Emergency Airway Education Index

Medical

Severe asthma / COPD crash airway

Before: Treat before tube when possible: bronchodilators, steroids, magnesium/epinephrine as appropriate, NIV if safe, and call RT early. Plan the ventilator before induction: low RR, high inspiratory flow/short Ti, long expiratory time, permissive hypercapnia when clinically acceptable.…

During: Avoid prolonged apnea; maintain oxygenation but do not over-bag. After tube, bag slowly and feel for air trapping; disconnect briefly if peri-intubation auto-PEEP shock is suspected. Confirm with waveform EtCO2 and assess…

After / pitfalls: Low RR, long expiratory time, monitor flow-time waveform, evaluate auto-PEEP. Deep sedation ± paralysis for dangerous dyssynchrony per local protocol. Reassess BP; dynamic hyperinflation can cause hypotension. High RR after intubation causing breath stacking. Treating high peak pressure as tube…

obstructiveasthmaCOPDauto-PEEPhypercapnia

Medical

Flash pulmonary edema / SCAPE

Before: Aggressive NIV/CPAP is often the key pre-intubation intervention when mental status and airway protection allow. Treat afterload and sympathetic surge per local protocol; prepare for intubation only if failing NIV or unable to protect airway. Preoxygenate…

During: Use PEEP from the start; avoid derecruitment during transition. Anticipate hemodynamic changes from induction and positive pressure. Confirm tube and quickly transition to ventilator with adequate PEEP.

After / pitfalls: Titrate PEEP/FiO2 and reassess BP/afterload strategy. Look for myocardial ischemia, arrhythmia, renal failure, or valvular trigger. Avoid leaving FiO2 at 100% once stabilized. Intubating before a real NIV/afterload-reduction trial when NIV is safe. Dropping PEEP during transitions. Post-intubation hypotension from…

hypoxemiapulmonary edemaNIVhypertension

Medical

DKA / severe metabolic acidosis

Before: Recognize high pre-intubation minute ventilation; the patient may be compensating for severe acidosis. Optimize fluids, potassium, insulin pathway, vasopressor if needed, and involve ICU/RT early. Plan minimal apnea and post-tube ventilation that approximates physiologic demand while…

During: Avoid prolonged paralysis/apnea; assign someone to start ventilation immediately after tube confirmation. Use continuous EtCO2 and rapid blood gas reassessment. Consider hemodynamic collapse risk from acidosis, hypovolemia, and PPV.

After / pitfalls: Set RR/minute ventilation intentionally and reassess pH/CO2 quickly. Continue DKA resuscitation; airway does not fix the metabolic problem. Watch for cerebral edema risk in pediatrics and severe cases. Routine low RR after tube leading to abrupt CO2 rise/acidemia. Long apnea…

DKAacidosisminute ventilationshock

Medical

Septic shock / peri-arrest airway

Before: Resuscitate first when possible: fluids/blood when indicated, vasopressor ready/running, source control pathway. Choose induction strategy with hypotension in mind; dose reduction/titration per local protocol. Have push-dose/infusion pressor, arterial monitoring plan, and post-intubation sedation ready.

During: Minimize apnea; avoid excessive PEEP/vent pressures early if preload-dependent. Assign BP watcher and pressor nurse. Confirm tube, then immediately reassess MAP, EtCO2, perfusion, and sedation effect.

After / pitfalls: Treat post-intubation hypotension aggressively. Use lung-protective ventilator strategy if ARDS/sepsis lung injury present. Debrief whether airway timing/resuscitation sequence worked. Paralyzing before pressor/resuscitation plan is ready. Over-sedation immediately after tube. Excessive intrathoracic pressure in preload-dependent shock.

shocksepsispressorhypotension

Medical

Massive PE / RV failure

Before: Intubation can precipitate collapse; optimize RV preload/afterload strategy and call critical care early. Use oxygenation/vasopressor/inotrope strategy per local protocol; keep peri-arrest rescue plan ready. Avoid hypoxia, hypercarbia, and acidosis when possible; they worsen pulmonary vascular resistance.

During: Gentle transition to PPV; avoid excessive PEEP and high intrathoracic pressure. Have pressors running/ready and resuscitation team prepared. Consider thrombolysis/embolectomy pathway depending on context.

After / pitfalls: Reassess RV shock, EtCO2, MAP, lactate/perfusion. Use ventilator settings that protect RV physiology. Continue definitive PE/RV failure management. Treating as a routine hypoxic airway. High PEEP/pressures worsening RV output. Underestimating peri-intubation arrest risk.

RV failurePEshockhypoxia

Trauma

Facial trauma / blood-soiled airway

Before: Two suctions tested and in hand; consider SALAD-style continuous suction strategy. Prepare VL/DL, bougie, cric kit, and blood/emesis management. Assess for C-spine, facial instability, midface trauma, and need for surgical airway backup.

During: Suction first, suction continuously, and do not pass into a dark contaminated view. Use the device/operator most likely to succeed quickly; change approach early if view is lost. Have cric trigger explicit…

After / pitfalls: Secure tube carefully; facial injuries make dislodgement risk higher. Ongoing hemorrhage/aspiration management and imaging/ENT/trauma pathway. Recheck tube depth after movement/transport. One weak Yankauer only. Repeated attempts through blood without changing technique. Failure to prepare front-of-neck access.

traumadirty airwaybleedingsuction

Trauma

Cervical spine trauma

Before: Clarify manual inline stabilization, collar strategy, and backup plan. Optimize position as allowed; ramp torso if needed while maintaining spinal precautions. Video laryngoscopy can help reduce head movement but must be paired with good technique.

During: One person owns C-spine stabilization; operator verbalizes difficulty early. Avoid levering; use bougie/tube delivery strategy deliberately. If attempt fails, oxygenate and change something.

After / pitfalls: Secure tube without losing alignment; recheck depth after transfers. Maintain spinal precautions and communicate airway difficulty to trauma team. Document device, view, attempts, and confirmation. Rigid adherence to collar preventing mouth opening without a plan. Poor positioning because “C-spine” was…

C-spinetraumapositioning

Medical

Airway edema / angioedema

Before: Call anesthesia/ENT early if progressive swelling or anatomy risk. Consider awake strategy, topicalization, fiberoptic/video plan, and surgical airway readiness. Do not wait until the patient cannot phonate/swallow/handle secretions.

During: Maintain spontaneous ventilation if awake approach is chosen. Have cric/trach backup immediately available; edema may make oral route fail. Avoid traumatic repeated attempts that worsen swelling.

After / pitfalls: Secure tube; anticipate prolonged airway swelling. Treat underlying cause per protocol and arrange ICU/ENT management. Extubation planning is high-risk and not a routine decision. Delayed airway decision until complete obstruction. RSI in an airway that should be awake/surgical. No surgical…

angioedemaedemaawakeENT

Trauma

Burns / inhalation injury

Before: Look for facial burns, soot, hoarseness, stridor, enclosed-space exposure, CO/cyanide risk. Early airway may be safer before edema progresses. Prepare smaller tubes if swelling; call burn/ICU/anesthesia/ENT as appropriate.

During: Avoid delay if airway edema is progressing. Use gentle technique; swollen tissue bleeds and distorts easily. Confirm tube and secure well; facial burns complicate fixation.

After / pitfalls: Treat CO/cyanide exposure when indicated. Anticipate edema progression and difficult tube exchanges. Communicate airway findings to burn/ICU team. False reassurance from initial normal exam. Poor tube securement on burned face. Forgetting toxic inhalation physiology.

burninhalationedemasoot

Mechanical

Foreign body / choking / upper airway obstruction

Before: Assess whether BLS obstruction maneuvers, suction, Magill removal, bronchoscopy/ENT, or cric pathway is most appropriate. Have suction, Magills, VL/DL, forceps, and backup surgical airway ready. Avoid pushing the object deeper.

During: Visualize before manipulating; remove only if safely reachable. Maintain oxygenation; consider rigid bronchoscopy/OR pathway if distal object. If cannot ventilate/cannot oxygenate, declare CICO and move to front-of-neck access.

After / pitfalls: Evaluate aspiration, airway trauma, residual obstruction. CXR/bronchoscopy/ENT/peds pathway depending on object and age. Debrief object management and rescue timing. Blind finger sweeps. Pushing object below cords. Repeated laryngoscopy without oxygenation.

foreign bodyobstructionMagill

Medical

Anaphylaxis with airway compromise

Before: IM epinephrine and anaphylaxis treatment come first; airway plan runs in parallel. Assess for tongue/laryngeal edema, wheeze, hypotension, vomiting. Prepare difficult airway/surgical backup if swelling is progressing.

During: Preoxygenate with PEEP if needed; avoid delay in crashing edema. Choose induction with shock risk in mind and have pressors/resuscitation ready. Expect bronchospasm and high pressures after tube.

After / pitfalls: Continue epinephrine infusion/adjuncts per protocol. Watch for biphasic reaction and ongoing bronchospasm/edema. Plan ICU/airway observation if edema significant. Focusing on intubation while delaying epinephrine. No cric backup for progressive edema. Under-treating post-tube bronchospasm/shock.

anaphylaxisedemashock

Trauma

TBI / intracranial pressure risk

Before: Avoid hypoxia and hypotension; preoxygenate and resuscitate before induction when possible. Set BP/EtCO2 targets with trauma/neuro team if available. Plan sedation/analgesia to prevent coughing/agitation after tube.

During: Smooth, fast airway with hemodynamic protection. Avoid prolonged hypoxia/apnea. Confirm tube and control ventilation intentionally.

After / pitfalls: Target EtCO2 per local neuro/trauma policy. Maintain oxygenation, BP, sedation, head positioning, and imaging/definitive care. Avoid reflex hyperventilation unless herniation protocol or specialist direction. Post-intubation hypotension. Unintentional hyper/hypoventilation. Forgetting sedation after paralysis.

TBIneuroEtCO2

Medical

Overdose / aspiration risk

Before: Assess reversible tox causes and naloxone/glucose as appropriate. Prepare suction x2, lateral positioning if vomiting, and BVM/airway adjuncts. Preoxygenate despite poor cooperation when possible.

During: Suction aggressively before and during laryngoscopy. Avoid gastric insufflation; gentle BVM if needed. Confirm placement and protect against aspiration during transition.

After / pitfalls: Ventilate based on tox physiology; avoid unnecessary hyperoxia. Treat aspiration, toxidrome, hypothermia, rhabdo, or co-ingestions. Plan sedation carefully; intoxication does not equal analgesia/sedation. Dirty airway without suction. Assuming all obtunded patients need the same ventilator plan. No post-intubation sedation because…

overdoseaspirationdirty airway

Medical

Massive upper GI bleed / hematemesis

Before: Resuscitate hemorrhagic shock: blood, access, pressor only as bridge if needed, GI/ICU pathway. Two suctions, head-up/positioning, and backup operator/device ready. Plan for contaminated view and rapid desaturation.

During: Suction continuously; do not chase a view through pooling blood. Minimize hypotensive induction; reassess after PPV. Confirm with waveform EtCO2 despite contamination.

After / pitfalls: Secure tube, continue massive transfusion/bleed control, decompress stomach when appropriate. Reassess shock and ventilator settings. Communicate high aspiration risk. Under-resuscitated induction. Single suction. Tube dislodgement during procedures/transport.

GI bleeddirty airwayshock

Medical

Morbid obesity / OSA / difficult preoxygenation

Before: Ramp to ear-to-sternal-notch; head-up positioning. Use PEEP/NIV/HFNC strategy as appropriate; desaturation occurs quickly. Stage longer equipment/redundant oxygenation/rescue plan.

During: Maintain apneic oxygenation if possible. Optimize view with position and external laryngeal manipulation. Be ready for two-hand BVM, adjuncts, and SGA rescue.

After / pitfalls: Use appropriate PEEP, recruitment strategy, and sedation. Confirm tube depth carefully; habitus can mislead. Plan safe transport with oxygen reserve. Flat positioning. No PEEP during preoxygenation. Assuming “large patient” only changes ETT size.

obesitypreoxygenationramp

Medical

Pregnancy airway

Before: High aspiration/desaturation risk; preoxygenate well and position with left uterine displacement if viable gestation. Prepare smaller tube, suction, difficult airway backup, OB/anesthesia/neonatal resources. Treat preeclampsia/eclampsia physiology and hemodynamics.

During: Minimize apnea; suction ready; cricoid use per local practice and operator judgment. Avoid hypotension/hypoxia. Confirm placement quickly and secure.

After / pitfalls: Coordinate OB/neonatal/ICU pathway. Ventilate and sedate with maternal-fetal context. Document airway difficulty and medications. Underestimating rapid desaturation. No suction/aspiration plan. No obstetric coordination.

pregnancyaspirationpreoxygenation

Peds

Pediatric severe asthma

Before: Maximize medical therapy and NIV/HFNC when safe; intubation is high risk. Use measured/length-based weight, peds color zone, and stage age-appropriate equipment. Plan obstructive ventilator settings before the tube.

During: Avoid air trapping with bagging; gentle rate and pressure. Cuffed tube size from weight/age, one size up/down ready. Confirm with EtCO2 but remember severe obstruction can produce low waveform initially.

After / pitfalls: Low RR, long exhalation, close waveform monitoring. Sedation/paralysis for dangerous dyssynchrony per peds ICU/ED protocol. Continuous bronchodilators and ICU consultation. Ventilating like a normal child. No backup tube sizes. Delayed recognition of auto-PEEP shock.

pedsasthmaobstructive

Peds

Pediatric DKA / metabolic acidosis

Before: Intubation is dangerous; preserve compensation if possible and involve pediatric critical care early. Use measured/length-based weight and peds DKA protocol. Plan minute ventilation and avoid prolonged apnea.

During: Immediate ventilation after tube; careful EtCO2/pH follow-up. Avoid hypotension/hypoxia. Use peds equipment/meds from weight-based references.

After / pitfalls: Frequent gas/electrolyte/neuro reassessment. Watch cerebral edema risk. Continue DKA protocol; tube is supportive, not definitive therapy. Under-ventilation after paralysis. No peds critical care involvement. Using adult assumptions for tube size/vent RR.

pedsDKAacidosis

Peds

Bronchiolitis / infant respiratory failure

Before: Assess apnea, fatigue, dehydration, hypoxemia; use peds/RT support early. Small airway equipment, suction, appropriately sized BVM/mask, and backup tubes ready. Preoxygenate gently; avoid excessive pressures.

During: Gentle BVM and tube placement; infants desaturate and brady down quickly. Confirm tube depth; mainstem/dislodgement risk is high. Use peds dosing and temperature/glucose awareness.

After / pitfalls: Age-appropriate RR/VT; monitor leak, tube depth, and sedation. Frequent reassessment after any movement. Peds ICU/neonatal pathway. Adult-size mask or poor seal. Tube too deep. Forgetting glucose/temperature.

infantbronchiolitisBVM

Peds

Croup / upper airway obstruction

Before: Keep child calm; nebulized epinephrine/steroids and ENT/anesthesia/peds support early. Intubation should be controlled with smaller tubes and expert help when possible. Avoid agitating a tenuous upper airway.

During: Smaller ETT than age formula may be needed. Gentle technique; avoid repeated traumatic attempts. Surgical airway in small children is complex; get expert help early.

After / pitfalls: Monitor edema, leak, and tube security. Continue croup therapy and ICU planning. Extubation planning requires airway expertise. Agitating the child unnecessarily. Tube too large. No smaller backup tube.

croupupper airwaystridor

Peds/Adult

Epiglottitis / deep neck infection

Before: Call ENT/anesthesia/OR early; preserve spontaneous ventilation when appropriate. Avoid unnecessary oral exam/agitation in unstable epiglottitis. Prepare awake/video/fiberoptic/surgical backup depending on age and anatomy.

During: Controlled approach with expert support; avoid traumatic repeated attempts. Have front-of-neck plan ready in adults; pediatric surgical airway complexity requires early expert mobilization. Maintain oxygenation and hemodynamics.

After / pitfalls: Antibiotics/steroids/source control per local protocol. ICU airway monitoring. Communicate airway findings and difficulty. Casual RSI in distorted infectious airway. No ENT/anesthesia backup. Multiple attempts worsening edema/bleeding.

infectionstridorENT

Mechanical

Tracheostomy obstruction / displaced trach

Before: Identify fresh vs mature trach and type/size if possible. Bring trach kit, suction catheter, replacement tube, BVM with face mask and trach adapter. Call ENT/anesthesia/RT early, especially for fresh trach.

During: Oxygenate both face and stoma as needed. Remove inner cannula, suction, deflate cuff, assess patency. If mature and obstructed/dislodged, replace per local algorithm; if fresh, avoid blind reinsertion and get expert help.

After / pitfalls: Confirm with EtCO2, secure tube, treat cause of obstruction. Document tube type/size and emergency plan. Educate team/family about emergency steps if appropriate. Forgetting to oxygenate the face. Blind reinsertion of a fresh trach. No EtCO2 confirmation.

trachobstructiondisplacement

Mechanical

Tracheostomy bleeding / possible sentinel bleed

Before: Treat significant trach bleeding as high risk; call ENT/surgery/anesthesia immediately. Prepare for airway control, suction, blood products, and OR pathway. Differentiate minor bleeding from sentinel bleed but do not be falsely reassured.

During: Suction, oxygenate, control airway. If massive bleeding, emergency maneuvers may include cuff hyperinflation/digital compression per local protocol/expert guidance. Move rapidly to definitive surgical management.

After / pitfalls: ICU/OR pathway; do not discharge/ignore sentinel bleeding. Document timing, volume, tube details, and interventions. Debrief emergency roles. Labeling sentinel bleed as minor irritation. Delay in surgical call. Poor suction/airway control during hemorrhage.

trachbleedingTIF

Mechanical

Laryngectomy patient with respiratory distress

Before: Recognize total laryngectomy: no connection between mouth/nose and lungs. Oxygenate/ventilate through stoma; mouth/nose oxygen will not ventilate. Bring laryngectomy/trach supplies and call ENT/RT.

During: Remove stoma cover/HME, suction stoma, ventilate with pediatric mask or adapter over stoma. Do not attempt oral intubation for a total laryngectomy. Place cuffed tube in stoma if needed and trained/appropriate.

After / pitfalls: Confirm with EtCO2 at stoma. Secure airway device and communicate laryngectomy status. Treat underlying obstruction/infection/plug. Trying to BVM the face only. Confusing trach with laryngectomy. No stoma EtCO2 confirmation.

laryngectomystomaneck breather

Mechanical

Postoperative neck hematoma

Before: Rapidly progressive neck swelling/stridor after neck surgery is an airway emergency. Call surgeon/anesthesia/ENT; prepare airway and decompression pathway per local policy. Have suction, smaller tubes, and surgical airway backup.

During: If crashing, decompression of wound may be lifesaving per surgical guidance/local protocol. Airway may be distorted; avoid repeated failed attempts. Oxygenate and move to definitive OR/ICU management.

After / pitfalls: ICU/surgical care, bleeding control, tube security. Document timeline and interventions. Plan extubation carefully. Waiting for imaging in a crashing airway. No surgeon/anesthesia call. Repeated oral attempts through distorted anatomy.

neck hematomasurgical airwayENT

Peds/Trauma

Pediatric trauma / shock airway

Before: Use length-based weight/color zone, blood/resuscitation, C-spine strategy, and peds equipment. Assign roles: airway, BVM, meds, monitor, blood, parent/team communication. Stage one smaller/larger tube and peds suction/BVM.

During: Avoid hypoxia/hypotension; gentle bagging and rapid confirmation. Use appropriate meds/doses and equipment size. Reassess after every move; tube dislodgement is common.

After / pitfalls: Secure tube, peds vent settings, shock resuscitation, and trauma imaging/OR plan. Recheck depth after transport. Document length-based estimate and actual tube size/depth. Adult equipment assumptions. Tube migration with movement. Airway focus while shock resuscitation stalls.

pedstraumashock

Medical

Caustic ingestion / airway burns

Before: Assess drooling, stridor, voice change, burns, vomiting; call ENT/GI/anesthesia early. Avoid blind NG/oral instrumentation unless directed. Prepare for progressive edema and difficult airway.

During: Controlled airway if needed; avoid traumatic attempts. Suction secretions and protect from aspiration. Have surgical airway backup for distorted upper airway.

After / pitfalls: GI/ENT/ICU management and endoscopy timing per protocol. Monitor edema progression. Pain/sedation and aspiration management. Underestimating delayed edema. Traumatic instrumentation. No specialty involvement.

causticedemaENT

Medical

Opioid overdose / aspiration risk

Before: Treat reversible hypoventilation first when safe: oxygen, BVM, naloxone per protocol, suction ready. Assess aspiration/emesis risk and airway protective reflexes. Prepare intubation if ventilation, oxygenation, or protection remain inadequate.

During: Suction and preoxygenate; expect vomit/secretions. Use standard confirmation and avoid anchoring on overdose alone. Assign post-tube sedation/analgesia even if patient was initially obtunded.

After / pitfalls: Treat aspiration pneumonitis/pneumonia risk as clinically indicated. Reassess ventilation, EtCO2, and acid-base status. Continue tox workup and recurrent opioid toxicity monitoring. Delaying BVM because naloxone is coming. No suction plan. No sedation after paralysis as mental status improves.

overdoseaspirationnaloxone

Medical

Status epilepticus airway

Before: Treat seizure aggressively per protocol and correct hypoxia/hypoglycemia. Prepare suction and aspiration precautions; check jaw/tongue trauma. Plan hemodynamics and continuous sedation/anti-seizure strategy after tube.

During: Rapid oxygenation/ventilation and tube confirmation. Avoid hypotension and prolonged apnea. Coordinate ongoing antiseizure therapy rather than treating intubation as definitive seizure control.

After / pitfalls: Continuous sedation/antiepileptic pathway, temperature/glucose/electrolyte evaluation. Ventilator and EtCO2 reassessment. Neuro/ICU pathway and debrief medication timing. Stopping antiseizure care after tube placement. Aspiration without suction readiness. Hypotension from sedative stacking.

seizurestatusaspiration

Medical

GI bleed / hematemesis airway

Before: Resuscitate hemorrhagic shock: blood products/access/pressor only as bridge per protocol. Two suctions and dirty-airway strategy ready; anticipate ongoing emesis. Assign blood/pressor and airway roles separately.

During: Suction continuously and avoid advancing through pooled blood. Consider head-up/positioning as physiology allows. Confirm tube with EtCO2 and secure despite ongoing contamination.

After / pitfalls: Continue hemorrhage control, endoscopy/IR pathway, ventilator and shock reassessment. Sedation/analgesia and aspiration management. Debrief suction strategy and failed-attempt prevention. One suction catheter only. Airway team distracts from hemorrhage resuscitation. No plan for re-contamination after successful tube.

GI bleedhematemesisshocksuction

Medical

Pregnancy / perimortem airway

Before: Pregnancy increases aspiration risk, edema risk, and oxygen consumption; preoxygenation matters. Left uterine displacement/positioning and obstetric/neonatal help early when applicable. Plan smaller tube, suction, and backup oxygenation/rescue airway.

During: Minimize apnea; use skilled operator and clear backup plan. Avoid repeated traumatic attempts in edematous airway. If maternal arrest/late pregnancy, follow perimortem/resuscitative hysterotomy pathway per local protocol.

After / pitfalls: Reassess oxygenation, BP, obstetric status, and fetal considerations when relevant. ICU/OB/anesthesia handoff. Document tube depth/confirmation and aspiration precautions. Underestimating rapid desaturation. No aspiration/suction plan. No OB/anesthesia/neonatal mobilization.

pregnancyaspirationdifficult airway

Medical

Morbid obesity / OSA hypoxemic airway

Before: Ramped/head-up position, ear-to-sternal-notch alignment, and aggressive preoxygenation/PEEP. Plan two-person BVM, adjuncts, longer preoxygenation if possible, and backup SGA/cric path. Dose and ventilator settings require deliberate PBW/actual-weight distinctions.

During: Avoid losing position after meds. Use apneic oxygenation when appropriate and skilled first attempt. Confirm placement; tube dislodgement and derecruitment risks are high.

After / pitfalls: Use PBW for VT, adequate PEEP/FiO2, and early recruitment strategy per protocol. Secure tube well and reassess after movement. Sedation/analgesia and hemodynamics review. Flat positioning. Underpowered preoxygenation. Using actual body weight for tidal volume targets.

obesityOSApositioningpreoxygenation

Medical

Anaphylaxis with airway involvement

Before: Epinephrine and resuscitation are first-line; airway plan depends on edema, stridor, and shock. Call help early; prepare for swelling and bronchospasm. Preoxygenate and stage smaller tube, suction, cric backup.

During: Avoid delays if airway edema is progressing. Expect bronchospasm and hypotension; ventilator/pressor plan ready. Confirm tube and reassess shock after PPV.

After / pitfalls: Continue anaphylaxis management and observation/ICU pathway. Treat bronchospasm and adjust ventilation as needed. Plan extubation carefully if edema persists. Airway focus without epinephrine/resuscitation. No smaller tube backup. Under-recognizing post-intubation bronchospasm.

anaphylaxisedemashock

Medical

Salicylate toxicity / toxicologic hyperventilation

Before: This is a dangerous airway: spontaneous hyperventilation may be life-preserving and difficult to match after paralysis. Treat toxin physiology first when possible: decontamination/alkalinization/renal replacement pathway per local toxicology protocol. Plan minimal apnea, immediate ventilation after tube,…

During: Avoid prolonged apnea and avoid hypoventilation after confirmation. Use EtCO₂ as a trend only; follow rapid blood gas and pH. Have bicarbonate/vasopressor/resuscitation pathway ready per protocol.

After / pitfalls: Set ventilation deliberately to avoid abrupt CO₂ rise and worsening acidemia. Continue alkalinization/elimination strategy; the airway is supportive, not definitive therapy. Frequent pH, potassium, glucose, temperature, and neurologic reassessment. Routine RSI with prolonged apnea. Post-intubation RR/ventilation far below pre-intubation demand.…

toxicologysalicylateacidosisminute ventilation

Medical

Neuromuscular weakness / impending respiratory failure

Before: Trend work of breathing, bulbar symptoms, secretion burden, cough strength, NIF/FVC where available. Avoid waiting for hypoxemia; ventilatory failure may occur with normal SpO₂ until late. Call ICU/neurology/RT early; plan post-intubation sedation and ventilator support.

During: Preoxygenate, but recognize the problem is ventilation/muscle fatigue rather than oxygenation alone. Use airway adjuncts and suction for secretion burden. Choose medications with neuromuscular disease considerations and local protocol guidance.

After / pitfalls: Ventilator support, secretion clearance, aspiration prevention, and disease-specific therapy. Reassess sedation, weakness, and extubation readiness carefully. Communicate baseline respiratory mechanics and trajectory. Waiting for SpO₂ to fall before acting. Underestimating bulbar dysfunction/aspiration risk. No plan for prolonged ventilatory failure.

myastheniaGBSneuromuscularNIF

Medical

Massive hemoptysis / airway flooding

Before: Call ICU/pulmonary/anesthesia/IR/thoracic resources early; prepare blood and suction. Position bleeding side down if known and clinically feasible. Plan airway control with large enough tube for suction/bronchoscopy when appropriate.

During: Suction continuously; avoid contaminating the non-bleeding lung when possible. Confirm tube and consider mainstem/isolation strategy only with expert/local pathway. Maintain oxygenation while arranging definitive bleeding control.

After / pitfalls: Urgent bronchoscopy/IR/surgical pathway and ongoing hemorrhage resuscitation. Ventilator strategy depends on oxygenation, lung contamination, and hemodynamics. Secure tube and communicate suspected bleeding side. Small ETT limiting suction/bronchoscopy. Supine position with bilateral contamination when avoidable. Delayed definitive hemorrhage-control team activation.

hemoptysisbleedingdirty airwayisolation

Medical

Drowning / submersion injury

Before: Correct hypoxemia and hypothermia; evaluate trauma if mechanism suggests it. Use PEEP/CPAP/NIV when safe; prepare intubation for persistent hypoxemia, AMS, or failing ventilation. Suction and aspiration precautions are important.

During: Preoxygenate with PEEP; avoid derecruitment during transition. Confirm tube and start lung-protective, oxygenation-focused ventilation. Avoid unnecessary C-spine assumptions unless trauma risk exists.

After / pitfalls: Treat hypothermia, aspiration/ARDS physiology, and associated trauma. Titrate FiO₂/PEEP and reassess gases/imaging. ICU pathway for severe hypoxemia or neurologic injury. Assuming all drowning patients need prophylactic antibiotics. Dropping PEEP during transport/transition. Missing hypothermia or trauma.

drowninghypoxemiaaspirationhypothermia

Medical

Carbon monoxide / cyanide smoke exposure

Before: High-flow oxygen immediately; pulse oximetry may be misleading in CO exposure. Evaluate for inhalation injury, burns, soot, hoarseness, altered mental status, severe lactic acidosis. Consider cyanide/CO treatment pathways per local protocol and early burn/toxicology resources.

During: If intubating, anticipate airway edema and smaller tube needs. Avoid delaying toxic inhalation treatment while focusing on the tube. Secure tube carefully if facial burns are present.

After / pitfalls: Continue CO/cyanide pathway, burn/ICU consultation, and ventilator reassessment. Serial lactate, ABG/co-oximetry as available, neuro/cardiac monitoring. Plan for evolving edema. Relying on standard pulse oximetry to exclude CO. Missing cyanide physiology in enclosed-space fire with shock/lactate. Poor tube securement on burned…

COcyanidesmokeburn

Medical

Cardiac arrest airway priorities

Before: High-quality CPR/defibrillation/epinephrine priorities should not be displaced by airway fixation. Use BVM or SGA if it maintains oxygenation/ventilation with fewer interruptions. Decide whether ETI adds value now or after stabilization/ROSC.

During: Minimize chest-compression interruptions for advanced airway attempts. Confirm with waveform EtCO₂ and clinical context; low EtCO₂ may reflect low perfusion. Avoid hyperventilation after advanced airway placement.

After / pitfalls: After ROSC: oxygenation, ventilation, BP, temperature, ECG/cath/neuro pathways. Secure airway and reassess tube depth after movement. Debrief airway timing and CPR interruptions. Repeated intubation attempts interrupting CPR. Hyperventilation during arrest. Treating low EtCO₂ as only a tube problem during low-flow…

cardiac arrestBVMSGAETICPR

Anatomic

Awake intubation candidate / anticipated difficult airway

Before: If oxygenation is stable but anatomy is high-risk, consider awake/maintained-spontaneous-ventilation strategy with expert help. Topicalization, antisialagogue, sedation plan, and backup surgical airway must be explicit. Discuss Plan A/B/C and rescue trigger before starting.

During: Keep patient oxygenated and cooperative; avoid oversedation that converts an awake plan into a crash airway. Use the device/operator most likely to succeed: fiberoptic, VL-assisted, or combined technique. Stop and re-oxygenate/reassess rather…

After / pitfalls: Secure tube, document difficult-airway details, and communicate extubation risk. Arrange ICU/anesthesia/ENT follow-up when appropriate. Capture teaching pearl and successful technique. Using RSI because awake setup feels slow despite stable oxygenation. Oversedation before topicalization and rescue readiness. No surgical airway backup.

awakedifficult airwayfiberopticENT

Anatomic

Limited mouth opening / trismus

Before: Assess mouth opening, floor-of-mouth swelling, voice, drooling, neck mobility, and progression. Call ENT/anesthesia early if oral access is limited or swelling is progressive. Plan nasal/fiberoptic/awake/surgical pathway depending on anatomy and local expertise.

During: Avoid repeated oral VL attempts if mouth opening is inadequate. Maintain spontaneous ventilation when the plan depends on tenuous anatomy. Have suction and surgical backup ready.

After / pitfalls: Treat infection/trauma source and monitor edema progression. Document mouth opening, approach, and backup plan for future teams. Extubation should be planned, not automatic. Discovering trismus only after paralytic. Forcing oral devices through inadequate mouth opening. Delayed specialty mobilization.

trismusdentaldeep spaceawake

Infection

Ludwig angina / floor-of-mouth swelling

Before: Progressive floor-of-mouth/neck swelling is an airway emergency; call ENT/anesthesia/ICU early. Avoid agitation and avoid blind instrumentation that worsens swelling/bleeding. Prepare awake/fiberoptic/surgical airway pathway while treating sepsis/infection.

During: Maintain spontaneous ventilation when appropriate; avoid a casual RSI in distorted anatomy. Suction and gentle technique; repeated attempts can worsen edema. Have surgical airway team and equipment in the room.

After / pitfalls: Antibiotics, source control, ICU airway monitoring, and edema reassessment. Plan extubation with ENT/anesthesia input. Document anatomy and technique. Waiting for imaging while airway is deteriorating. Paralyzing without a rescue plan. Underestimating how quickly edema progresses.

Ludwigdeep neckedemaawake

Anatomic

Jaw wired shut / mandibular fixation

Before: Find wire cutters or release tool immediately; confirm who can release fixation. Suction and aspiration plan are essential, especially with vomiting or bleeding. Plan nasal/oral/surgical route based on access, trauma, and local expertise.

During: Release fixation if airway/ventilation demands it and local protocol supports it. Avoid blind nasal route if basilar skull/midface trauma concern. Have front-of-neck access backup visible.

After / pitfalls: Re-secure mandibular plan with OMFS/ENT/trauma. Document release timing and airway route. Ongoing aspiration and bleeding management. No wire cutters at bedside. Trying to manage emesis with jaws fixed. Assuming standard oral laryngoscopy is possible.

jaw wiredmandiblewire cutterstrauma

Mechanical

Tube exchange / cuff leak / damaged ETT

Before: Decide if leak is tolerable, positional, pilot-balloon/cuff failure, or tube damage. Have airway exchange catheter, backup airway team, suction, and reintubation plan ready. If difficult airway, do not casually extubate to exchange.

During: Maintain oxygenation; perform exchange with skilled operator and rescue plan. Confirm new tube with waveform EtCO₂ and depth. Do not lose the airway for a non-emergent leak without preparation.

After / pitfalls: Reassess cuff pressure, leak, depth, ventilator volumes, and aspiration risk. Communicate difficult exchange details. Document old/new tube sizes and technique. Pulling the tube before a reintubation plan. Ignoring a large leak causing inadequate ventilation. No EtCO₂ after exchange.

ETTcuff leaktube exchangeairway exchange catheter

Mechanical

Accidental extubation / tube dislodgement

Before: Recognize risk: movement, transport, agitation, loose securement, facial trauma, burns, pediatrics. Have BVM, suction, rescue airway, and reintubation pathway ready before transport/procedures. Use waveform EtCO₂ and tube depth as continuous situational awareness.

During: If patient deteriorates, remove from ventilator, bag with 100% O₂, and verify tube position immediately. Absent/changed waveform or depth change should trigger displacement concern. Reintubate/rescue oxygenate if tube is out or not…

After / pitfalls: Re-secure, document depth, reassess CXR/ultrasound as appropriate, and debrief why it occurred. Adjust sedation/restraints/transport plan to prevent recurrence. Update handoff with high dislodgement risk. Attributing hypoxia to lungs while the tube has moved. No tube-depth checks after transport. Loose securement…

extubationdislodgementtransportDOPES

Post-intubation

Ventilator dyssynchrony / biting tube

Before: Assess pain, anxiety, hypoxia, hypercarbia, bronchospasm, tube depth, and ventilator settings. Analgesia/sedation should be adequate before assuming “agitation.” Bite block/oral airway if biting threatens ventilation or tube integrity.

During: Bag manually if unstable and classify resistance, compliance, or synchrony problem. Treat the cause: bronchospasm, auto-PEEP, pain, under-sedation, hypoxia, tube position, or settings mismatch. Paralysis is a rescue bridge, not a substitute…

After / pitfalls: Reassess vent waveforms, sedation score, hemodynamics, and analgesia. Document boluses/infusions and ongoing plan. Involve RT/ICU for persistent dyssynchrony. Only increasing sedatives while missing pneumothorax/auto-PEEP/tube issue. Paralyzing without sedation. No bite block with tube occlusion risk.

dyssynchronysedationbite blockventilator

Peds

Pediatric foreign body aspiration

Before: Keep child calm if partial obstruction; avoid converting partial to complete obstruction. Call ENT/anesthesia/peds surgery/bronchoscopy resources early. Prepare suction, Magills if object visible, and age-appropriate airway rescue.

During: If complete obstruction, use age-appropriate obstruction maneuvers and rescue pathway. Do not blindly sweep or push object distally. If intubating, anticipate object movement and difficult ventilation.

After / pitfalls: Bronchoscopy/imaging/observation depending on object and symptoms. Treat aspiration, edema, or pneumothorax if present. Debrief whether oxygenation or object removal was the priority. Agitating a child with partial obstruction. Blind finger sweep. Assuming normal CXR excludes foreign body.

foreign bodypedsobstructionbronchoscopy

Peds

Pediatric septic shock airway

Before: Shock resuscitation, antibiotics, access/IO, fluids/blood/vasopressors per pediatric sepsis pathway before paralysis when feasible. Use length-based weight for meds and equipment. Plan induction and PPV transition around hypotension risk.

During: Assign BP/pressor watcher; minimize apnea and excessive intrathoracic pressure. Confirm tube and immediately reassess perfusion, EtCO₂, glucose, temperature, and BP. Use peds-appropriate ventilator settings.

After / pitfalls: Continue shock bundle, source control, and ICU transfer. Analgesia/sedation without hemodynamic collapse. Reassess lactate/perfusion and ventilator interaction with preload. Airway before resuscitation when not forced. Adult dosing/equipment assumptions. Over-sedation after tube.

pedssepsisshockpressor

Peds

Pediatric anaphylaxis airway

Before: IM epinephrine and oxygenation/resuscitation are first-line; airway planning runs in parallel. Use weight/color-zone dosing and equipment; call pediatric/anesthesia/RT help early. Prepare for edema, bronchospasm, vomiting, and hypotension.

During: Avoid delaying epinephrine for airway setup. Use smaller backup tubes if swelling is present. Expect bronchospasm/high pressures after intubation.

After / pitfalls: Continue anaphylaxis treatment/observation and ventilator bronchodilator strategy. Reassess edema before extubation planning. Document trigger, treatments, and weight source. Delayed epinephrine. No smaller tube ready. Treating post-tube high pressure as only a tube problem.

pedsanaphylaxisedemashock

Peds

Neonate / young infant apnea

Before: Call neonatal/peds help early; prepare warmer, glucose, temperature, small suction, correct mask size, and tiny tubes. Ventilation is often the lifesaving intervention; prioritize effective BVM with visible chest rise. Use weight/gestational-age references and avoid adult assumptions.

During: Gentle ventilation, small volumes, good seal, and rapid correction of bradycardia/hypoxia. Tube depth errors happen quickly; verify with EtCO₂ and clinical exam. Avoid repeated intubation attempts by low-experience operators if BVM is…

After / pitfalls: Temperature/glucose/infection/toxic/metabolic workup as appropriate. Secure tube and reassess depth after any movement. Neonatal/peds ICU pathway. Mask too large or poor seal. Excessive ventilation pressure. Tube too deep after movement.

neonateinfantapneaBVM

Medical

Pulmonary hypertension crisis

Before: Intubation is high risk; avoid hypoxia, hypercarbia, acidosis, pain, and hypotension. Call critical care/cardiology/anesthesia early and prepare vasopressor/inotrope/pulmonary vasodilator pathway per local practice. Use the least destabilizing oxygenation strategy that works.

During: Gentle PPV and avoid excessive PEEP/high pressures. Maintain systemic pressure to support RV perfusion. Be prepared for peri-intubation arrest.

After / pitfalls: Ventilator strategy should protect RV: avoid hypoxia/hypercarbia/acidosis and unnecessary intrathoracic pressure. Continue PH/RV therapies and advanced support planning. Reassess EtCO₂, MAP, echo/POCUS if available. Treating like routine hypoxemic respiratory failure. High PEEP/pressures worsening RV output. Underestimating hypotension risk from induction.

pulmonary hypertensionRV failurehypoxiaacidosis

Medical

Severe pneumonia / ARDS physiology

Before: Maximize preoxygenation with NIV/HFNC/BVM-PEEP as appropriate and safe. Anticipate rapid desaturation and post-intubation oxygenation failure; call RT/ICU early. Prepare ventilator, PEEP/FiO₂ strategy, and rescue oxygenation pathway before meds.

During: Avoid derecruitment during transition and confirm with waveform EtCO₂. Use lung-protective PBW-based tidal-volume concepts after intubation. Escalate early if oxygenation remains poor despite basic optimization.

After / pitfalls: Monitor plateau/driving pressure if available, oxygenation trajectory, hemodynamics, and sedation. Consider ARDS/ICU pathway, paralysis/proning/advanced support per local protocol. Titrate FiO₂ down when safe. No PEEP during transition. Large tidal volumes based on actual weight. Late escalation for refractory hypoxemia.

ARDSpneumoniahypoxemiaPEEP

Post-intubation

Post-intubation hypotension

Before: Before meds, identify shock/acidosis/RV failure/volume depletion and prepare pressors/resuscitation. Choose induction/sedation strategy with hypotension risk in mind. Have a named post-tube BP reassessment owner.

During: If hypotension occurs: check tube/oxygenation, reduce excessive intrathoracic pressure, assess sedation effect, volume/bleeding/RV/auto-PEEP. Treat reversible causes quickly; use pressor/resuscitation pathway per protocol. Do not ignore falling EtCO₂/MAP after tube.

After / pitfalls: Reassess sedation/analgesia, ventilator pressures/PEEP, volume status, bleeding/sepsis/PE/RV failure. Trend MAP, EtCO₂, lactate/perfusion and adjust plan. Debrief if airway sequence precipitated collapse. Calling it “just sedation” without checking auto-PEEP/RV/bleeding/tension. High PEEP in preload-dependent patient. No pressor plan before paralysis.

hypotensionshocksedationPPV