Chapter 122. Intubation and Airway Support

1. What are the indications for rapid sequence intubation?

2. What are the predictors of a difficult airway?

3. When is “awake intubation” indicated?

4. What are the alternative methods available for intubation and/or ventilation?

Airway management can significantly affect outcomes for hospitalized critically ill patients. Failure to deliver adequate oxygen may cause irreversible brain damage or preclude successful resuscitation. Options for management may range from assisted ventilation with a bag-valve-mask (BVM) to noninvasive ventilation (NIV) support to endotracheal intubation. A successful outcome in any intubation demands proficiency in patient assessment, knowledge of the equipment (basic and advanced), requisite technical skills, appreciation of individual limitations, and an alternative plan to deal with the difficult or failed airway.

In 2006 the Society for Hospital Medicine published the Core Competencies in Hospital Medicine, which listed endotracheal intubation as one of the procedural competencies for hospitalists. However, a small survey published in 2010 noted that individual hospitalists (n = 175) performed on average only 10 endotracheal intubations in the previous year with a range of 3 to 20. This limited clinical experience with advanced airway management highlights the importance of a valuable educational program for the hospitalists as well as clinicians' understanding of their own practice and skill limitations. Depending on their clinical environment and work setting, the expectations for different hospitalists in advanced airway management will vary. However, all hospitalists should be versed in initial airway management and stabilization, including effective use of oral and nasal airway and BVM devices.

Airway Anatomy

Successful intubation requires knowledge of basic airway anatomy landmarks and locations of various airway structures relative to each other to identify the glottic opening and successfully intubate. The larynx and in particular the vocal cords lie just below the epiglottis, and proper elevation of the epiglottis should allow the clinician to visualize the arytenoids and the vocal cords prior to insertion of the endotracheal tube (ETT) (Figure 122-1).

Predictors of a Difficult Airway

A difficult airway refers to complex or challenging BVM or endotracheal intubation. Difficult oxygenation is the inability to maintain the oxygen saturation > 90% despite using a BVM and 100% oxygen. A failed airway refers to the inability to either ventilate or intubate a patient after three intubation attempts by the same operator using multiple blades. Experienced operators uncommonly encounter this problem. Difficult ventilation occurs in 1 in 50 anesthesia cases. In one study of emergency department cases 2.7% were deemed failed intubation attempts due to unsuccessful first attempts requiring rescue techniques. A higher rate of poor clinical outcomes occurs when the airway is managed as an emergent (rather than elective) procedure. In addition, an increased number of airway attempts predicts poorer outcomes; thus a backup plan is necessary if initial intubation attempts are not successfully executed. Medical diagnoses that increase the likelihood of difficult airways range from congenital conditions that typically affect the airway anatomy to acquired conditions such as trauma, tumors, edema, infections, arthritis, and obesity. All affect the ability to adequately visualize the larynx during the intubation attempt (Table 122-1).

Patients with large incisors, reduced distance between incisors, and reduced thyromental distance are more likely to have a poor laryngoscopic view and potentially more difficulty with intubation. Rapid assessment of these factors when one is first evaluating the patient can provide key data in development of an airway management plan. When presented with a patient that has one or more risk factors for difficult airway, additional equipment and/or personnel should be brought to the patient to assist with the airway management.

Many clinical assessment tools have been developed to predict a difficult airway, but insufficient evidence supports recommending any individual tool. The LEMON rule is one popular rule for assessment for difficult intubation (Table 122-2).

Operator and environmental factors may also contribute to challenges or failure to control the airway. Trainees and inexperienced clinicians (with low total numbers or infrequent intubations) may have greater difficulty intubating. When attempting to ventilate or intubate outside the controlled environment of the operating room, lack of proper patient positioning or inadequate equipment or medications may contribute to challenging intubations.

Many other factors have been associated with a difficult airway, but none accurately predicts, which patient will ultimately need more advanced techniques. Some patients who have several risk factors are intubated with ease while other patients who have no high-risk predictors on rare occasions have unforeseen difficulty with intubation or ventilation. In all cases the clinician should assess the potential risk for a difficult airway and always have a backup plan of action should initial attempt(s) at securing an airway prove unsuccessful.

Difficulty with BVM ventilation has been reported to occur in 5% of patients. Five independent risk factors for difficult BVM ventilation include age greater than 55 years, body mass index > 26 kg/m2, beard, lack of teeth, and history of snoring (Table 122-3, MOANS assessment). BVM ventilation can effectively maintain airway patency while an alternative plan is developed and implemented. However, patients with a high risk of failing BVM ventilation may require more rapid and definitive airway evaluation and management.

All indications for endotracheal intubation can be classified as (1) failure to maintain a patent airway, (2) failure of oxygenation and/or ventilation, and (3) anticipation of a rapidly deteriorating clinical course (Table 122-4).

Failure to Maintain a Patent Airway

The ability to maintain a patent airway preserves normal oxygenation and ventilation is essential to life. Maintenance of the airway protects against aspiration of gastric contents, which can have serious short- and long-term consequences for the patient after loss of consciousness or poisoning or during major acute upper gastrointestinal bleeding.

There are several ways to effectively assess the patency of the airway. Although widely used, the presence of a gag reflex is not one of those methods. The gag reflex is physiologically absent in many normal adults. Additionally, stimulation of the gag reflex in an altered or obtunded patient increases the likelihood of vomiting and, consequently, aspiration of gastric contents. The ability to phonate and/or converse is a reliable indicator of a patent airway. When the patient is unable to speak, the patient's ability to handle secretions (ie, swallow) can be used as a surrogate to determine whether the airway is patent.

Noninvasive maneuvers such as a chin lift or jaw thrust or devices such as an oropharyngeal (oral) airway or a nasopharyngeal airway adjunct (nasal trumpet) may allow time to prepare for intubation by temporarily maintaining a patent airway.

Failure of Oxygenation and/or Ventilation

When a patient's inability to oxygenate does not respond to supplemental oxygen, endotracheal intubation is indicated. Rather than relying solely on the results of an arterial blood gas (ABG) value, the patient's clinical appearance, including an assessment of vital signs and mentation, guides the decision to intubate. Awaiting ABG results may delay intubation, especially if the results conflict with the clinical impression.

Ventilatory failure is another indication for endotracheal intubation. Continuous pulse oximetry monitoring usually effectively determines the adequacy of oxygenation and the response to supplemental oxygen, but it does not assess ventilation. Capnography or ABG analysis can be used to determine a patient's ability to ventilate or to track the patient's response to noninvasive positive pressure ventilation. Results of these tests must also be interpreted cautiously and in conjunction with close observation of a patient's clinical course.

Anticipation of Clinical Deterioration

Despite patent airway and adequate oxygenation and ventilation, some patients may still require elective intubation to avoid emergent intubation later. Common examples include airway protection in an overdose patient or massive gastrointestinal (GI) bleeder, rest from labored breathing that cannot be sustained in a patient with severe asthma or pneumonia, or to maintain airway patency compromised from angioedema or other conditions. Anticipation of deterioration relies heavily on the physician's personal experience and judgment.

Contraindications to endotracheal intubation can be divided into either absolute or relative but these need to be tailored to the specific clinical situation. Absolute contraindications to intubation include total airway obstruction and total loss of facial or oropharyngeal landmarks, both necessitating a surgical airway. An anticipated difficult airway as described earlier is a relative contraindication to rapid sequence intubation (RSI), and in this situation consideration of awake intubation or use of the difficult airway adjuncts should be entertained. During cardiac or respiratory arrest, ventilation with a BVM, intubation, or both should be performed despite any contraindications.

Airway Plan

Rapid Sequence Intubation versus Awake Intubation

RSI is now the predominant and preferred method in managing the emergent airway in a patient who requires sedation (ie, not the patient requiring a crash airway). RSI is defined as the simultaneous administration of a sedative and paralytic agent to assist in endotracheal intubation, usually via direct laryngoscopy. Central to the concept of RSI is the avoidance of assisted BVM ventilation to avoid insufflation of the stomach and minimize the risk of aspiration. Outcomes evidence supports RSI as a safe and effective technique for emergency airway management that maximizes the patient and physician likelihood of timely, successful airway management.

Seven steps (“7 Ps of RSI”) essential to successful rapid sequence intubation include (1) preparation, (2) preoxygenation, (3) premedication, (4) paralysis, (5) positioning, (6) placement of the ETT, and (7) postintubation care.

1. Preparation refers to the initial assessment of the patient's airway and the decision to intubate. The clinician assesses the patient's airway. Predictors of a difficult airway must be addressed, and backup airway devices (such as a laryngeal mask airway, gum elastic bougie, etc) prepared. Additionally, clinicians should prepare any monitors, medications, and oxygen sources. Preparation also requires appropriately trained staff to manage the airway and establishment of plans for the difficult or failed airway.

2. Preoxygenation involves applying 100% supplemental oxygen to induce nitrogen wash-out and maximize the amount of time available for direct laryngoscopy without oxygen desaturation. In a normal healthy adult, adequate preoxygenation can permit 7–9 minutes of apnea before oxygen desaturation occurs. In patients with comorbid diseases (eg, cardiac disease, underlying lung disease, pregnancy, etc), desaturation can occur more rapidly.

3. Premedication involves administration of drugs 3–5 minutes before induction and paralysis to blunt the effects of direct laryngoscopy, including bronchospasm and a strong sympathetic response. Options for pretreatment include fentanyl (3 μg/kg) administration in patients who are severely hypertensive, have underlying coronary disease, or intracranial hemorrhage if no contraindications exist. Additionally, lidocaine (1.5 mg/kg) may be administered in patients with asthma or elevated intracranial pressure. Premedication with lidocaine, however, may be labor intensive, adds time, and has little proven benefit. Care should be taken when considering any premedication due to the added complexity, adverse affects of the premedication agents, and limited proven benefit.

4. Paralysis involves administration of a paralytic agent in conjunction with a sedative agent to rapidly induce paralysis and sedation. Unless contraindicated, etomidate (for sedation) and succinylcholine (for paralysis) are the most commonly used agents in this step. Several clinical conditions preclude the use of succinylcholine (Table 122-5). Etomidate is relatively safe but may induce transient adrenal suppression; its use may necessitate corticosteroids supplementation in septic patients.

5. Positioning refers to the positioning of the patient in the “sniffing position” to improve the physician's view of the vocal cords (Figure 122-2).

6. Placement of the ETT is performed under direct visualization of the vocal cords. Methods of confirming correct ETT placement include the presence of condensation of the ETT, presence of bilateral breath sounds, absence of breath sounds over the midepigastrium, end-tidal carbon dioxide detection, and visualization on a chest X-ray. The gold standard to confirm appropriate tube positioning is use of end-tidal carbon dioxide detection.

7. Postintubation care includes the administration of sedatives, analgesics, and paralytics as needed. Patients who are medically paralyzed require sedation and pain control.

Although RSI (by trained operators) is the preferred method of airway management in most patients, RSI is not advised if difficulty with BVM is predicted, such as in patients whose airway anatomy is unknown or the ability to intubate via direct laryngoscopy is in question (eg, upper airway obstruction, stridor, angioedema, head and neck cancers). In such cases, awake intubation or awake direct laryngoscopy should be strongly considered as a safer option. In patients with possible upper airway or laryngeal obstruction, the administration of a topical anesthetic agent, opioid, and/or a sedative agent can allow direct visualization of the airway via direct laryngoscopy or flexible bronchoscopy. Following visualization of the airway, the patient may be intubated directly via RSI, as already described, or one of the alternative intubation methods, such as nasotracheal or fiberoptic intubation.

In general, RSI is safer and more successful than awake intubation. In select patients in which awake intubation is indicated, it should be approached with caution, and backup rescue airway methods should be readily available (Table 122-6).

Basic Endotracheal Intubation

Bag-Valve-Mask Ventilation

The most important skill required for inpatient clinicians in airway management is use of a BVM and airway adjuncts to ventilate and oxygenate the patient. The ability to ventilate a patient can be an effective bridge prior to intubation and is a requirement prior to use of any paralytic agents. Equipment necessary for effective ventilation includes BVM (Figure 122-3), an oxygen source, and airway adjuncts (oropharyngeal and nasopharyngeal airways) (Figure 122-4).

Prior to ventilating with a BVM the clinician should place an airway adjunct. A nasopharyngeal airway is used if the patient's airway reflexes (eg, gag reflex) are still intact (see Figure 122-4). If the patient has no airway reflexes an oropharyngeal airway is placed (Figure 122-4). These devices help maintain a patent airway and maximize ventilation during BVM ventilation. Placing the patient in a sniffing position (if no concern for cervical spine injury) optimizes the airway alignment of the oral, pharyngeal, and laryngeal axes. A rolled-up towel under the occiput of the patient can effectively align the patient in this position (see Figure 122-2). The mask is placed over the bridge of the nose and mouth. The hands are positioned to create a tight seal. The hand position is commonly described as a “C” and “E.” The thumb and index finger wrap around the top of the mask and apply downward pressure to create a seal. The little finger is typically placed behind the angle of the mandible, the ring finger along the mandible, and the middle finger under the mandibular symphisis performing a chin lift and pulling the jaw forward (Figure 122-5). If the patient has dentures they should be left in place during BVM ventilation and removed just prior to insertion of the laryngoscope. If the clinician is having problems maintaining a seal or ventilating, two-hand BVM ventilation should be attempted. Pulse oximetry can be used to assess adequate oxygenation but will not provide any information about adequate ventilation.

Endotracheal Intubation

Airway control is typically established through direct laryngoscopy and orotracheal intubation. This technique requires several pieces of equipment, a trained operator, and a plan of action. Anyone attempting intubation, particularly if using paralytic agents, should be very comfortable with the technique, the equipment, rescue devices, and other resources available for assistance. A plan to address any contingency is advisable.

Equipment: Endotracheal intubation requires knowledge of equipment and its appropriate use. Necessary initial procedure elements include equipment availability within the facility, and organization that facilitates rapidly finding needed pieces. The equipment may be located within an airway box or crash cart. Preparation for intubation requires basic airway supplies (Table 122-7).

Various ETT sizes should be available (ETT sizes 7.0, 7.5, and 8.0 and more than one of the same size tube should be available in case the balloon does not function). Several blade types can be employed, curved (Macintosh) and straight (Miller). Individual preference determines which blade will be used. The tip of the curved blade is placed in the Vallecula anterior to the epiglottis and pulls the epiglottis up revealing the vocal cords. The straight blade is placed posterior to the epiglottis and pushes the epiglottis up to reveal the cords. Basic airway equipment (BVM and airway adjuncts) should always be available.

Preparation: Preparation for endotracheal intubation includes assuring all equipment is available and functions properly (eg, light on the blade works, the ETT balloon does not have an air leak). The stylet is placed within the ETT, such that the tip is not protruding beyond the end of the ETT. The ETT is curved either as a gentle curve or at a 45-degree angle at the distal end. The oxygen source should be available either through wall mounted oxygen or an oxygen tank. Suction should be available. Availability of several assistants facilitates a successful intubation. A respiratory therapist can help with ventilation, equipment, and cricoid pressure. Nurses assist with intravenous lines, monitoring, and medications. Intravenous access should be ensured and the patient placed on a cardiac monitor and pulse oximeter. The patient should be evaluated as described earlier for a difficult airway, and if necessary expert assistance should be sought. The patient should be positioned in the sniffing position (see Figure 122-2) by placing a folded towel, sheet, or pillow under the occiput raising the head by approximately 10 cm. The sniffing position lines up the oral, pharyngeal, and laryngeal axes optimizing the view of the cords. This maximizes the alignment of the oral, pharyngeal, and laryngeal axes to improve the visualization of the vocal cords during laryngoscopy. Neck manipulation (eg, sniffing position) is not recommended in a patient with a suspected cervical spine injury or other conditions that limit extension of the head.

Technique: After choosing the appropriate equipment and positioning the patient, intubation can be attempted. Application of the Sellick maneuver (cricoid pressure) is no longer routinely recommended during intubation. Originally thought to decrease aspiration and improve visualization of the larynx, current evidence does not support these historical claims. The handle and blade are always held in the left hand. The mouth is opened and the blade initially placed on the right side of the mouth sweeping the tongue to the left so that the tongue does not obscure the view. The blade is advanced toward the posterior pharynx. The blade is placed into the vallecula (Miller, curved blade) or deep into the posterior pharynx (Macintosh, straight blade). If the blade is unintentionally placed into the esophagus, constant upward pressure is exerted while the blade is slowly withdrawn until the cords come into view. The blade must be pulled up and out at a 45-degree angle to the patient (Figure 122-6). Failure to pull up properly risks using the teeth as a fulcrum and fracturing them, or increasing the difficulty viewing the larynx.

While maintaining visualization of the vocal cords, the ETT is placed with the balloon passed just beyond the cords, approximately 2–3 cm. The ETT should be passed along the right side of the mouth and visualized as it passes through the vocal cords. In an adult male the ETT is typically advanced to the 23 cm marker at the lip and in a female 21 cm to the lip. These are approximate depths and will need to be adjusted based on auscultation and chest radiograph. The stylet is removed, the balloon is inflated, and placement should be immediately confirmed. An assistant should monitor vital signs and pulse oximetry readings during the intubation. If oxygen saturations start to drop, the intubation should be stopped and the patient ventilated with the BVM.

Confirmation: Confirmation that the ETT is in the trachea and properly positioned should be performed immediately after intubation. Auscultation should be performed over the bilateral chest, axilla, and epigastrium. The clinician should pay particular attention to decreased breath sounds over the left chest indicating a right mainstem intubation. An end-tidal carbon dioxide (CO2) detection device serves as the gold standard for ETT placement confirmation. If the device does not change to the appropriate color, immediately reassess the patient since this is highly indicative of an esophageal intubation and necessitates repeat laryngoscopy after ventilation. Chest X-ray will confirm correct ETT placement (2–3 cm above the carina) and detect any other complications (eg, pneumothorax).

Advanced skills for difficult or failed intubation: In some patients, direct laryngoscopy and endotracheal intubation present challenges to clinicians. Alternative airway devices or techniques should be considered and used when traditional airway management fails or when practitioner experience or expertise level precludes routine endotracheal intubation.

Laryngeal Mask Airway

The laryngeal mask airway (LMA) should be considered when endotracheal intubation has failed and BVM is difficult or inadequate. The LMA is a supraglottic device that is designed to be blindly inserted into the oral cavity and, when inflated, allows selective ventilation of the trachea (Figure 122-7). The LMA requires minimal technical skill and has a high success rate. However, it does not provide definitive airway control and serves only as a temporizing measure while a more definitively secured airway is established. Additionally, the LMA is contraindicated in patients who have airway anomalies or upper airway deformities such as oral cancer or a supraglottic mass.

Elastic Gum Bougie or Tube Changer

The elastic gum bougie or tube changer can be used to assist in tube placement when the airway can be partially or fully visualized but the placement of an ETT is difficult. In this case, a flexible tube changer is placed in the airway and an ETT is advanced over the tube using the Seldinger technique, and the flexible tube is subsequently removed.

Fiberoptic Intubation

Fiberoptic intubation can be used in patients whose airway anatomy is unknown or in whom a difficult airway is anticipated. For example, patients with limited neck mobility or distorted airway anatomy may require this technique, which requires significant operator skill and experience. To perform a fiberoptic intubation, the patient must be sedated. An ETT is then placed over the fiberoptic scope. The scope is then maneuvered through the oropharynx or the nasopharynx and advanced toward the epiglottis into the trachea, and the ETT is advanced over the scope into the trachea.

Video Laryngoscope

Video laryngoscopes use laryngoscopes in combination with video imaging to allow visualization of the vocal cords with decreased manipulation of the airway and cervical spine. While this technique is relatively new, its role is quickly expanding, and it may play a central role in endotracheal intubation in the near future (Figure 122-8).

Nasotracheal Intubation

Nasotracheal intubation is indicated for a spontaneously breathing patient with difficult airway anatomy and when paralysis bears high risk. Bleeding diathesis or anticipated severe epistaxis makes this procedure unadvisable. Topical anesthetic or sedative is utilized to prepare patients just prior to the procedure. In nasotracheal intubation, a blind technique, the ETT is advanced along the floor of the nare and toward the larynx. While the tube is being advanced, the operator continuously listens for breath sounds to determine proximity to the vocal cords. Additionally, auscultation is used to assess the phases in the breathing cycles and, consequently, time the advancement of the tube past the vocal cords. Nasotracheal intubation can be added with direct laryngoscopy guiding the ETT through the vocal cords with McGill forceps.

Twin-Lumen Devices (Combitube)

Twin-lumen devices, such as the Combitube or the King Airway, are frequently used in prehospital airway management. The tube is inserted blindly and may enter the trachea or, more commonly, the esophagus. The tube is equipped with a proximal (high-volume) cuff and distal (low-volume) cuff. If the tube is inserted into the trachea, oxygenation and ventilation are achieved using the more distal lumen, similar to a standard ETT. If the tube is inserted into the esophagus, oxygenation and ventilation are achieved using the lumen proximal to the distal cuff (Figure 122-9). These devices are rarely used for definitive airway management.

Cricothyrotomy

In a patient in whom the intubation cannot be achieved and BVM is inadequate in achieving adequate oxygenation and ventilation, surgical establishment of the airway (cricothyrotomy) is indicated. Although this invasive approach is rarely necessary, when emergently indicated the clinician creates a passage through the cricothyroid membrane using a tube cannula. Percutaneous cricothyrotomy technique employs a prepared kit that uses the Seldinger technique to advance an ETT over a dilator to allow oxygenation and ventilation (Figure 122-10).

Noninvasive Ventilation

There are several clinical scenarios in which the use of NIV can decrease morbidity and mortality. NIV can be used in patients with chronic obstructive lung disease (COPD), congestive heart failure (CHF), and immunocompromised patients with respiratory distress (see Chapter 137).

NIV significantly reduces mortality, endotracheal intubation, and hospital length of stay in patients with acute exacerbation of COPD (see Chapter 239). NIV should be applied early in the emergency department after ABG analysis and is indicated for pH 7.25–7.35 but can be utilized cautiously with pH < 7.25.

Acute cardiogenic pulmonary edema can also be treated with NIV. Continuous positive airway pressure (CPAP) can decrease the need for intubation. Meta-analyses have shown decreased in-hospital mortality with CPAP in acute heart failure exacerbation, although a recent large, randomized, controlled trial has shown no mortality benefit but does show more rapid symptom improvement with the intervention. Overall, NIV use reduces the need for intubations and improves respiratory symptoms in patients with acute cardiogenic pulmonary edema. In selected immunocompromised patients with respiratory failure from pneumonia early initiation of NIV resulted in decreased need for intubation, serious complications, and improved likelihood of survival to hospital discharge.

The decision to consult in airway management depends on the operator's experience and comfort in the techniques described as well as the resources available to the practitioner. Hospitalists should attain proficiency and mastery of BVM skills and use of airway adjunct equipment (oral airway, nasopharyngeal airway, and LMA). Endotracheal intubation skills may be mastered by some hospitalists, especially when few other advanced practitioners intensivists to the list of advanced practitioners with such skills practice within the local facilities. Advanced practitioners with mastery in airway management—including anesthesiology, Emergency Medicine, otolaryngology, or general surgery specialists—should be consulted when a hospitalist lacks sufficient training or skill with airway techniques or when individual patient characteristics likely indicate a difficult airway.

Components of a sample procedure note for intubation are delineated as follows :

• A time-out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment if applicable.
• Patient was evaluated and required intubation for [____]. [list diagnosis]
• The patient was prepared in the usual fashion, and a [____] French ET tube was placed through the vocal cords under direct visualization to [____] centimeters at the teeth. Bilateral breath sounds were heard at the lung apices without air sounds in the abdomen. Tube condensation was present. An end-tidal CO2 monitor was used to confirm tracheal placement of the ET tube.
• Sedation/Paralysis: ______________________ [list agents used]
• Chest X-ray was ordered to assess for pneumothorax and ETT placement.
• Patient tolerated the procedure well and there were (check one) ___no complications, or ___complications included: _________________________________________________________.

Various complications can occur during the course of accessing an advanced airway in a patient (Table 122-8). Clinicians should assess patients for a difficult airway in an effort to prevent a failed intubation attempt. Prompt recognition of an esophageal intubation will allow immediate removal of the ETT and reventilation and oxygenation with a BVM prior to reattempting intubation. Proper technique is essential to avoid any local trauma to oral anatomy and airway structures. A pneumothorax needs to be considered in a patient with hypoxia and hypotension and should be evaluated for all patients with postprocedure chest radiography. Finally accidental dislodgment of the ETT should be avoided by proper stabilization and restraint of the patient.

Proper stabilization of the ETT is critical to preventing movement of the tube or accidental dislodgment. ETTs can be taped or held in place with commercial tube holders. The site should be kept clean. Skin and mucosal assessment should occur at least every 24 hours. Placement of a nasogastric (NG) or orogastric (OG) tube following endotracheal intubation can help decompress any insufflated air that occurred during BVM use and will help reduce the risk of emesis and aspiration.

Effective advanced airway management in clinical practice requires frequent education or frequent use of the skill. Simulation education can allow clinicians to practice both basic and advanced airway management techniques in a structured setting. Simulation education utilizing airway models and equipment allows mastery of psychomotor skills and practice of less common airway encounters in a safe environment. Simulation-based educational programs can be used to assess competence prior to incorporation of these skills into clinical practice (Table 122-9).

Furthermore, local institutional policies and protocols should be accessible and specify available equipment, medications, hospital staff (including nursing and respiratory therapy) and availability of airway experts can assist hospitalists when confronted with a patient requiring airway management. Finally, continuous quality improvement within an institution should include review of all airway cases with a structured evaluation of documentation and any complications related to airway management.

Policies regarding education, competency assessment, protocols, and quality review should be in place to maintain patient safety.