Airway Management, Intubation and Tracheostomy

Acute Airway Assessment, Rapid Sequence Intubation, and Placement Confirmation

Caring for unstable patients requires vigilant physical assessment to identify upper airway compromise before full obstruction occurs. Inspiratory stridor serves as a hallmark sign of upper airway narrowing and demands an immediate clinical evaluation for impending respiratory failure. Rapidly evolving presentations, such as angioedema with acute swelling of the lips, tongue, and pharynx, require early preparation for definitive airway control before the passage is completely occluded. When managing a patient with a suspected cervical spine injury, the critical care team must maintain manual in-line stabilization throughout all airway maneuvers and intubation efforts while keeping the primary focus on oxygenation and airway rescue.

Rapid sequence intubation (RSI) is frequently utilized in the critical care setting to secure the airway promptly. This process involves thorough preoxygenation followed by the administration of an induction agent and a neuromuscular blockade. Although classical approaches minimized positive-pressure ventilation before securing the tube, bag-mask ventilation may be provided when needed to prevent hypoxemia according to the airway team's plan. Video laryngoscopy provides an indirect, camera-assisted view of the glottis that may improve first-pass intubation success, particularly in patients with difficult airways. Notably, cricoid pressure is no longer routinely recommended during rapid sequence intubation because it does not reliably prevent aspiration and can significantly worsen the clinician's laryngoscopic view.

Immediately following intubation, the critical care registered nurse participates in verifying tube placement. Continuous waveform capnography is the gold standard to confirm initial endotracheal tube placement and continuously monitor tube position. Disposable colorimetric end-tidal carbon dioxide detectors provide qualitative verification by changing from purple to yellow in the presence of exhaled carbon dioxide. However, clinicians must recognize that severe low cardiac output states or cardiac arrest can cause false-negative capnography readings due to inadequate pulmonary blood flow delivering carbon dioxide to the lungs. A sudden loss of the end-tidal carbon dioxide waveform during mechanical ventilation mandates an immediate assessment for tube displacement, tube obstruction, circuit or monitor disconnection, or catastrophic circulatory collapse.

Immediate physical assessment must accompany capnography. The nurse performs bilateral auscultation of breath sounds in the midaxillary lines and auscultates over the epigastrium. Hearing epigastric gurgling during ventilation raises immediate concern for esophageal intubation; the nurse must promptly assess waveform capnography, alert the airway team, and support oxygenation while tube placement is urgently evaluated. A portable chest radiograph confirms endotracheal tube depth, with the optimal position of the tube tip located 3 to 5 centimeters above the carina on a neutral-neck image. However, a chest radiograph cannot reliably rule out esophageal intubation compared to capnography.