When respiratory function is interrupted, the whole body becomes compromised. Brain damage occurs within 5 minutes, and brain cell death occurs within 10 minutes. Therefore, maintaining a patent airway and restoring respiratory function are vital to advanced cardiac life support (ACLS) success.

The conducting airways allow air into and out of the lungs. Conducting airways include the upper and lower airways.

When you approach a patient in possible cardiopulmonary compromise, the first step in airway management is proper positioning of both yourself and the patient. Without proper positioning, it’s difficult to assess the patient’s breathing and ensure a patent airway. You should be at the patient’s side, at about the level of his upper chest. From this position, you can perform both rescue breathing and chest compressions.

A patient’s airway can become obstructed or compromised by vomitus, food, edema, his tongue or teeth, saliva, or a foreign object. The most common cause of airway obstruction is the tongue. Muscle tone decreases when a person is unconscious or
unresponsive, which increases the potential for the tongue and epiglottis to obstruct the pharynx.

Assess airway patency. Check to see if the chest rises with inspiration and falls with expiration. Wheezing; suprasternal, supraclavicular, or intracostal retractions; and cyanosis may all point to airway obstruction.

Advanced airway devices include the endotracheal (ET) tube, supraglottal airways (esophageal-tracheal tube airway, laryngeal tube airway, and laryngeal mask [LMA] airway), nasopharyngeal airway, and oropharyngeal airway. If the use of these advanced airway devices is unsuccessful or inappropriate, a transtracheal catheter or a surgical cricothyroidotomy may be necessary. These techniques may be explained during ACLS instruction; however, they are considered beyond the scope of practice of most ACLS providers.

During a cardiac arrest, the best device to use to manage the airway depends upon the patient’s condition, the provider’s experience, the health care facility, and the emergency response system available.

Staff training and the continual monitoring of skills, complications, and success are essential components of airway management.

ET intubation involves inserting a tube through the patient’s mouth or nose into the trachea to obtain or maintain a patent airway. In the past, ET intubation was considered the gold standard of advanced airway control. Studies have shown, however, that the rate of complications due to staff inexperience may be unacceptably high. Frequent staff training, experience, and monitoring are required.

The esophageal-tracheal tube airway consists of a plastic tube with two lumens and a ventilation bag attachment port for each lumen. Proximal and distal balloons help secure the tube and prevent ventilation gases from escaping around the tube. Rings on the proximal tube indicate the depth of the tube’s insertion and should be at the level of the patient’s teeth. The pharyngeal lumen of the tube has the longer primary port (port #1) at the proximal end, holes along the lumen between the balloons for supraglottic ventilation, and a blind distal end. The tracheoesophageal lumen has the shorter secondary proximal port (port #2), is patent between the balloons, and has an open distal end.