Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android. Learn more here!


Glottic Opening. Standard direct laryngoscopy reveals the glottic opening in this cadaver. A Mac 4 blade is used like a Miller blade in this instance as the epiglottis lies anterior to the blade tip. (Photo contributor: Lawrence B. Stack, MD)


MAXIM: Endotracheal intubation is not always the best initial intervention for respiratory failure.

Clinical Summary

Some patients in respiratory distress may benefit from other interventions, short of intubation. Patients with flash pulmonary edema may have dramatic improvement with intravenous nitroglycerin, intravenous furosemide, and BiPAP (Bi-Level Positive Airway Pressure) ventilation (see Fig. 22.1). Patients with airway narrowing (edema, neoplasm, stricture, foreign body) can have significant decreased work of breathing by decreasing airway resistance to inspired gas using administration of helium-oxygen (HELIOX) mixture. HELIOX, usually as a 78%: 22% helium: oxygen mixture, is much less dense than either air or 100% oxygen by virtue of helium replacing nitrogen or oxygen, respectively. This lowers resistance to laminar flow by as much as 20% to 25% and the effects are immediate.


Bi-Level Positive Airway Pressure. This patient with COPD rapidly improved with the application of BiPAP. (Photo contributor: Steven J. White, MD.)


  1. Alternative ventilatory adjuncts include HELIOX, CPAP, BiPAP, and Vapotherm (see Fig. 22.2). These adjuncts may prevent the need for intubation in selected patients.


Vapotherm.  Application of Vapotherm (high-flow warmed oxygen) rapidly improved this toddler with pneumonia and reactive airway disease. (Photo contributor: Lawrence B. Stack, MD.)


MAXIM: The most important initial airway intervention may be to ask for help.

Clinical Summary

Clinical scenarios where asking for help include:

  1. Laryngeal injury/tracheal disruption, for whom a nonendoscopic intubation attempt can result in tracheal disruption and fatally lost airway (see Fig. 22.3).

  2. Recent neck surgery, with pending loss of airway from an expanding hematoma; definitive and life-saving intervention in this case is to open up the recent incision and evacuate the hematoma.

  3. Suspected epiglottitis, where an immediate operative tracheostomy or cricothyroidotomy may be required if intubation fails due to epiglottic edema.

  4. Severe angioedema with tongue, oropharynx swelling where endotracheal or nasotracheal intubation may be obstructed (see Fig. 22.4).


Laryngeal Fracture. This 17-year-old male was kicked in the neck by a bull at a rodeo causing a laryngeal fracture. (Photo contributor: Rudy Kink, MD.)


Angioedema. This patient with ACE-inhibitor angioedema and respiratory ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.