Decision making in airway management

The resuscitator must have many tools at hand to deal with the acutely compromised airway. Although proficiency may exist for all of the available maneuvers, the specific procedural choice often must be made in challenging circumstances. Rescuers should practice potential scenarios before facing actual airway management scenarios in the clinical situation. Failure to do so may lead to unnecessarily aggressive management in some situations or to irreversible hypoxic injury as a result of unnecessary hesitation in others.

Several parameters must be assessed quickly before an airway management choice can be made. The parameters to be considered are as follows:

1. Adequacy of current ventilation

2. Time of hypoxia

3. Patency of airway

4. Need for neuromuscular blockade (muscle tone, teeth clenching, severe obstructive pulmonary disease or asthma)

5. Cervical spine stability

6. Safety of technique and skill of operator

Consideration of these factors should guide a choice among those techniques described. This initial choice is often straightforward. Difficulty rises precipitously when the initial choice fails. Time becomes critical and safety of technique less important as the risk of irreversible hypoxic injury rises. Anxiety increases and error potential compounds under these circumstances. Forethought and practice are invaluable when making these decisions.

Now that the decision to manage the airway surgically has been made, one need only choose among three available options. Consideration of patient condition, security of the airway approach, and invasive nature of the procedure are factors to be weighed in the final decision.