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Searchable airway situation database
Manage the physiology before, during, and after the tube
Fast, scenario-based airway guidance for ED learners and clinicians. Each card is organized as before intubation, during intubation, post-intubation, and pitfalls. Educational guide only: local protocols and supervising clinicians control bedside care.
53 scenarios shown
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.
- Have sedation/paralysis strategy ready to avoid severe dyssynchrony and breath stacking.
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 peak/plateau if high pressures occur.
After
- 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.
Pitfalls
- High RR after intubation causing breath stacking.
- Treating high peak pressure as tube obstruction without checking bronchospasm/auto-PEEP.
- Forgetting that hypotension may improve after disconnecting the ventilator.
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 with PEEP; have suction ready for frothy secretions.
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
- 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.
Pitfalls
- Intubating before a real NIV/afterload-reduction trial when NIV is safe.
- Dropping PEEP during transitions.
- Post-intubation hypotension from induction/PPV.
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 respecting lung protection.
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
- 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.
Pitfalls
- Routine low RR after tube leading to abrupt CO2 rise/acidemia.
- Long apnea during RSI.
- Focusing only on the tube while forgetting K/fluids/insulin physiology.
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
- Treat post-intubation hypotension aggressively.
- Use lung-protective ventilator strategy if ARDS/sepsis lung injury present.
- Debrief whether airway timing/resuscitation sequence worked.
Pitfalls
- Paralyzing before pressor/resuscitation plan is ready.
- Over-sedation immediately after tube.
- Excessive intrathoracic pressure in preload-dependent shock.
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
- Reassess RV shock, EtCO2, MAP, lactate/perfusion.
- Use ventilator settings that protect RV physiology.
- Continue definitive PE/RV failure management.
Pitfalls
- Treating as a routine hypoxic airway.
- High PEEP/pressures worsening RV output.
- Underestimating peri-intubation arrest risk.
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 if oxygenation/visualization fails.
After
- Secure tube carefully; facial injuries make dislodgement risk higher.
- Ongoing hemorrhage/aspiration management and imaging/ENT/trauma pathway.
- Recheck tube depth after movement/transport.
Pitfalls
- One weak Yankauer only.
- Repeated attempts through blood without changing technique.
- Failure to prepare front-of-neck access.
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
- 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.
Pitfalls
- Rigid adherence to collar preventing mouth opening without a plan.
- Poor positioning because “C-spine” was treated as no-positioning.
- No backup oxygenation plan.
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
- 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.
Pitfalls
- Delayed airway decision until complete obstruction.
- RSI in an airway that should be awake/surgical.
- No surgical airway backup in the room.
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
- Treat CO/cyanide exposure when indicated.
- Anticipate edema progression and difficult tube exchanges.
- Communicate airway findings to burn/ICU team.
Pitfalls
- False reassurance from initial normal exam.
- Poor tube securement on burned face.
- Forgetting toxic inhalation physiology.
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
- Evaluate aspiration, airway trauma, residual obstruction.
- CXR/bronchoscopy/ENT/peds pathway depending on object and age.
- Debrief object management and rescue timing.
Pitfalls
- Blind finger sweeps.
- Pushing object below cords.
- Repeated laryngoscopy without oxygenation.
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
- Continue epinephrine infusion/adjuncts per protocol.
- Watch for biphasic reaction and ongoing bronchospasm/edema.
- Plan ICU/airway observation if edema significant.
Pitfalls
- Focusing on intubation while delaying epinephrine.
- No cric backup for progressive edema.
- Under-treating post-tube bronchospasm/shock.
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
- 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.
Pitfalls
- Post-intubation hypotension.
- Unintentional hyper/hypoventilation.
- Forgetting sedation after paralysis.
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
- 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.
Pitfalls
- Dirty airway without suction.
- Assuming all obtunded patients need the same ventilator plan.
- No post-intubation sedation because patient was “overdosed.”
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
- Secure tube, continue massive transfusion/bleed control, decompress stomach when appropriate.
- Reassess shock and ventilator settings.
- Communicate high aspiration risk.
Pitfalls
- Under-resuscitated induction.
- Single suction.
- Tube dislodgement during procedures/transport.
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
- Use appropriate PEEP, recruitment strategy, and sedation.
- Confirm tube depth carefully; habitus can mislead.
- Plan safe transport with oxygen reserve.
Pitfalls
- Flat positioning.
- No PEEP during preoxygenation.
- Assuming “large patient” only changes ETT size.
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
- Coordinate OB/neonatal/ICU pathway.
- Ventilate and sedate with maternal-fetal context.
- Document airway difficulty and medications.
Pitfalls
- Underestimating rapid desaturation.
- No suction/aspiration plan.
- No obstetric coordination.
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
- Low RR, long exhalation, close waveform monitoring.
- Sedation/paralysis for dangerous dyssynchrony per peds ICU/ED protocol.
- Continuous bronchodilators and ICU consultation.
Pitfalls
- Ventilating like a normal child.
- No backup tube sizes.
- Delayed recognition of auto-PEEP shock.
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
- Frequent gas/electrolyte/neuro reassessment.
- Watch cerebral edema risk.
- Continue DKA protocol; tube is supportive, not definitive therapy.
Pitfalls
- Under-ventilation after paralysis.
- No peds critical care involvement.
- Using adult assumptions for tube size/vent RR.
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
- Age-appropriate RR/VT; monitor leak, tube depth, and sedation.
- Frequent reassessment after any movement.
- Peds ICU/neonatal pathway.
Pitfalls
- Adult-size mask or poor seal.
- Tube too deep.
- Forgetting glucose/temperature.
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
- Monitor edema, leak, and tube security.
- Continue croup therapy and ICU planning.
- Extubation planning requires airway expertise.
Pitfalls
- Agitating the child unnecessarily.
- Tube too large.
- No smaller backup tube.
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
- Antibiotics/steroids/source control per local protocol.
- ICU airway monitoring.
- Communicate airway findings and difficulty.
Pitfalls
- Casual RSI in distorted infectious airway.
- No ENT/anesthesia backup.
- Multiple attempts worsening edema/bleeding.
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
- Confirm with EtCO2, secure tube, treat cause of obstruction.
- Document tube type/size and emergency plan.
- Educate team/family about emergency steps if appropriate.
Pitfalls
- Forgetting to oxygenate the face.
- Blind reinsertion of a fresh trach.
- No EtCO2 confirmation.
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
- ICU/OR pathway; do not discharge/ignore sentinel bleeding.
- Document timing, volume, tube details, and interventions.
- Debrief emergency roles.
Pitfalls
- Labeling sentinel bleed as minor irritation.
- Delay in surgical call.
- Poor suction/airway control during hemorrhage.
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
- Confirm with EtCO2 at stoma.
- Secure airway device and communicate laryngectomy status.
- Treat underlying obstruction/infection/plug.
Pitfalls
- Trying to BVM the face only.
- Confusing trach with laryngectomy.
- No stoma EtCO2 confirmation.
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
- ICU/surgical care, bleeding control, tube security.
- Document timeline and interventions.
- Plan extubation carefully.
Pitfalls
- Waiting for imaging in a crashing airway.
- No surgeon/anesthesia call.
- Repeated oral attempts through distorted anatomy.
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
- 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.
Pitfalls
- Adult equipment assumptions.
- Tube migration with movement.
- Airway focus while shock resuscitation stalls.
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
- GI/ENT/ICU management and endoscopy timing per protocol.
- Monitor edema progression.
- Pain/sedation and aspiration management.
Pitfalls
- Underestimating delayed edema.
- Traumatic instrumentation.
- No specialty involvement.
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
- Treat aspiration pneumonitis/pneumonia risk as clinically indicated.
- Reassess ventilation, EtCO2, and acid-base status.
- Continue tox workup and recurrent opioid toxicity monitoring.
Pitfalls
- Delaying BVM because naloxone is coming.
- No suction plan.
- No sedation after paralysis as mental status improves.
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
- Continuous sedation/antiepileptic pathway, temperature/glucose/electrolyte evaluation.
- Ventilator and EtCO2 reassessment.
- Neuro/ICU pathway and debrief medication timing.
Pitfalls
- Stopping antiseizure care after tube placement.
- Aspiration without suction readiness.
- Hypotension from sedative stacking.
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
- Continue hemorrhage control, endoscopy/IR pathway, ventilator and shock reassessment.
- Sedation/analgesia and aspiration management.
- Debrief suction strategy and failed-attempt prevention.
Pitfalls
- One suction catheter only.
- Airway team distracts from hemorrhage resuscitation.
- No plan for re-contamination after successful tube.
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
- Reassess oxygenation, BP, obstetric status, and fetal considerations when relevant.
- ICU/OB/anesthesia handoff.
- Document tube depth/confirmation and aspiration precautions.
Pitfalls
- Underestimating rapid desaturation.
- No aspiration/suction plan.
- No OB/anesthesia/neonatal mobilization.
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
- 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.
Pitfalls
- Flat positioning.
- Underpowered preoxygenation.
- Using actual body weight for tidal volume targets.
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
- Continue anaphylaxis management and observation/ICU pathway.
- Treat bronchospasm and adjust ventilation as needed.
- Plan extubation carefully if edema persists.
Pitfalls
- Airway focus without epinephrine/resuscitation.
- No smaller tube backup.
- Under-recognizing post-intubation bronchospasm.
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, and early tox/ICU/nephrology support.
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
- 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.
Pitfalls
- Routine RSI with prolonged apnea.
- Post-intubation RR/ventilation far below pre-intubation demand.
- Focusing on the tube while delayed toxin therapy continues.
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
- Ventilator support, secretion clearance, aspiration prevention, and disease-specific therapy.
- Reassess sedation, weakness, and extubation readiness carefully.
- Communicate baseline respiratory mechanics and trajectory.
Pitfalls
- Waiting for SpO₂ to fall before acting.
- Underestimating bulbar dysfunction/aspiration risk.
- No plan for prolonged ventilatory failure.
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
- 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.
Pitfalls
- Small ETT limiting suction/bronchoscopy.
- Supine position with bilateral contamination when avoidable.
- Delayed definitive hemorrhage-control team activation.
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
- Treat hypothermia, aspiration/ARDS physiology, and associated trauma.
- Titrate FiO₂/PEEP and reassess gases/imaging.
- ICU pathway for severe hypoxemia or neurologic injury.
Pitfalls
- Assuming all drowning patients need prophylactic antibiotics.
- Dropping PEEP during transport/transition.
- Missing hypothermia or trauma.
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
- Continue CO/cyanide pathway, burn/ICU consultation, and ventilator reassessment.
- Serial lactate, ABG/co-oximetry as available, neuro/cardiac monitoring.
- Plan for evolving edema.
Pitfalls
- Relying on standard pulse oximetry to exclude CO.
- Missing cyanide physiology in enclosed-space fire with shock/lactate.
- Poor tube securement on burned tissue.
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
- After ROSC: oxygenation, ventilation, BP, temperature, ECG/cath/neuro pathways.
- Secure airway and reassess tube depth after movement.
- Debrief airway timing and CPR interruptions.
Pitfalls
- Repeated intubation attempts interrupting CPR.
- Hyperventilation during arrest.
- Treating low EtCO₂ as only a tube problem during low-flow states.
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 than pushing through failure.
After
- Secure tube, document difficult-airway details, and communicate extubation risk.
- Arrange ICU/anesthesia/ENT follow-up when appropriate.
- Capture teaching pearl and successful technique.
Pitfalls
- Using RSI because awake setup feels slow despite stable oxygenation.
- Oversedation before topicalization and rescue readiness.
- No surgical airway backup.
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
- Treat infection/trauma source and monitor edema progression.
- Document mouth opening, approach, and backup plan for future teams.
- Extubation should be planned, not automatic.
Pitfalls
- Discovering trismus only after paralytic.
- Forcing oral devices through inadequate mouth opening.
- Delayed specialty mobilization.
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
- Antibiotics, source control, ICU airway monitoring, and edema reassessment.
- Plan extubation with ENT/anesthesia input.
- Document anatomy and technique.
Pitfalls
- Waiting for imaging while airway is deteriorating.
- Paralyzing without a rescue plan.
- Underestimating how quickly edema progresses.
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
- Re-secure mandibular plan with OMFS/ENT/trauma.
- Document release timing and airway route.
- Ongoing aspiration and bleeding management.
Pitfalls
- No wire cutters at bedside.
- Trying to manage emesis with jaws fixed.
- Assuming standard oral laryngoscopy is possible.
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
- Reassess cuff pressure, leak, depth, ventilator volumes, and aspiration risk.
- Communicate difficult exchange details.
- Document old/new tube sizes and technique.
Pitfalls
- Pulling the tube before a reintubation plan.
- Ignoring a large leak causing inadequate ventilation.
- No EtCO₂ after exchange.
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 functioning.
After
- 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.
Pitfalls
- Attributing hypoxia to lungs while the tube has moved.
- No tube-depth checks after transport.
- Loose securement in facial burns/trauma/pediatrics.
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 for diagnosis, and requires deep sedation.
After
- Reassess vent waveforms, sedation score, hemodynamics, and analgesia.
- Document boluses/infusions and ongoing plan.
- Involve RT/ICU for persistent dyssynchrony.
Pitfalls
- Only increasing sedatives while missing pneumothorax/auto-PEEP/tube issue.
- Paralyzing without sedation.
- No bite block with tube occlusion risk.
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
- Bronchoscopy/imaging/observation depending on object and symptoms.
- Treat aspiration, edema, or pneumothorax if present.
- Debrief whether oxygenation or object removal was the priority.
Pitfalls
- Agitating a child with partial obstruction.
- Blind finger sweep.
- Assuming normal CXR excludes foreign body.
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
- Continue shock bundle, source control, and ICU transfer.
- Analgesia/sedation without hemodynamic collapse.
- Reassess lactate/perfusion and ventilator interaction with preload.
Pitfalls
- Airway before resuscitation when not forced.
- Adult dosing/equipment assumptions.
- Over-sedation after tube.
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
- Continue anaphylaxis treatment/observation and ventilator bronchodilator strategy.
- Reassess edema before extubation planning.
- Document trigger, treatments, and weight source.
Pitfalls
- Delayed epinephrine.
- No smaller tube ready.
- Treating post-tube high pressure as only a tube problem.
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 effective and help is coming.
After
- Temperature/glucose/infection/toxic/metabolic workup as appropriate.
- Secure tube and reassess depth after any movement.
- Neonatal/peds ICU pathway.
Pitfalls
- Mask too large or poor seal.
- Excessive ventilation pressure.
- Tube too deep after movement.
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
- 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.
Pitfalls
- Treating like routine hypoxemic respiratory failure.
- High PEEP/pressures worsening RV output.
- Underestimating hypotension risk from induction.
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
- 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.
Pitfalls
- No PEEP during transition.
- Large tidal volumes based on actual weight.
- Late escalation for refractory hypoxemia.
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
- 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.
Pitfalls
- Calling it “just sedation” without checking auto-PEEP/RV/bleeding/tension.
- High PEEP in preload-dependent patient.
- No pressor plan before paralysis.