Safety First: Advanced Airway


Study Notes:

  1. 1. To remove an FBAO: grab it, suck it, finger it and/or ram it.

  2. 2.If that doesn’t work, create a surgical airway (IF you are trained to).

  3. 3.We intubate people who have existing or impending problems with their airway or their breathing.

  4. 4.If you can Yankuer ... intubate ‘er.

  5. 5. Five types of patients are airway disasters waiting to happen, so we intubate them early:  Anaphylaxis/Angioedema, Burns to the airway, CHF/pulmonary edema, Decreasing LOAs (metabolic exhaustion - especially asthmatics and those in shock.)

“Secondary Airway”


“Safety First” ... Table of Contents

Safety    Use your BSI - Biological Safety

              F is for Fire - Scene Safety

I                 I is for Incident: MOI/NOI          

R                Determine the numbeR of patients

S                Send for help

T                Trauma to the C-spine?

G                General impression of the patient

E                Estimate LOAs

T                Threats to you or your patient?

1°A             1° Airway

1°B             1° Breathing

1°C             1° Circulation

1°D             1° Decision

2°A             2° Airway

2°B             2° Breathing

2°C             2° Circulation

2°D             2° Decision

The Tube of Life.

Now that we've completed the Primary ABCD's, we're going to immediately go back to 'A' again to start the Secondary ABCDs. Each letter in the secondary ABDCs stands for the same thing as in the primary ABCD's, but as we go through the secondary approach we are getting more information, and fortifying our position in order to protect our patient.

The 2°A step is all about using advanced life support skills to maintain a patients airway.  Most of our patient’s will not need this level of care, but for those few that do, it will be live saving.

In this section, I’m going to be focusing primarily on intubation.  Intubation is the insertion of a breathing tube down the trachea. Instead of going into detail about how we intubate, I’ll be focusing on explaining why we intubate, and the decision of when we should or shouldn’t intubate.  This is information that’s useful to both basic and advanced level paramedics (because basic level paramedics can use it to realize when they need to call for help).

Getting your patient endotracheally intubated has several benefits. The tube will ensure that you're not ventilating their stomach (which will make them barf), it will help keep secretions out of their trachea (though not entirely, but it helps), it will give you a route for suctioning out the airway, and it is a potential route for administering some medications (even though recent studies have questioned how effective this route is we're still using it for now).

However, even for experienced clinicians, the question ‘Should I intubate’ is sometimes very difficult to answer.  In fact, it’s almost always more difficult that the psychomotor act of actually intubating.

So, when do we intubate? Unfortunately, there’s no mnemonic or set of simple rules you can use reliably to make the decision for you.  Having said that, here is a quick little mnemonic and set of rules that you can use, to help you make the decision.

In general, we intubate people who have existing or impending problems with their airway or their breathing. 

An Anaesthesiologist might have a problem with that statement because it’s so vague, but let’s go through it step by step.


Let’s look at the worst case scenario with the patient’s airway.  If it is completely blocked, we are probably going to end up intubating.  But first, there is a 4 step sequence of skills that we need to try in order to unblock a FBAO  (Foreign Body Airway Obstruction).  Let me tell you a story that happened to me as a student.

This young guy lived in a group home, and late at night he decided he was hungry. So he went downstairs to the fridge and started taking handfuls of black forest cake and packing his airway with it. Pretty soon, he was completely obstructed and he passed out from lack of oxygen.  When we arrived, the picture was pretty clear.

My first instinct of course was to grab the laryngoscope and Magill forceps and grab whatever I could.  But that didn’t work very well - you can’t grab spongy cake with forceps.  So I tried using our portable suction.  But the cake was too thick to be sucked, so I asked my preceptor ‘now what’?  He said ‘maybe try a spoon’?

I managed to scoop and finger a lot of the cake out of his oropharynx, but the very back of his airway was still totally plugged.

So my preceptor said: ‘Look this is pretty radical, but see if you can ram what’s left down into his right lung with the endotracheal tube so we can ventilate his left lung’. So I did, and the tube filled up with cake.  I took out that tube and put another in, and I was able to ventilate.  I watched the monitor go from asystole to a sinus bradycardia, and then eventually to sinus tach.  We got him back.

We discussed that call a lot afterwards, and from it we developed a quick 4 point action list for relieving FBAO’s which I later condensed into a memorable sequence:

•Grab it,
•Suck it,
•Finger it (scoop it),
•Ram it.


If that doesn’t work, then you have a patient that you can’t ventilate and you can’t intubate.  This sort of patient scares us so much that we have a special acronym just for them – the CVCI patient (can’t ventilate, can’t intubate).  These patients need a surgical airway. 

To do this, we cut into their neck just below the larynx, through the cricothyroid membrane, and insert some sort of breathing tube.  Hopefully that works.  If it doesn’t, they’re dead.

NOTE!  Please, don’t even THINK of doing this unless you’ve been properly trained and certified.  The number of first-aiders who have told me that they would happily cut into a patients’ neck with a pocket knife and then insert an empty pen case to save a choking patient is truly frightening!  Don’t practice medicine without a license!


If we have a patient whose airway isn’t actually blocked, the question we need to ask ourselves is this – are they going to be able to keep their airway open on their own, or do we need to intubate them?

Unfortunately, there is no clear clinical indicator that tells us whether they will, or will not, be able to protect their airway, and thus, whether we need to intubate them or not. So, what clinicians generally assess is the patients ability to swallow, and if they have a gag reflex. If the patient can’t swallow, and/or they don’t have a gag reflex then they probably don’t have the ability to protect their airway and we will usually intubate them.

The way I test this is to use what I call the ‘Yankuer test’.

To do this, I attach a Yankuer tip to a working suction tube, but I don’t cover up the small hole at the top of the Yankuer.  That way the tip isn’t actually sucking.

Then, I slowly introduce the tip of the Yankuer further and further into the back of the patients mouth.  If I can stick the Yankuer right in without the patient biting it or gagging, then they probably aren’t able to protect their airway, and they need to be intubated.

So remember: “If you can ‘Yank her’ … you can intubate her”!

Nyuk nyuk ... :-)

Actually, no one laughs at that in real life either, but it does help you to remember to use the Yankuer test.


We also need to check - as a part of the secondary airway exam - if our patient is breathing.  Since people who aren’t breathing at all usually fail the Yankuer test, and since ventilating a patient is much easier and safer if they are intubated, we generally say that:  ‘not breathing = intubation’, and that’s a fairly simple rule.

However, there are four types of patients who are often breathing when we meet them but, because of their clinical condition, are heading for a rapid respiratory collapse.  It’s important to identify these patients right away because we often intubate them early in order to get the tube in before they stop breathing.  (How to do that is too detailed for this, basically we stone and anesthetize them or knock them out and chemically paralyze their voluntary muscles).  Who are those patients?  Again, we can remember them using an ABCD mnemonic (mmmm, I love mnemonics!)

A = Anaphylaxis/Angioedema
Anaphylaxis and Angioedema patients have airways that are swelling and may soon close, so we get a tube in before the swelling gets to be too much.

B = Burns to the airway
Similary patients with inhalational burns will have airways that swell up like wieners on a barbeque.  Intubate them while you can.

C = CHF/Pulmonary Edema
Patient’s with CHF and pulmonary edema will often need to be intubated, especially if you can’t do CPAP in the field.

D = Decreasing LOAs (metabolic exhaustion)
Finally patients with Decreasing LOA’s - exhausted patients, such as those in profound shock or asthmatics who are becoming sleepy – will need to be intubated before they crash.

So… that’s how we approach the airway.  Next, let’s look at ...