Airway Emergencies

Urgent Airway Assessment and the A-B-C-D-E Framework

Airway emergencies are among the most critical presentations in urgent and emergency care. Failure to secure a patent airway can lead to hypoxia, brain injury, or death within minutes.^[1] Family nurse practitioners (FNPs) must rapidly recognize and manage airway obstruction — whether from foreign bodies, anaphylaxis, trauma, infection, or altered mental status. This section covers high-yield concepts for the FNP exam and clinical practice, emphasizing the primary survey (A-B-C-D-E) and stepwise interventions per current AHA and ACLS guidelines.^[2]

Core Airway Obstruction Terminology and Clinical Indicators

• Patent airway – An unobstructed passage for air to move from the nose/mouth to the lungs.
• Partial obstruction – Some air exchange present; may be accompanied by stridor, hoarseness, or accessory muscle use.
• Complete obstruction – No air movement despite respiratory effort; silent chest and cyanosis are ominous signs.
• Stridor – A high-pitched, inspiratory sound indicating upper airway obstruction (e.g., croup, epiglottitis, foreign body).^[3]
• Snoring respirations – Suggest pharyngeal obstruction, often due to reduced consciousness (e.g., drug overdose).^[4]
• Gurgling – Indicates blood, secretions, or vomitus in the airway.
• Agonal respirations – Gasping, irregular breaths seen during cardiac arrest; not effective ventilation.
• Cyanosis – Late sign of hypoxia; indicates severe desaturation.

Primary Survey and Stepwise Airway Interventions

Primary Survey and the “A”

In every emergency encounter, the FNP should first assess airway patency. The AHA’s BLS and ACLS algorithms place airway management as the highest priority.^[2] The sequence is:

1. Look – for chest rise, signs of obstruction, or foreign body visible in the mouth.
2. Listen – for breath sounds, stridor, or absence of sound.
3. Feel – for air movement at the mouth/nose.

Maneuvers to Open the Airway

• Head-tilt, chin-lift – For non-trauma patients; relieves pharyngeal obstruction by lifting the tongue.
• Jaw-thrust – For patients with suspected cervical spine injury; avoids neck hyperextension.^[1]

Airway Adjuncts (Basic → Advanced)

Stepwise Approach to Airway Emergencies

1. Assess level of consciousness and attempt to speak with the patient.
2. If unconscious or obstructed: activate emergency response; open airway manually.
3. Suction visible secretions/foreign bodies.
4. Insert OPA or NPA as indicated.
5. Provide bag-valve-mask (BVM) ventilation with 100% O₂ if spontaneous breathing is inadequate.
6. If unable to ventilate: consider supraglottic airway or intubation.
7. If airway remains insecure: perform cricothyrotomy.^[5]

Clinical Presentations of Airway Emergencies by Cause

• Upper airway obstruction – Stridor, hoarseness, “seal bark” cough (croup), drooling and tripod positioning (epiglottitis).
• Lower airway obstruction – Wheezing, prolonged expiration, accessory muscle use (e.g., asthma, COPD).
• Foreign body aspiration – Sudden onset of choking, universal sign (hands on throat), inability to speak.
• Anaphylaxis – Urticaria, angioedema, stridor, hypotension, rapid onset after allergen exposure.
• Trauma – Facial fractures, neck hematoma, tracheal deviation (tension pneumothorax).
• Depressed level of consciousness – Drug overdose, stroke, seizure – predispose to airway loss.

Diagnostic Workup and Differential Identification in Airway Emergencies

• Rapid primary survey: Determine if the patient can speak or cough. Inability to speak indicates severe obstruction.
• Vital signs: Tachycardia, hypertension (early), bradycardia, hypotension (late). Oxygen saturation ≤94% is concerning.
• Capnography (EtCO₂): Waveform analysis confirms correct ETT placement and adequacy of ventilation.^[2]
• Imaging: Only if patient is stable; X-ray may show radiopaque foreign body or thumbprint sign (epiglottitis). Do not force examination of the throat in suspected epiglottitis.
• Differential diagnoses: Allergic reaction, asthma, COPD, anaphylaxis, epiglottitis, croup, foreign body, tumor, trauma.

Comprehensive Airway Management: Basic Life Support to Advanced Procedures

Basic Life Support (BLS) Interventions

• Conscious choking (adult): Perform abdominal thrusts (Heimlich maneuver) until object expelled or patient loses consciousness.^[1]
• Unconscious choking: Start CPR – give chest compressions after each cycle and look for object.
• Anaphylaxis: Immediate IM epinephrine (0.3 mg, 1:1000) anterolateral thigh; repeat every 5–15 min as needed.^[6]

Medications for Airway Management

• Oxygen: 100% via non-rebreather mask if breathing spontaneously; BVM with reservoir if assisted.
• Rapid Sequence Intubation (RSI): Induction agent (e.g., etomidate, ketamine) + paralytic (succinylcholine or rocuronium).^[5]
• Nebulized racemic epinephrine: For severe croup or post-extubation stridor.
• Corticosteroids: Dexamethasone 0.6 mg/kg for croup; methylprednisolone for reactive airway disease.

Advanced Airway Procedures

• Bag-valve-mask ventilation: Two-person technique preferred for better seal and tidal volume.
• Endotracheal intubation: Confirm placement with EtCO₂ and bilateral breath sounds.
• Surgical airway (cricothyrotomy): Scalpel-bougie or needle technique; indicated when “cannot intubate, cannot ventilate” (CICV).^[5]

Risk Mitigation and Adverse Event Prevention in Airway Management

• Aspiration: Use cricoid pressure (Sellick maneuver) only in cardiac arrest or if directed; no evidence for routine use.^[2]
• Hypoxia: Pre-oxygenate (denitrogenate) for 3–5 minutes before intubation attempts.
• Trauma from airway devices: OPA can cause gagging, vomiting, or laryngospasm if inserted incorrectly. NPA can cause epistaxis or intracranial placement in basilar skull fracture.
• Barotrauma: Avoid excessive ventilation rates (10–12 breaths/min) and large tidal volumes.
• Unrecognized esophageal intubation: Always confirm with capnography and auscultation.^[5]
• Delayed cricothyrotomy: Fear of performing surgical airway leads to prolonged hypoxemia; practice simulated drills to gain competence.

Exam-Focused Clinical Priorities and Common Scenarios

• Memory aid “A-B-C-D-E”: Always reassess airway before moving to breathing and circulation.
• Stridor = upper airway. Differentiate infectious vs. mechanical causes.
• “Cannot ventilate, cannot intubate” → immediate cricothyrotomy. This is a common exam scenario.
• Signs of complete airway obstruction: No air movement, “silent chest,” cyanosis, altered mental status.
• RSI medications: Know induction agents (etomidate, ketamine, propofol) and paralytics (succinylcholine, rocuronium).
• Anaphylaxis: First-line epinephrine IM – not antihistamines or corticosteroids alone.^[6]
• Pediatric considerations: Croup vs. epiglottitis – croup responds to racemic epinephrine and steroids; epiglottitis requires immediate airway team.
• Common exam distractors: Always prioritize airway (A) over other concerns. Do not start CPR without opening airway.

References and Sources

1. American Heart Association. (2020). Highlights of the 2020 AHA Guidelines for CPR and ECC. https://doi.org/10.1161/CIR.0000000000000911
2. Link, M. S., et al. (2020). Part 1: Executive summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142(16_suppl_2), S337–S357. https://doi.org/10.1161/CIR.0000000000000911
3. Bhatia, R., & Kole, S. (2020). Stridor in children: An approach to assessment and management. Pediatric Emergency Medicine Practice, 17(11), 1–24. https://www.ncbi.nlm.nih.gov/pubmed/33119800
4. Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier. https://doi.org/10.1016/B978-0-323-32966-7.00002-9
5. Brown, C. A., & Wears, R. L. (2018). The difficult airway algorithm: A review. Emergency Medicine Clinics of North America, 36(1), 1–17. https://doi.org/10.1016/j.emc.2017.08.002
6. Lieberman, P., et al. (2015). Anaphylaxis – A practice parameter update 2015. Annals of Allergy, Asthma & Immunology, 115(5), 341–384. https://doi.org/10.1016/j.anai.2015.09.014