Part III of the Airway Series – Advanced Airway Adjuncts

By Frank Hubbell, DO

 Illustrations by T.B.R. Walsh

 In this section we will discuss the use of the endotracheal tube and the remaining airway adjuncts.

 Endotracheal Intubation (ETT)

 Gum Elastic Bougie/Flex-Guide Tube Introducers

 Digital Intubation

 Nasopharyngeal Intubation


 Pulse Oximetry

 Capnography and End-Tidal CO₂ detectors (EtCO₂)


 Stoma and Tracheostomy Care

TOTAL AIRWAY CONTROL – Endotracheal Intubation:

Last, but not least, of the airway adjuncts is endotracheal tube (ETT) intubation.

This is the most advanced airway, and it provides the greatest protection for the airway. This airway technique requires the most knowledge of airway anatomy and many hours of practice to develop the skills of using it. This is also a classic example of a, “use it or lose it” skill, requiring frequent live ETT intubations or practice on airway manikins.




Respiratory or cardiac arrest

Unconscious without a gag reflex

Rapidly deteriorating respirations or impending respiratory failure

Glottis seen through laryngoscopy

Glottis seen through laryngoscopy

Significant risk of aspiration from vomiting and obtundation

Potential airway obstruction from trauma, burns, or anaphylaxis


Epiglottitis (patient is sitting up, in the sniff position, and drooling).

Head, neck, or facial trauma that prevents visualization of the airway anatomy.

Advantages of Endotracheal Intubation:

  Complete control of the airway.

Isolates the airway.

Minimizes the risk of aspiration of gastric contents.

Eliminates the need to maintain a mask seal.

Allows direct suctioning of the trachea and respiratory passages.

It permits administration of some medications via the endotracheal tube –

naloxone, atropine, vasopressin (adults), epinephrine, and lidocaine.


Disadvantages of endotracheal intubation:

The techniques require considerable training and ongoing practice.

Intubation requires specific equipment.

Typically it is necessary to directly visualize the vocal cords.

Intubation bypasses the upper airway, and its functions of cleaning, warming, and

 humidifying the air en route to the alveoli.

Complications of endotracheal intubation:

Risk of equipment malfunction

Soft tissue damage

Broken teeth

Esophageal intubation

Tension pneumothorax

Endobronchial intubation (tube advanced too far into the right or left mainstem bronchus)

Breath sounds present on one side of the chest, diminished on the other side.

 Resistance to ventilations with a bag-valve-mask (BVM).

Pallor, cyanosis, evidence of hypoxia.

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