) or by LMA, you must perform a cricothyroidotomy.
  • You might be able to adequately ventilate and oxygenate the patient until the succinylcholine wears off. If the patient’s airway and oxygenation are inadequate you must be prepared to perform a surgical cricothyroidotomy.
  • Follow your local guidelines and know the alternative procedures your medical director has made available in your operating guidelines.

7. Confirm the endotracheal tube placement and secure it.

  • Direct endotracheal visualization
  • Esophageal intubation detector
  • Absence of epigastric sounds
  • Presence of bilateral breath sounds
  • Equal chest rise
  • Misting or fogging in the ETT
  • CO2 detection device
  • Secure the tube. (Consider cervical collar to prevent extubation).
  • Reassessment tube placement after each patient movement (may be done with CO2 detection device).
  • If any doubt about proper placement, use direct visualization to confirm.