Reference — Airway Management
Artificial Airways Reference
The airways used to open, secure, and protect the respiratory tract — from simple oral and nasal airways to endotracheal tubes and tracheostomies — with sizing, cuff-pressure targets, and the way placement is confirmed.
Written by Apex Respiratory Editorial Team
Educational use only. This material supports respiratory therapy education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or physician orders. Always follow facility policies and current provider orders, and verify calculations independently before clinical use.
Overview
Artificial airways range from simple adjuncts that hold the tongue off the posterior pharynx to definitive tubes that seal the trachea for ventilation and aspiration protection. The right device depends on the level of consciousness, the gag reflex, and whether the need is brief or long-term. The sizing rules and confirmation steps below are starting estimates — always verify placement on the individual patient.
Airway Types
| Airway | Use | Key Points |
|---|---|---|
| Oropharyngeal airway (OPA) | Maintains an open airway in the unconscious patient | Use only when there is no gag reflex; size from the corner of the mouth to the angle of the jaw |
| Nasopharyngeal airway (NPA) | Maintains an airway in the semi-conscious patient | Tolerated with an intact gag reflex; size from the nare to the tragus; avoid with basilar skull fracture |
| Supraglottic airway / LMA | Rescue ventilation and short procedures | Seats above the glottis; not a definitive airway and does not protect against aspiration |
| Endotracheal tube (ETT) | Definitive airway for ventilation and airway protection | Adult sizes ~7.0–8.0 mm ID for women, 7.5–8.5 mm for men; starting depth ~21 cm (women) / 23 cm (men) at the teeth; confirm with waveform capnography, bilateral breath sounds, and a CXR showing the tip 3–5 cm above the carina |
| Tracheostomy | Long-term ventilation, weaning, or upper-airway obstruction | Surgical or percutaneous airway through the neck; bypasses the upper airway so inspired gas must be humidified |
Cuff Management
- Target 20–30 cmH₂O. Maintain cuff pressure within this range — high enough to seal the airway, low enough to minimize tracheal mucosal injury.
- Use minimal leak or MOV technique. The minimal-leak and minimal-occluding-volume methods inflate the cuff to just seal (or seal with a tiny audible leak) rather than over-inflating it.
- Measure with a manometer. Confirm cuff pressure with a cuff manometer rather than by feel; palpating the pilot balloon does not reliably estimate pressure.
Confirming Endotracheal Tube Placement
| Method | Role | What to Look For |
|---|---|---|
| Waveform capnography | Gold standard | A sustained end-tidal CO₂ waveform confirms tracheal placement and continuously monitors it thereafter |
| Auscultation | Supporting | Equal bilateral breath sounds; absent sounds over the epigastrium |
| Chest rise | Supporting | Symmetric chest expansion with each delivered breath |
| Chest radiograph | Confirms depth | Tip positioned 3–5 cm above the carina |
Clinical Notes
- Capnography confirms and monitors. Waveform capnography is the standard not only for confirming tracheal placement at intubation but for catching a tube that later dislodges — a sudden loss of the waveform is an extubation until proven otherwise.
- Check cuff pressure each shift. Verify the cuff sits at 20–30 cmH₂O with a manometer at least once per shift and after any repositioning.
- Secure the tube and document depth. Record the centimeter marking at the teeth or lip so any migration is obvious on the next check.
- Watch for accidental extubation and mainstem migration. A tube that slips out, or advances into the right mainstem, changes breath sounds and gas exchange — reassess depth whenever those change.
Related Resources
Sources
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021. Airway management chapter.
- American Association for Respiratory Care. AARC Clinical Practice Guideline: Management of airway emergencies. Respir Care. 1995;40(7):749-760.