Paramedic Airway Management Study Guide
Download Study Guide PDFThis study guide covers airway management for paramedics, aligned with NREMT paramedic certification standards (National EMS Scope of Practice Model 2019 with updates), AHA BLS/ACLS 2025 Guidelines (current as of 2026), and national EMS education standards. Airway is a high-priority, high-frequency skill on the NREMT exam (approximately 20% of questions in Airway, Respiration & Ventilation category). Focus areas include assessment, basic adjuncts, advanced airways, ventilation strategies, monitoring (especially waveform capnography), and special considerations (e.g., trauma, pediatrics, cardiac arrest). Always follow local protocols, use BSI/PPE, and prioritize minimal interruptions during CPR. Key Principle (AHA 2025): Patent airway is priority #1. Avoid hypoventilation or hyperventilation. Use visible chest rise as guide for tidal volume in arrest. For trauma with suspected head/neck injury: Prefer jaw thrust + adjunct; if ineffective, use head tilt-chin lift to secure airway.
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Section 1: Airway Anatomy & Physiology Review
- Upper Airway: Nose/mouth → pharynx → larynx (protects lower airway; epiglottis, vocal cords).
- Lower Airway: Trachea → bronchi → bronchioles → alveoli (gas exchange).
- Adult vs. Pediatric Differences: Pediatric: Larger tongue relative to mouth, higher larynx (C3-C4 vs. C5-C6 in adults), narrower cricoid ring (cuff pressure risk in uncuffed ETT).
- Minute Ventilation (MV): Tidal volume (Vt) × Respiratory rate (RR). Adequate MV requires proper Vt and RR.
- Adequate vs. Inadequate Breathing: Adequate: Clear speech, normal rate/depth, SpO&sub2; ≥94%, equal chest rise. Inadequate: Respiratory distress/failure → cyanosis, accessory muscle use, altered mental status → requires intervention.
Section 2: Assessment & Indications for Intervention
| Step | Assessment Findings Indicating Intervention |
|---|---|
| Look/Listen/Feel Airway patency, respiratory effort | Obstruction, gurgling, stridor, absent sounds |
| Rate & Depth RR 10-20 adult; Vt ~500-600 mL adult | <8 or >30 RR; shallow or absent chest rise |
| SpO&sub2; & EtCO&sub2; Pulse ox, capnography | SpO&sub2; <94% on RA; EtCO&sub2; abnormal waveform |
| Mental Status AVPU/GCS | Altered → protect airway |
| Special Trauma, overdose, anaphylaxis | Suspected c-spine injury, facial trauma |
Indications for Positive Pressure Ventilation (PPV): Apnea, inadequate respiratory effort, GCS ≤8, severe hypoxia despite O&sub2;.
Section 3: Basic Airway Management Techniques
| Technique | Indications | Steps | Key Notes (AHA/NREMT) |
|---|---|---|---|
| Manual Opening | All patients | Head tilt-chin lift (non-trauma); Jaw thrust (trauma/suspected c-spine) | 2025 Update: In trauma, if jaw thrust + adjunct fails, use head tilt-chin lift for patent airway priority. |
| Oropharyngeal Airway (OPA) | Unconscious, no gag reflex | Measure corner of mouth to angle of jaw; Insert inverted, rotate 180° | Contraindicated if gag present; Causes obstruction if too small. |
| Nasopharyngeal Airway (NPA) | Conscious or semi-conscious | Measure tip of nose to earlobe; Lubricate, insert bevel toward septum | Contraindicated in severe facial trauma, suspected basilar skull fracture. |
| Suctioning | Secretions, vomitus, blood | Yankauer/rigid for oral; Soft catheter for ET tube | Max 10-15 sec; Pre-oxygenate; Monitor for hypoxia. |
Oxygen Delivery Devices: Nasal cannula: 1-6 L/min (24-44%). Non-rebreather: 10-15 L/min (60-90%). High-flow nasal cannula: Up to 60 L/min (for select patients). Titrate to SpO&sub2; 94-98% (avoid hyperoxia in some cases).
Section 4: Ventilation Techniques
| Method | Rate (Adult Arrest) | Tidal Volume | Notes |
|---|---|---|---|
| Bag-Valve-Mask (BVM) | 10-12/min (1 every 5-6 sec) | Visible chest rise (~500-600 mL) | Two-person preferred; Avoid hyperventilation (causes decreased venous return). |
| With Advanced Airway | 10/min continuous | Visible chest rise | No pauses for compressions in arrest. |
| CPAP/BiPAP | N/A (pressure support) | N/A | For respiratory distress (e.g., CHF, COPD); Contraindicated in vomiting/unprotected airway. |
AHA 2025 Ventilation Updates: In arrest: Enough volume for visible chest rise; Avoid hypo- or hyperventilation. With advanced airway: 1 breath every 6 sec (10/min) continuous compressions.
Section 5: Advanced Airway Management (Paramedic Scope)
Per NREMT/National Scope: Paramedics perform endotracheal intubation (ETT) and supraglottic airways (e.g., King LT, i-gel, LMA).
| Device | Indications | Insertion Steps | Confirmation | Complications |
|---|---|---|---|---|
| Endotracheal Intubation (ETT) | Definitive airway; Cardiac arrest, failure of basic methods | Pre-oxygenate; Sellick (if used); Blade insertion; Pass tube; Inflate cuff (20-30 cmH&sub2;O) | Waveform capnography (gold standard); Bilateral breath sounds; No epigastric sounds; Chest rise | Esophageal intubation; Right mainstem; Trauma; Vomiting/aspiration |
| Supraglottic Airway (SGA) | Alternative to ETT; Easier/faster in arrest | Blind insertion; Inflate cuffs; Ventilate | Capnography; Chest rise; Breath sounds | Inadequate seal; Aspiration risk higher than ETT |
| Needle Cricothyrotomy | Can’t intubate/ventilate | Surgical or needle | N/A | Temporary bridge; High complication rate |
Confirmation of Placement (Mandatory): Continuous waveform capnography (EtCO&sub2;): >0 mmHg and consistent waveform = tracheal placement. Auscultation, chest rise, absence of epigastric sounds. Secure device; Monitor for dislodgement. NREMT Skill Emphasis: Successful placement within attempts limit; No dangerous maneuvers; Confirm properly.
Section 6: Special Situations
- Cardiac Arrest (AHA ACLS 2025): Start with BVM + OPA/NPA. Advanced airway if needed (supraglottic preferred if intubation difficult). Continuous compressions if advanced airway in place. Avoid routine advanced airway early if BVM effective.
- Trauma: C-spine precautions; Jaw thrust first; If fails, head tilt-chin lift (2025 update).
- Pediatrics: Padding under shoulders; Smaller equipment; Avoid over-ventilation.
- Obstruction (FBAO): Abdominal thrusts (conscious); CPR + finger sweep (unconscious adult).
- Post-Intubation Care: Secure tube; Continuous EtCO&sub2;; Reassess frequently.
Section 7: Common NREMT-Tested Scenarios & Tips
- Apneic adult → Immediate BVM ventilation.
- Unconscious overdose → OPA + ventilate if inadequate.
- Trauma patient with poor jaw thrust → Head tilt-chin lift if airway priority.
- Failed intubation → Supraglottic airway or cric.
- Always: Pre-oxygenate, minimize attempts (≤3 for ETT), use backup plans.
Math Example (Ventilation Rate Calculation): In arrest with advanced airway: Ventilate at 10 breaths/min. How many seconds between breaths? Solution: 60 seconds ÷ 10 breaths = 6 seconds per breath. Reasoning: Divide 60 by desired rate for interval. Review NREMT skill sheets for exact steps (e.g., Ventilatory Management - Adult, Supraglottic Airway Device). Practice with manikins and capnography simulators. Good luck on your paramedic certification! Stay current with AHA 2025 highlights and NREMT updates.