7-step sequence from scene size-up to advanced airway escalation. Never rush past a working BVM.
Step-by-Step Protocol
- 1Scene + Primary AssessmentIdentify "airway NOW" patients: unable to speak, silent chest, cyanosis, stridor at rest, severe retractions, altered mentation, extreme RR with fatigue, poor chest rise
- 2Position + Manual ManeuverHead-tilt/chin-lift (no trauma) OR jaw-thrust (trauma/C-spine concern). Sniffing position aligns oral-pharyngeal-laryngeal axes.
- 3SuctionGurgling = suction FIRST! Limits: ≤15 sec adult, ≤10 sec child, ≤5 sec infant. Suction on the way OUT. Pre-oxygenate when possible.
- 4Basic AdjunctsOPA: unconscious, NO gag reflex. NPA: gag present or OPA not tolerated; avoid with facial/head trauma or suspected basilar skull fracture.
- 5Oxygenate + VentilateTwo-person BVM preferred. Ventilate to visible chest rise. Avoid excessive volume/pressure (especially peds). Use capnography.
- 6CPAP (when appropriate)Breathing but failing oxygenation/ventilation (CHF, COPD, asthma with adequate mentation). Monitor for hypotension/barotrauma.
- 7Escalate AirwayIf BVM/CPAP inadequate → SGA → ETI → Cric (CICO only). Never rush past a working BVM.
Airway Sound Recognition
| Sound | Meaning | Immediate Action |
|---|---|---|
| Snoring | Tongue/soft tissue obstruction | Reposition, jaw thrust, OPA/NPA |
| Gurgling | Fluid in airway | SUCTION IMMEDIATELY |
| Stridor (inspiratory) | Upper airway narrowing | Emergency — act fast, risk of complete obstruction |
| Wheeze (expiratory) | Lower airway/bronchospasm | Bronchodilators, CPAP |
| Barking cough | Croup — viral subglottic edema | Minimize agitation, blow-by O2, neb epi if severe |
| Silent chest | Near-complete obstruction OR severe failure | CRITICAL — imminent arrest |
| Hoarse/muffled voice | Epiglottitis, angioedema, burns | Do NOT manipulate — prepare for abrupt closure |
CRITICAL RULE: If you can oxygenate and ventilate with BVM, do NOT rush to an advanced airway. Optimize BVM first.
Stridor indicates narrowed upper airway. Anticipate sudden complete obstruction. Treat as emergency.
1A — Tongue / Soft Tissue Obstruction
Pathophysiology: Loss of muscle tone → tongue falls back → occludes posterior pharynx.
Signs: Snoring respirations, poor air movement, improves with repositioning.
Signs: Snoring respirations, poor air movement, improves with repositioning.
- 1Position + manual maneuver (head-tilt/chin-lift or jaw-thrust)
- 2Suction as needed
- 3OPA if no gag / NPA if gag present (no contraindication)
- 4BVM with high-flow O2 + capnography
- 5If unable to maintain: escalate to advanced airway per protocol
1B — Foreign Body Airway Obstruction (FBAO)
Partial: coughing, wheeze/stridor with some air movement | Complete: cannot speak/cough, silent efforts, rapid hypoxia, cyanosis
- 1Conscious: age-appropriate obstruction maneuvers (Heimlich/back blows per protocol)
- 2Worsening/unresponsive: open airway, suction, attempt ventilation
- 3Direct visualization with laryngoscope → remove with Magill forceps (especially peds)
- 4If not removable: attempt intubation with smaller tube to push obstruction down
- 5CICO: rescue airway / needle cricothyrotomy per protocol
1C — Croup (Viral Subglottic Edema)
Pathophysiology: Parainfluenza → subglottic edema → barking cough + stridor. Peak age 6mo–3yr. Worse at night.
Signs: Barking "seal" cough, inspiratory stridor, retractions, low-grade fever after URI.
Signs: Barking "seal" cough, inspiratory stridor, retractions, low-grade fever after URI.
- 1Keep child CALM — agitation worsens obstruction. Position of comfort.
- 2Blow-by oxygen if tolerated (NRB may increase agitation)
- 3Nebulized racemic epinephrine for moderate/severe stridor at rest per protocol
- 4Corticosteroid per protocol (dexamethasone — reduces edema, onset delayed)
- 5Prepare to ventilate if fatigue/deterioration; transport and reassess frequently
NREMT ALERT: Croup gets racemic epinephrine for respiratory distress — NOT a tongue depressor, NOT oral airway manipulation.
Bacterial or allergic-mediated supraglottic swelling with risk of sudden complete obstruction. Keep calm, don't agitate.
1D — Epiglottitis — The "4 D's"
Pathophysiology: Bacterial infection (H. influenzae or Strep) → swollen epiglottis → risk of sudden complete obstruction. Now most common in adults.
D
Drooling
D
Dysphagia
Can't swallow
D
Dysphonia
Hot potato voice
D
Distress
Tripod, toxic look
- 1CALM environment — do NOT agitate the patient
- 2Do NOT inspect oropharynx — no tongue depressor (can trigger spasm/complete obstruction)
- 3Do NOT insert OPA or routine oral devices
- 4Blow-by oxygen ONLY if patient tolerates — do not force a mask
- 5BVM + suction + backup airway ready for abrupt closure
- 6Rapid transport; advanced airway only by most experienced provider with surgical cric backup
NEVER use a tongue depressor in suspected epiglottitis — this can trigger complete obstruction and death.
1E — Anaphylaxis / Angioedema
Pathophysiology: IgE-mediated mast cell degranulation → tongue/laryngeal edema + bronchospasm + vasodilation. Progression can be RAPID — minutes to complete obstruction.
Signs: Facial/tongue swelling, hoarseness, stridor, wheeze, urticaria, hypotension, tachycardia.
Signs: Facial/tongue swelling, hoarseness, stridor, wheeze, urticaria, hypotension, tachycardia.
- 1Epinephrine IM immediately — 1:1,000, 0.3–0.5mg IM anterior/lateral thigh. This is the primary lifesaving drug.
- 2High-flow O2; continuous monitoring (SpO2, ECG, capnography); prepare for rapid deterioration
- 3Repeat epinephrine in 5–15 min if no improvement per protocol
- 4Add-ons: diphenhydramine, corticosteroids, albuterol for bronchospasm, IV fluids/vasopressors for shock
- 5Intubation with EXTREME caution — edema distorts anatomy; use smaller-than-expected tube; video laryngoscopy if available
- 6If CICO: SGA attempt, then cricothyrotomy per protocol
Thermal/chemical irritation causes progressive airway edema that worsens over hours. CO and cyanide poisoning possible.
Signs & Symptoms
- Facial burns, singed nasal/facial hair, soot in nares/oropharynx
- Carbonaceous (black) sputum — hallmark of inhalation injury
- Hoarseness, stridor, progressive swelling
- Cherry-red skin (CO) or altered mentation (CO/cyanide)
Treatment — First to Last
- 1High-flow 100% O2 via NRB immediately — reduces CO half-life
- 2TIME-CRITICAL — edema will worsen; early airway control before swelling closes it
- 3Suction as needed; plan early advanced airway with smaller tube if edema present
- 4Cyanide antidote per protocol if suspected (hydroxocobalamin)
- 5Progressing obstruction beyond intubation ability → cricothyrotomy per protocol
Bronchospasm + air trapping → increased WOB. DANGER: silent chest, rising EtCO2, fatigue = pre-arrest.
2A — Asthma / Status Asthmaticus
Pathophysiology: Bronchial smooth muscle spasm + mucosal inflammation + mucus plugging → air trapping → increased WOB. Status asthmaticus = refractory to standard treatment.
Capnography: "Shark fin" waveform (slow obstructed exhalation). Rising EtCO2 in tiring patient = pre-arrest.
Capnography: "Shark fin" waveform (slow obstructed exhalation). Rising EtCO2 in tiring patient = pre-arrest.
- 1O2 + continuous monitoring (SpO2, capnography, cardiac)
- 2Nebulized albuterol per protocol — repeat as needed
- 3Add ipratropium (moderate-severe) — synergistic with albuterol
- 4Corticosteroid early (methylprednisolone/dexamethasone) — onset delayed
- 5CPAP if persistent bronchospasm and patient can protect airway
- 6Magnesium sulfate IV for severe/refractory bronchospasm per protocol
- 7If tiring/failing: SLOW rate BVM, allow FULL exhalation, prepare advanced airway
ASTHMA VENTILATION: Avoid rapid/aggressive bagging — worsens air trapping (auto-PEEP) and causes hypotension. Use slow rate (6–8 bpm), long expiratory time (I:E = 1:3 or longer).
2B — COPD Exacerbation
Pathophysiology: Chronic airflow limitation + acute trigger → ventilation failure and CO2 retention.
Signs of CO2 retention: Headache, flushing, altered mentation, asterixis (flapping tremor).
Signs of CO2 retention: Headache, flushing, altered mentation, asterixis (flapping tremor).
- 1Controlled O2 titrated to SpO2 88–92% in known COPD — but NEVER withhold O2 if hypoxic
- 2Bronchodilators (albuterol + ipratropium) + corticosteroids per protocol
- 3CPAP — watch for hypotension and barotrauma
- 4If failing: BVM ventilatory support and advanced airway per protocol
Pulmonary edema: CPAP is the primary intervention. Opioid OD: BVM FIRST, then naloxone — not the other way around.
2C — Pulmonary Edema / CHF
Pathophysiology: Fluid in alveoli → diffusion failure → severe hypoxia.
Signs: Severe dyspnea, orthopnea, bilateral crackles, pink frothy sputum, JVD, peripheral edema, hypoxia.
Signs: Severe dyspnea, orthopnea, bilateral crackles, pink frothy sputum, JVD, peripheral edema, hypoxia.
- 1Sit patient upright — legs dependent reduces preload
- 2High-flow O2 + continuous monitoring
- 3CPAP early if tolerated — PEEP recruits alveoli, pushes fluid back, reduces WOB
- 4Nitroglycerin per protocol if hypertensive (preload reduction)
- 5Diuretics per protocol if indicated; BVM/advanced airway if failing
3A — Opioid Overdose / Respiratory Depression
Signs: Slow/shallow respirations or apnea, altered MS, pinpoint pupils (KEY), possible hypotension, track marks.
Key point: EtCO2 rises BEFORE SpO2 drops — capnography catches respiratory depression early.
Key point: EtCO2 rises BEFORE SpO2 drops — capnography catches respiratory depression early.
- 1Open airway + BVM with O2 FIRST — do NOT wait for naloxone
- 2Naloxone per protocol — titrate to adequate respirations, NOT full wakefulness (avoid acute withdrawal)
- 3Suction ready — anticipate vomiting on waking; consider recovery position
- 4Monitor for re-sedation (naloxone wears off faster than most opioids) — repeat dosing as needed
BVM BEFORE NALOXONE — fix oxygenation first. Naloxone without ventilation doesn't save a hypoxic brain.
Waveform capnography is the most important airway monitoring tool available. Catches problems before SpO2 changes.
EtCO2 Values & Meanings
| Value | Meaning |
|---|---|
| 35–45 mmHg | Normal — adequate ventilation |
| <35 mmHg | Hyperventilation, decreased perfusion (shock, PE, cardiac arrest) |
| >45 mmHg | Hypoventilation, COPD/asthma air trapping, rising ICP |
| Absent waveform | Esophageal intubation, cardiac arrest with no CPR, circuit disconnection |
| <10 mmHg during CPR | Inadequate compression quality — switch compressors |
| Sudden spike to 35–45 | ROSC — check pulse BEFORE stopping CPR |
Waveform Pattern Interpretation
| Pattern | Clinical Meaning |
|---|---|
| Normal rectangle | Adequate ventilation and airway patency confirmed |
| "Shark fin" (sloped plateau) | Lower airway obstruction: asthma, COPD, bronchospasm |
| Elevated baseline | Incomplete exhalation / rebreathing CO2 — extend expiratory time |
| Sudden waveform loss | Check pulse FIRST (cardiac arrest?), THEN confirm tube position |
| Gradually rising trend | CO2 retention: hypoventilation, tiring patient, increasing air trapping |
| Gradually falling trend | Improving ventilation OR decreasing cardiac output — reassess |
| Bumps during plateau | Patient breathing against ventilation or inadequate sedation |
ETT Confirmation Protocol
- Gold standard: Continuous waveform capnography showing consistent rectangular waveform after intubation
- Colorimetric detector: ALWAYS confirm with at least 6 ventilations; can give false negative in low-flow states
- Confirm after EVERY patient move: tube position + chest rise + breath sounds + waveform
- Sudden waveform loss post-intubation: check pulse first, then confirm tube position (DOPE)
Use LEMON before every advanced airway attempt to anticipate problems and prepare backup plans.
LEMON — Predict Difficult Intubation
L
Look Externally
Facial trauma, obesity, short neck, beard, large tongue, goiter
E
Evaluate 3-3-2
3 fingers mouth | 3 chin to hyoid | 2 hyoid to thyroid
M
Mallampati
Class I (all visible) → Class IV (hard palate only)
O
Obstruction
Angioedema, epiglottitis, FB, burns, tumor
N
Neck Mobility
C-collar, arthritis, obesity limit extension
S
Saturation
SpO2 100% = reserve | <90% = no reserve, act fast
MOANS — Predict Difficult BVM
M
Mask Seal
Beard, facial trauma, obesity, absent teeth
O
Obstruction
Oropharyngeal obstruction, morbid obesity
A
Age
Elderly (decreased compliance); infants (different anatomy)
N
No Teeth
Paradoxically makes BVM seal harder — leave dentures in if stable
S
Stiff / Snoring
Stiff lungs (fibrosis, ARDS), snoring (tongue obstruction)
Advanced Airway Escalation Sequence
- 1Optimize BVM: two-person seal, OPA/NPA, suction, PEEP valve — preoxygenate 3+ min
- 2SGA/LMA/i-gel/King LT if BVM inadequate or intubation delayed/failed
- 3ETI — BURP if needed, Cormack-Lehane grading, confirm with waveform capnography
- 4CICO → Cricothyrotomy — last resort if all above fail
RSI = concurrent induction agent + neuromuscular blocking agent. Used when airway cannot wait and patient is not apneic/unconscious.
RSI Phase Sequence
| Phase | Key Actions |
|---|---|
| Preparation | LEMON assessment, equipment ready, backup plan, CICO kit available |
| Preoxygenation | 3–5 min high-flow O2 (NRB + NC at 15 LPM); creates O2 reserve — extends safe apneic time |
| Pretreatment | Lidocaine (ICP concern), atropine (peds bradycardia prevention) — per protocol |
| Induction Agent | Sedative/hypnotic (ketamine, etomidate) — provides unconsciousness per protocol |
| Paralytic (NMBA) | Succinylcholine (fast onset/offset) or Rocuronium (non-depolarizing) — per protocol |
| Intubation | Laryngoscopy; BURP if needed; Grade 1–4 (Grade 1 = full glottis view) |
| Confirmation | Waveform capnography + chest rise + breath sounds |
| Post-Intubation | Sedation/analgesia; SpO2, EtCO2, vitals; secure tube; reassess after every move |
Cricothyrotomy (CICO — Last Resort)
- Indication: CANNOT INTUBATE + CANNOT OXYGENATE/VENTILATE by any other method
- Anatomy: Cricothyroid membrane — inferior to thyroid cartilage, superior to cricoid ring ("soft spot")
- Warning: Complete obstruction above insertion site can prevent exhalation — risk of hypercarbia/barotrauma
- Peds: Reserved for complete occlusion when NO other method works — needle technique preferred in young children
SUCCINYLCHOLINE CONTRAINDICATIONS: Hyperkalemia risk with burns >48h, crush injury, prolonged immobility, denervation injuries, renal failure. Know your local protocol.
Higher metabolic rate, less reserve, and different anatomy mean kids decompensate rapidly and without warning.
Anatomic Differences vs Adult
| Feature | Pediatric Difference & Implication |
|---|---|
| Large Occiput | Neutral/sniffing position achieved more easily; avoid over-extension in infants |
| Large Tongue | Larger relative to oral cavity → more easily obstructs airway |
| Epiglottis | Softer, omega-shaped, more horizontal → Miller blade often preferred |
| Narrowest Point | Cricoid ring (subglottic) in <8 yrs vs glottic in adults → uncuffed tubes in young children |
| Small Airway | Minor edema = MAJOR resistance increase (resistance ∝ 1/radius⁴) |
| Respiratory Reserve | Higher metabolic rate → desaturate MUCH faster than adults |
| Bradycardia | Late/OMINOUS sign of hypoxia — do NOT wait; act immediately |
ETT Size Quick Reference
| Age Group | ETT Size (uncuffed) | Formula |
|---|---|---|
| Newborn/Neonate | 3.0–3.5 mm | (Age÷4) + 4 |
| Infant (1–12 mo) | 3.5–4.0 mm | |
| Toddler (1–3 yr) | 4.0–4.5 mm | |
| Preschool (3–5 yr) | 4.5–5.0 mm | |
| School age (6–12 yr) | 5.0–6.5 mm | |
| Adolescent (>12 yr) | Adult sizing |
Key Peds Pearls
- Treat respiratory distress EARLY — kids decompensate rapidly and without warning
- AVOID agitation in croup and epiglottitis — crying/agitation worsens obstruction
- Suction causes vagal bradycardia — limit duration, re-oxygenate immediately
- Gastric distention most common secondary cause when ventilations suddenly become difficult → insert NG/OG tube
- Use Broselow tape or length-based estimation for drug and equipment sizing
D — Displacement | O — Obstruction | P — Pneumothorax | E — Equipment failure. Check in order.
DOPE Assessment
| Problem | Signs | Fix |
|---|---|---|
| D — Displacement | Absent/unequal breath sounds, no waveform, epigastric sounds | Visualize tube, confirm with capnography, re-intubate if needed |
| O — Obstruction | Increased resistance, poor chest rise, secretions, high peak pressures | Suction tube, check for kinking, consider bite block |
| P — Pneumothorax | Absent unilateral breath sounds, hypotension, JVD, tracheal deviation | Needle decompression (2nd ICS MCL or 4th/5th ICS AAL) |
| E — Equipment Failure | BVM malfunction, O2 supply failure, tube leak, circuit disconnection | Switch equipment, check O2 supply, verify connections |
Complete mnemonic master list for NREMT exam and field reference.
| Mnemonic | Meaning & Use |
|---|---|
| LEMON | Difficult Intubation: Look | Evaluate 3-3-2 | Mallampati | Obstruction | Neck mobility (+S for Saturation) |
| MOANS | Difficult BVM: Mask seal | Obstruction/Obesity | Age | No teeth | Stiff/Snoring lungs |
| RODS | Difficult SGA: Restricted mouth | Obstruction | Distorted airway | Stiff lungs |
| SMART | Difficult Cric: Surgery/scarring | Mass/Tumor | Access | Radiation | Thick neck |
| DOPE | Sudden deterioration intubated patient: Displacement | Obstruction | Pneumothorax | Equipment failure |
| BURP | Improve laryngoscopic view: Backward | Upward | Right | Pressure on thyroid cartilage |
| 4 Ds | Epiglottitis: Drooling | Dysphagia | Dysphonia | Distress |
| SALAD | Contaminated airway: Suction Assisted Laryngoscopy and Airway Decontamination |
| CICO | Cannot Intubate Cannot Oxygenate → triggers surgical airway |
Airway makes up 8–12% of NREMT questions. Clinical judgment is the largest domain — most questions test decision-making.
Exam Traps & Correct Thinking
- Epiglottitis: NEVER tongue depressor, NEVER OPA. Answer = keep calm, blow-by O2, rapid transport.
- Croup with severe stridor at rest: Answer = racemic epinephrine. NOT cool mist on NREMT.
- Asthma silent chest: Near-complete obstruction = CRITICAL. Do NOT celebrate — escalate immediately.
- COPD O2: Target SpO2 88–92% — but NEVER withhold O2 from a hypoxic patient.
- Anaphylaxis: Epinephrine is ALWAYS first and primary. Not diphenhydramine.
- Opioid OD: BVM FIRST, THEN naloxone. Not naloxone first.
- Gurgling sound: SUCTION first — not OPA, not BVM.
- OPA contraindicated: Gag reflex present → use NPA instead.
- NPA contraindicated: Suspected basilar skull fracture or significant facial/head trauma.
- ETT confirmation: Continuous waveform capnography is the GOLD STANDARD.
- Rising EtCO2 in intubated patient: Hypoventilation or fatigue — increase rate/depth.
- EtCO2 suddenly zero post-intubation: Check pulse FIRST (cardiac arrest?), THEN confirm tube.
High-Yield Numbers
| Value | What It Represents |
|---|---|
| 35–45 mmHg | Normal EtCO2 range |
| <10 mmHg during CPR | Poor CPR quality — improve compressions or switch |
| Sudden spike to 35–45 | ROSC — check pulse before stopping CPR |
| SpO2 88–92% | COPD target oxygenation |
| SpO2 94–99% | Standard target for most adult patients |
| ≤15 sec | Maximum suction time for adults |
| ≤10 sec | Maximum suction time for children |
| ≤5 sec | Maximum suction time for infants |
| 10–12 bpm | Adult ventilation rate with advanced airway in place |
| 0.3–0.5 mg IM | Adult epinephrine dose for anaphylaxis (1:1,000, anterolateral thigh) |
The foundational rules that govern every airway decision. BLS before ALS — always.
ALWAYS: BLS before ALS. Suction before adjuncts. Preoxygenate before any advanced attempt. Confirm ETT with waveform capnography. DOPE for every sudden deterioration.
NEVER: Tongue depressor in epiglottitis. Fast bagging in asthma. Naloxone before BVM in opioid OD. Force mask on epiglottitis/croup. Amiodarone for Torsades.
WATCH FOR: Silent chest (asthma near-arrest). Sudden EtCO2 loss (tube displacement or arrest). Peds bradycardia (hypoxia, not primary cardiac). Rising EtCO2 in intubated patient (hypoventilation). RV infarct with inferior STEMI (hold nitro).
Condition Snapshot
| Condition | Key Sign | First Action |
|---|---|---|
| Tongue obstruction | Snoring | Reposition + jaw thrust |
| FBAO conscious | Silent, can't speak | Heimlich/back blows |
| Croup | Barking cough + stridor | Calm + blow-by O2 |
| Epiglottitis | Drooling + tripod + hoarse | Calm — NO manipulation |
| Anaphylaxis | Facial swelling + wheeze | Epi 0.3–0.5mg IM NOW |
| Airway burn | Soot + hoarseness | 100% O2 + early ETI |
| Asthma severe | Wheeze → silent chest | Albuterol + CPAP |
| COPD exac. | Wheeze + CO2 signs | Controlled O2 88–92% |
| Pulm. edema | Crackles + frothy sputum | Upright + CPAP |
| Opioid OD | Miosis + slow RR | BVM FIRST then Narcan |