Reference — Respiratory · Emergency Nursing
Emergency Airway Management Reference
Oxygen delivery devices, basic airway adjuncts (NPA/OPA), BVM ventilation technique, supraglottic airways, endotracheal intubation (RSI medications), ETT confirmation, and surgical airway — quick reference for emergency and critical care nursing.
Emergency Nursing · Respiratory
Educational use only. Airway management requires hands-on training and clinical supervision. RSI and advanced airway procedures are provider-performed — nurses support, monitor, and assist. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Oxygen Delivery Devices
| Device | FiO₂ | Flow | Indication | Key Notes |
|---|---|---|---|---|
| Nasal Cannula | 24–44% | 1–6 L/min | Mild hypoxia; conscious patient tolerating cannula | Each 1 L/min increases FiO₂ ~4%. Actual FiO₂ varies with respiratory pattern. |
| Simple Face Mask | 35–50% | 6–10 L/min | Moderate hypoxia requiring higher FiO₂ than cannula | Minimum 6 L/min to wash out exhaled CO₂. Cannot use for hypoventilation. |
| Non-Rebreather Mask (NRB) | 60–90% | 10–15 L/min | Severe hypoxia, CO poisoning, anaphylaxis, trauma, chemical exposure | One-way valve prevents rebreathing exhaled gas. Reservoir bag must remain inflated. Highest non-invasive O₂ delivery. |
| Venturi Mask | 24%, 28%, 31%, 35%, 40%, 60% | Varies by color-coded adapter | COPD patients requiring precise FiO₂ titration; chronic CO₂ retainers | Delivers precise and consistent FiO₂ regardless of respiratory pattern. Preferred for COPD to avoid hypercapnia-driven respiratory suppression. |
| High-Flow Nasal Cannula (HFNC) | Up to 100% | 10–60 L/min | Moderate-severe hypoxic respiratory failure; hypoxia unresponsive to simple devices | Provides positive pressure, washout of nasopharyngeal dead space, and precise FiO₂. May defer intubation. Heated and humidified. |
| CPAP/BiPAP (Non-Invasive Ventilation) | FiO₂ titrated | Set pressure-based | COPD exacerbation, pulmonary edema (cardiogenic), obstructive sleep apnea, post-extubation | CPAP = constant pressure. BiPAP = different inspiratory (IPAP) and expiratory (EPAP) pressures. Contraindicated: cannot protect airway, apnea, facial trauma, vomiting. |
Basic Airway Adjuncts
Nasopharyngeal Airway (NPA / Nasal Trumpet)
| Indication | Semi-conscious patient with gag reflex; unable to tolerate OPA; jaw clenching/trismus |
| Contraindication | Suspected basilar skull fracture (risk of intracranial placement); coagulopathy (relative); nasal polyps |
| Sizing | Measure: nostril to earlobe. Common adult size: 28–34 Fr (or 6.5–8 mm diameter) |
| Insertion technique | Lubricate well; insert perpendicular to face (NOT upward); beveled tip toward nasal septum; gentle rotation if resistance |
| Nursing Notes | Lubricate with water-soluble gel. May cause epistaxis (nares are highly vascular). Secure with tape. Can leave in longer periods than OPA. |
Oropharyngeal Airway (OPA / Guedel)
| Indication | Unconscious patient WITHOUT gag reflex; maintain airway patency during BVM ventilation; positioning tongue |
| Contraindication | Conscious or semi-conscious patient with gag reflex (triggers vomiting and aspiration) |
| Sizing | Measure: corner of mouth to earlobe. Too small: pushes tongue posteriorly. Too large: causes laryngospasm. |
| Insertion technique | Adult: insert curved end pointing toward palate (upside down), rotate 180° as it passes pharynx. OR use tongue depressor and insert correctly oriented. |
| Nursing Notes | Insert only if patient unresponsive to pain or voice. If patient gags → remove immediately. Do NOT tape in place. |
BVM (Bag-Valve-Mask) Ventilation
| Mask seal | EC-clamp technique: C-shape with thumb and index finger, E-clamp with remaining three fingers on mandible. 2-person technique is superior — one person holds mask with 2 hands, one squeezes bag. |
| Rate | Adult: 1 breath every 5–6 seconds (10–12 breaths/min). Avoid hyperventilation. With CPR: do NOT hyperventilate. |
| Volume | Deliver enough volume to see visible chest rise — not maximum bag squeeze. Approximately 6–8 mL/kg ideal body weight. |
| OPA use | Insert OPA to lift tongue and improve mask ventilation in unconscious patient before/during BVM use. |
| Gastric inflation risk | Avoid excessive pressure or volume — causes gastric insufflation → aspiration. Cricoid pressure (Sellick maneuver) may be applied during BVM by assistant (controversial evidence, still used in many protocols). |
| FiO₂ optimization | Connect to O₂ at 10–15 L/min with reservoir bag. FiO₂ approaches ~90–100% with reservoir inflated and good mask seal. |
Supraglottic Airways (SGAs)
| Device | Common Use | Key Limitation |
|---|---|---|
| Laryngeal Mask Airway (LMA / Classic) | Anesthesia, failed intubation rescue, BLS by trained laypersons | Does not protect against aspiration |
| LMA Supreme / i-gel | Allows gastric drainage channel to reduce aspiration risk; field or in-hospital use | Not a definitive airway |
| Combitube / King Airway | Difficult airway backup; blind insertion; EMS use | Cannot confirm position without capnography |
| Video Laryngoscope (GlideScope, McGrath) | Anticipated difficult intubation, limited mouth opening, C-spine precautions | Requires training; fogging can impair view |
Rapid Sequence Intubation (RSI) — Nursing Role
RSI is performed by providers (physicians, NPs, CRNAs). Nurses prepare medications, equipment, and assist as directed. Know the medications.
Sedative / Induction Agent
Etomidate — 0.3 mg/kg IV
Hemodynamically neutral — preferred in hypotension/shock/trauma. Single dose — may suppress adrenocortical function (avoid repeated dosing in sepsis).
Ketamine — 1–2 mg/kg IV
Maintains hemodynamic stability (catecholamine release); bronchodilator — preferred in bronchospasm/asthma/COPD. Increases secretions. Provides analgesia. Use with caution in suspected raised ICP (though controversial).
Propofol — 1.5–2.5 mg/kg IV
Causes hypotension — avoid in hemodynamic instability. Preferred for elective intubations in hemodynamically stable patients. Antiemetic properties.
Midazolam — 0.1–0.3 mg/kg IV
Can cause hypotension and prolonged sedation. Less preferred as primary induction agent. Use if other agents unavailable.
Neuromuscular Blocking Agent (NMBA)
Succinylcholine — 1.5 mg/kg IV (defasciculation: 1.1 mg/kg with pre-treatment)
Depolarizing NMBA — fastest onset (~45 sec), shortest duration (~10 min). Contraindications: crush injury, burns > 24h old, denervation injury, hyperkalemia, malignant hyperthermia history, pseudocholinesterase deficiency. May raise K⁺ by 0.5–1.0 mEq/L (safe in normal K⁺).
Rocuronium — 1.2 mg/kg IV for RSI (0.6 mg/kg for non-RSI)
Non-depolarizing NMBA — onset ~60 sec at 1.2 mg/kg dose. Duration: 45–70 min. No K⁺ risks. Reversal with sugammadex (Bridion) 16 mg/kg if needed (advantage over succinylcholine). Preferred when succinylcholine contraindicated.
ETT Confirmation Methods
| Method | Notes |
|---|---|
| Waveform capnography (PETCO₂) | GOLD STANDARD. Continuous waveform confirms ETT in airway — color change devices acceptable for prehospital/resource-limited settings. Flat waveform = esophageal intubation. |
| Auscultation (bilateral breath sounds + epigastrium) | Breath sounds bilateral axilla; absent epigastric sounds. Used in conjunction with capnography — NOT sufficient alone (can be falsely reassuring). |
| Visualization | Direct visualization of tube passing through vocal cords during laryngoscopy. |
| Chest X-ray | Confirms position post-intubation — ETT tip should be 3–5 cm above carina (carina ~ level of T4–T6, or 2–4 cm below clavicles on CXR). NOT used as primary confirmation — too slow. |
| SpO₂ / Pulse Oximetry | Delayed indicator — SpO₂ may remain high for minutes after esophageal intubation (oxygen reserve). Not a reliable immediate confirmation method. |
| Esophageal Detector Device (EDD) | Bulb or syringe — easy aspiration suggests tracheal placement; resistance suggests esophageal placement. Useful when capnography unavailable. |
Surgical Airway (Cricothyrotomy)
Indication: "Can't Intubate, Can't Oxygenate" (CICO)
When all airway attempts fail and the patient cannot be oxygenated by any other means. Emergency cricothyrotomy is a life-saving last resort performed by provider.
| Anatomy landmark | Cricothyroid membrane — between thyroid cartilage (Adam's apple) and cricoid cartilage ring |
| Types | Needle cricothyrotomy (temporary, jet ventilation); surgical cricothyrotomy (more definitive — vertical skin incision, horizontal membrane incision, cuffed tube) |
| Nursing role | Prepare emergency cricothyrotomy kit; maintain calm; assist provider; maintain continuous SpO₂ and ETCO₂ monitoring; document |
NCLEX Pearls
OPA: unconscious patients only (no gag reflex). NPA: semi-conscious patients (tolerated with gag reflex).
OPA sizing: corner of mouth to earlobe. NPA sizing: nostril to earlobe.
ETT confirmation: waveform capnography is gold standard. Auscultation alone is insufficient.
Succinylcholine contraindications: crush injury (> 24h), burns (> 24h), denervation, hyperkalemia, malignant hyperthermia hx. Alternative: rocuronium + sugammadex reversal.
Etomidate preferred in hypotension/shock (hemodynamically neutral). Ketamine preferred in bronchospasm/asthma.
Venturi mask for COPD — precise FiO₂ delivery prevents hypercapnia-driven respiratory drive suppression.
NRB mask minimum 10 L/min — reservoir bag must stay inflated. Used for CO poisoning, severe hypoxia, anaphylaxis.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American Association for Respiratory Care (AARC) · GOLD (COPD) / ATS / CHEST. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →