Airway Management & Tracheostomy Nursing

A comprehensive clinical reference for GCC nursing professionals

GCC / DHA / DOH / SCFHS Aligned · 2026

Airway Assessment

🔍LEMON Airway Assessment

L Look Externally

Facial trauma, burns, angioedema
Large tongue, short neck, receding chin
Obesity, beard, distorted anatomy
Stridor, hoarseness, drooling

E Evaluate 3-3-2 Rule

3 fingers — mouth opening (inter-incisor)
3 fingers — hyoid bone to chin (mandible)
2 fingers — hyoid bone to thyroid notch
Any measurement < target = predict difficulty

M Mallampati Score

Class	Visible	Significance
I	Soft palate, uvula, tonsils, pillars	Easy
II	Soft palate, upper uvula	Moderate
III	Soft palate base only	Difficult
IV	Hard palate only	Very difficult

O Obstruction

Epiglottitis, abscess, haematoma
Foreign body, tumour, oedema
Stridor = partial obstruction
Silence = complete obstruction — EMERGENCY

N Neck Mobility

Cervical spine injury / immobilisation
Rheumatoid arthritis, ankylosing spondylitis
Obesity limiting flexion/extension
Halo frame, collar in situ

OBESE Mnemonic — Predict Difficult Airway

O — Obstructive Sleep Apnoea (OSA)
B — Beard
E — Elderly (>55 years)
S — Small mouth (Mallampati III/IV)
E — Edentulous (no teeth — mask seal difficulty)
S — Snoring / history of failed intubation

📊Monitoring

SpO₂ Pulse Oximetry

Continuous monitoring mandatory
Pre-oxygenation target: SpO₂ ≥ 95% before intubation
Desaturation <90% — stop, oxygenate, reassess
Probe placement: finger, ear, forehead (poor perfusion)

Waveform Capnography (EtCO₂)

Gold standard for confirming ventilation
Normal EtCO₂: 35–45 mmHg
Flat trace after intubation = oesophageal intubation
Rising EtCO₂ = hypoventilation, ROSC indicator in arrest

🛏️Positioning

Sniffing Position (Standard)

Neck flexed on body + head extended at atlantoaxial joint. Aligns oral, pharyngeal, and laryngeal axes. Best for direct laryngoscopy (DL).

Ramped Position (Obese Patients)

Elevate upper body and head until external auditory meatus is horizontal with the sternal notch. Improves laryngoscopy grade and reduces desaturation time.

Caution: Never hyperextend the neck in suspected C-spine injury. Use manual inline stabilisation (MILS) instead.

🚨Airway Emergency Recognition

Stridor

High-pitched breath sound. Indicates partial obstruction — airway is present but narrowed. Inspiratory stridor = supraglottic. Expiratory = subglottic/tracheal. Biphasic = severe.

Silence

Complete obstruction — no air movement, no breath sounds. Silent chest in asthma is ominous. No stridor = no airway. Immediate action required.

Other Signs

Cyanosis (late sign)
Use of accessory muscles
Tracheal tug / paradoxical breathing
Altered consciousness
Inability to swallow secretions

Airway Devices

👃NPA — Nasopharyngeal Airway

Parameter	Detail
Sizing	Tip of nostril → earlobe (external). Adult: 6–7 mm ID
Insertion	Lubricate well. Right nostril preferred (valve anatomy). Bevel toward septum. Gentle rotation if resistance
Contraindications	Base of skull fracture (Battle's sign, raccoon eyes, CSF rhinorrhoea), coagulopathy, nasal obstruction
Advantages	Tolerated in semi-conscious / intact gag reflex
Complications	Epistaxis, malposition, laryngospasm

👄OPA — Guedel Oropharyngeal Airway

Parameter	Detail
Sizing	Incisors → angle of jaw (corner of mouth). Colour coded: adult 80–100 mm
Insertion (Adult)	Insert concave-down, rotate 180° as it passes hard palate
Insertion (Child)	Insert correct orientation (concave up) with tongue depressor — do NOT rotate in children
Contraindications	Conscious patient with intact gag reflex (induces vomiting/laryngospasm)
Complications	Vomiting, laryngospasm, dental trauma if wrongly sized

💨Supraglottic Airways (SGAs)

Device	Size	Features & Notes
Classic LMA	3 (small female), 4 (large female/small male), 5 (large male)	Inflatable cuff. First-line SGA. Not definitive airway — aspiration risk.
i-gel	4 (50–90 kg), 5 (>90 kg)	No inflatable cuff — thermoplastic gel forms seal. Faster insertion. Gastric port channel.
LMA ProSeal	3 / 4 / 5	Dual lumen: airway + gastric port for NG tube. Better seal — tolerates higher ventilation pressures. Preferred when regurgitation risk.
LMA Supreme	3 / 4 / 5	Reinforced, single-use, curved. Gastric port. Easier blind insertion.

Note: SGAs do NOT protect against aspiration. They are rescue / bridge devices. Failed intubation drill: LMA insertion buys time before FONA.

🫁Bag-Valve-Mask (BVM) Ventilation

E-C Grip Technique

C — Thumb and index finger form a C around the mask port to hold mask to face
E — Remaining three fingers form an E on the mandible/jaw for jaw-thrust and head-tilt
Ensure airtight seal — watch for chest rise
2-person BVM: one holds mask with both hands (two-thumbed technique), second squeezes bag — use for difficult airway or poor seal

Ventilation Rates

Patient	Rate	Volume
Adult	10–12 breaths/min	500–600 mL (6–8 mL/kg)
Paediatric	12–20 breaths/min	Visible chest rise
Arrest (with airway)	10 breaths/min	Avoid hyperventilation

Sellick's Manoeuvre (Cricoid Pressure)

Apply firm downward pressure on cricoid cartilage (not thyroid)
Purpose: compress oesophagus against vertebral body, reduce passive regurgitation risk
10 N awake, 30 N after unconscious
Controversial — may worsen laryngoscopy view; release if impeding intubation
Release if active vomiting occurs

Common BVM Pitfalls

Poor mask seal — most common failure
Excessive ventilation pressure → gastric insufflation
Head not positioned (sniffing position)
Forgotten oxygen attachment (deliver room air only)
Squeezing bag too fast — causes hypocapnia

Endotracheal Intubation

📋RSI Checklist — SOAPME

S Suction

Yankauer suction available, switched on, and tested at bedside

O Oxygen

100% O₂ via NRB mask × 3 min (pre-oxygenate). Target SpO₂ ≥95% before induction

A Airway Equipment

ETT (correct size + one size down), stylet, laryngoscope tested, 10 mL syringe for cuff, tape/tie

P Position

Sniffing position. Obese: ramp. C-spine: MILS. Bed height optimised for operator

M Monitoring

SpO₂, ECG, NIBP, waveform capnography all attached and displaying pre-induction

E Equipment / Emergency

Second laryngoscope, video laryngoscope, bougie, LMA rescue, surgical airway kit (FONA) — all confirmed present

💉RSI Drugs

Drug	Class	Dose	Onset	Notes
Suxamethonium (Succinylcholine)	Depolarising NMBA	1.5 mg/kg IV	60–90 sec	Duration ~10 min. Contraindicated: hyperkalaemia, burns >48h, crush injury, malignant hyperthermia risk, denervation injury
Rocuronium	Non-depolarising NMBA	1.2 mg/kg for RSI (high dose)	60–90 sec	Duration 60 min. Reversible with Sugammadex 16 mg/kg. Preferred when sux contraindicated
Ketamine	Induction agent	1–2 mg/kg IV	60 sec	Maintains airway reflexes, bronchodilator, haemodynamic stability — preferred in haemodynamic instability/asthma/trauma
Propofol	Induction agent	1.5–2.5 mg/kg IV	30–60 sec	Reduce dose in elderly/hypovolaemia. Causes hypotension. Good antiemetic properties
Thiopental	Induction agent	3–5 mg/kg IV	30 sec	Reduces ICP. Avoid in porphyria. Causes significant hypotension

🔦Direct Laryngoscopy (DL)

Macintosh blade: tip into vallecula (anterior to epiglottis)
Miller blade: tip under epiglottis (lifts directly)
Cormack-Lehane (CL) grading: I (full glottis) → IV (no glottic structures)
CL Grade III/IV = difficult — call for help, bougie, switch to VL
BURP manoeuvre (Back, Up, Right Pressure on larynx) to improve view
Maximum 3 attempts — after 3rd declare failed airway

📹Videolaryngoscopy (VL)

GlideScope / McGrath / C-MAC — most common devices
Camera at tip of blade transmits to external screen
Improves CL grade view by 1–2 levels vs DL
Hyperangulated blade: better view but requires stylet for tube delivery
Standard geometry blade (C-MAC): DL technique still works + screen benefit
First-line in anticipated difficult airway, C-spine precautions, obese patients

✅ETT Position Confirmation — 5-Point Auscultation

NEVER assume correct placement from visualising the tube pass. Confirm with ALL methods below.

Waveform capnography — flat line = oesophageal intubation
Epigastric auscultation — gurgling sounds = oesophageal
Left axilla auscultation
Right axilla auscultation
Left mid-zone auscultation
Right mid-zone auscultation — decreased sounds = right main bronchus intubation

CXR — Definitive Position

ETT tip should sit 3–5 cm above the carina on CXR. Carina typically at T4–T5. Order CXR immediately after intubation and check before starting sustained ventilation.

Tube Depth at Teeth (Adults)

Male: ~23 cm at teeth
Female: ~21 cm at teeth
Secure and document depth

🚨Failed Intubation Drill

Declare failed intubation after 3 attempts — call for senior/anaesthetics help immediately
Maintain oxygenation — return to bag-mask ventilation, 2-person technique if needed
Insert LMA / i-gel — rescue supraglottic airway. Ventilate through it
If LMA fails — consider awake fibreoptic approach if time allows
FONA (Front Of Neck Airway) — Surgical Cricothyrotomy if cannot intubate, cannot oxygenate (CICO)

CICO Drill: Cannot Intubate, Cannot Oxygenate → Surgical Cricothyrotomy is a life-saving procedure. Identify cricothyroid membrane (CTM) between thyroid and cricoid cartilages. Scalpel-bougie-tube technique preferred.

🏥Post-Intubation Management

Confirm tube position — 5-point auscultation + waveform ETCO₂ + CXR
Secure tube firmly — commercial holder or tape. Document depth
Inflate cuff — check pressure 20–30 cmH₂O
Connect to ventilator — initiate appropriate mode
Set initial ventilation: TV 6–8 mL/kg IBW, RR 12–16, PEEP 5

Sedation and analgesia — avoid awareness
NG tube insertion for gastric decompression
Oral care — 4-hourly. HOB 30–45° for VAP prevention
Ongoing monitoring: SpO₂, ETCO₂, ABG, CXR
Document: tube size, depth, cuff pressure, time of intubation

Tracheostomy Care

🔀Surgical vs Percutaneous Dilatational Tracheostomy (PDT)

Feature	Surgical Tracheostomy	Percutaneous (PDT)
Setting	Operating theatre	ICU bedside
Operator	Surgeon (ENT/general)	Intensivist/trained physician
Technique	Open dissection, tracheal window	Seldinger technique (Ciaglia Blue Rhino most common)
Timing	Any time, emergency or elective	Elective only; not first 72h post-intubation (some centres 7 days)
Complications	Higher bleeding, infection, longer scar	Paratracheal placement risk, lower infection
Nurse role	Post-op wound care, monitoring	Pre-procedure prep, bronchoscopy assist, monitoring

🧰Tracheostomy Tube Types

Type	Indications	Key Notes
Cuffed	Ventilated patients, aspiration risk, early post-op	Cuff seals airway for positive pressure ventilation. Check pressure every shift
Uncuffed	Long-term tracheostomy, weaned from ventilator, no aspiration risk	Allows more airflow around tube for phonation. No cuff pressure monitoring needed
Fenestrated	Weaning, speaking valve use, decannulation pathway	Hole(s) in outer/inner cannula allow airflow through larynx. MUST use non-fenestrated inner cannula when ventilating — fenestrated causes leak
Adjustable Flange (Tight-to-shaft / Adjustable Neck)	Obese patients, excessive SC tissue, unusual anatomy	Flange repositionable to accommodate any neck depth. Risk of displacement if not secured

🔵Cuff Pressure Management

Target cuff pressure: 20–30 cmH₂O — check with cuff pressure manometer every shift and after any tube movement or position change.

Under-inflation (<20 cmH₂O)

Aspiration of secretions into lungs
Air leak around tube — inadequate ventilation
Patient may phonate unexpectedly
Ventilator low-pressure alarm

Over-inflation (>30 cmH₂O)

Tracheal mucosal ischaemia → necrosis
Tracheomalacia (long-term)
Tracheo-oesophageal fistula (rare but serious)
Arterio-tracheal fistula risk

Inner Cannula Cleaning — Step-by-Step Protocol ▼

Frequency: Every 4–8 hours or as needed (blocked secretions, increased work of breathing)

Equipment: Sterile gloves, sterile water/saline, small brush, sterile bowl × 2, apron, eye protection

Explain the procedure to the patient. Perform hand hygiene. Don PPE (apron, gloves, eye protection).
Pre-oxygenate the patient if clinically indicated (SpO₂ <95% or FiO₂ requirement).
Suction the tracheostomy if secretions present before removing inner cannula.
Remove inner cannula: unlock (usually anti-clockwise rotation) and withdraw gently along the curve of the tube.
If disposable: discard in clinical waste. Insert new sterile inner cannula immediately.
If reusable (silver/plastic): place in sterile bowl with sterile water. Clean with inner cannula brush using in-out rotating movements. Rinse thoroughly in second sterile bowl. Inspect for damage/patency.
Shake off excess fluid. Do NOT dry with cotton fibres (risk inhalation). Reinsert inner cannula along the curve and lock (clockwise) until click/secure.
Confirm secure fit. Reconnect to ventilator/HME. Reassess patient.
Document: time, appearance of secretions, patient tolerance.

Never leave the patient without inner cannula in situ for more than necessary — outer cannula alone has larger lumen but is more prone to crust occlusion.

Suctioning Technique Protocol — Tracheostomy ▼

Catheter size: Internal diameter of tube (mm) × 2 = suction catheter size (French). Example: 8 mm tube → 16 Fr catheter. Never exceed 50% of tube internal diameter.

Depth: Insert to tip of tracheostomy tube ONLY — not beyond (avoid deep endobronchial suctioning routinely). Some centres allow 1 cm past tip.

Assess need: visible/audible secretions, SpO₂ drop, increased work of breathing, patient request. Suction only when clinically indicated — not on a time schedule.
Explain to patient. Position: semi-recumbent (30–45°).
Pre-oxygenate: increase FiO₂ to 1.0 for 30–60 seconds, or manually hyperinflate × 3–5 breaths.
Don sterile gloves. Use aseptic non-touch technique (ANTT). Maintain sterility of catheter tip at all times.
Insert catheter WITHOUT applying suction. Insert to measured depth.
Apply suction on withdrawal ONLY — use intermittent suction, rotating catheter gently. Duration <15 seconds per pass.
Withdraw and assess: amount, colour, consistency, odour of secretions. Allow patient to recover SpO₂ between passes.
Maximum 3 passes per suction episode. Rinse catheter between passes with sterile saline (closed system) or discard and use new catheter (open system).
Suction mouth/pharynx after tracheostomy suctioning (use separate catheter).
Post-oxygenate and reassess SpO₂. Return FiO₂ to baseline. Document.

STOP suctioning if: significant bradycardia, SpO₂ <85%, arrhythmia, excessive coughing/distress. Oxygenate and reassess.

🩹Stoma Care

Clean stoma at least once daily and PRN (secretion soiling)
Use sterile saline or chlorhexidine solution as per local protocol
Clean from stoma outward using non-shedding swabs
Change tracheostomy tapes/holder daily or when soiled
Two-person technique for tape changes in first 7 days (stoma may close if tube displaced)
Apply skin barrier/hydrocolloid dressing if excoriation present
Assess stoma site for erythema, granulation, breakdown, infection signs

💧Humidification

Heat and Moisture Exchanger (HME) — "Swedish Nose"

Minimum humidification standard for breathing tracheostomy patients. Captures exhaled heat and moisture, releases on inspiration. Change every 24h or sooner if visibly contaminated.

Active Heated Humidification

For ventilated patients or those with thick/tenacious secretions. Target: 37°C, 44 mg H₂O/L absolute humidity at airway opening. Circuit condensate is biohazardous — handle carefully.

GCC Note: Hot, dry climate increases evaporative loss from airways. Humidification is critical — secretion viscosity increases, raising occlusion risk.

Speaking Valve (Passy-Muir Valve) — Assessment Checklist ▼

CRITICAL: Passy-Muir Valve (PMV) is a ONE-WAY valve — air flows IN through valve but CANNOT exit via tracheostomy. All air must exit via mouth/nose. If cuff is inflated, there is NO exit pathway → patient will suffocate. NEVER use PMV with an inflated cuff.

Pre-Requisites (ALL must be met):

Cuffed tube: cuff MUST be fully deflated before applying PMV
OR patient has uncuffed/cuffless tracheostomy tube
Sufficient airflow past tube around larynx (adequate upper airway patency)
Patient alert, awake, and able to cooperate
Swallowing function assessment completed (SLT referral)
Medical team approval and SLT/respiratory therapist involvement

Assessment Steps:

Confirm multidisciplinary approval (physician, SLT, nurse)
Position patient upright (60–90°)
Suction tracheostomy and oral cavity
Fully deflate cuff — confirm with manometer (0 cmH₂O)
Occlude tracheostomy with finger momentarily — assess patient tolerance of oral airflow
Apply PMV — listen for phonation. Coach patient to speak/cough
Monitor: SpO₂ (must remain ≥95%), respiratory rate, distress signs
First trial: maximum 15–30 minutes. Increase gradually as tolerated
Remove PMV if: SpO₂ drops, respiratory distress, patient request, fatigue
Re-inflate cuff after PMV removal (if cuffed tube) — confirm pressure
Document tolerance, phonation quality, duration, any issues

Tracheostomy Emergencies

UNIVERSAL RULE: For ALL tracheostomy emergencies — call for senior help immediately. Activate resuscitation team if airway is lost. Do not manage alone.

🧳Mandatory Bedside Emergency Equipment (Always Present)

Same-size spare tube

Identical replacement tube with intact cuff, tested and ready

One size smaller tube

Rescue tube if reinsertion of same size fails

Scissors

To cut securing tapes urgently if tube needs emergency removal

Tracheal dilators

Roscoe-style dilators to maintain/open stoma during reintubation

Bag-Valve-Mask

For both tracheostomy and oral ventilation (if stoma covered/oral intubation needed)

Suction + Capnography

Yankauer + suction catheter + portable capnography to confirm tube position

All equipment must be checked at the start of every shift and documented on the bedside safety checklist.

🚨Emergency Management — Quick Reference

Emergency	Priority Actions	Caution
Tube Displacement	1. Call for help. 2. Attempt reinsertion of same tube with obturator. 3. If fails: insert smaller tube through stoma. 4. If stoma patent: cover stoma + oral airway. 5. Oral intubation through mouth as rescue route.	Do NOT force tube blindly. Use dilators to maintain stoma patency.
Tube Occlusion	1. Remove inner cannula — if immediate improvement: clean/replace inner cannula. 2. Pass suction catheter to clear secretions. 3. Deflate cuff — trial of oral breathing. 4. Change tube if above fails.	Always remove inner cannula first — quickest action. Diagnose before changing tube.
Significant Bleeding	1. Nurse senior help + emergency call. 2. Over-inflate cuff (above 30 cmH₂O as temporising measure only). 3. Lie patient flat. 4. Suction blood from airway. 5. Urgent surgical review — suspicion of arterio-tracheal fistula.	Innominate artery/arterio-tracheal fistula = life-threatening. Do NOT deflate cuff until surgical team present.
Inadvertent Decannulation (First 5–7 Days)	1. Call for help immediately. 2. Do NOT attempt to reinsert — stoma may close. 3. Oral airway/BVM via mouth. 4. Anaesthetics/ENT for oral intubation or stoma maintenance. 5. Treat as lost airway.	Stoma not yet epithelialised — closes within minutes. High risk of paratracheal placement if forced reinsertion attempted.
Subcutaneous Emphysema	1. Stop ventilating via tracheostomy. 2. Ensure tube in correct position (capnography). 3. Consider tube displacement into SC tissue. 4. CXR — check for pneumothorax. 5. Urgent surgical review.	Crepitus on palpation of neck = SC emphysema. May indicate false passage creation or pneumothorax.

Tracheostomy Problem Solver — Interactive Emergency Guide

Select the clinical problem(s) you are facing, then click "Get Emergency Guide" for priority-colour-coded action steps.