Airway management is a fundamental skill for respiratory therapists and a crucial topic on the TMC Exam. This section assesses your ability to maintain a patent airway, use various airway devices, and respond to emergencies such as airway obstructions or difficult intubations.
Proper mastery of these concepts is essential—not only for passing the exam but also for ensuring patient safety and effective care in clinical settings.
In this guide, we’ll provide key tips and strategies to help you confidently navigate the airway management section of the TMC Exam, bringing you one step closer to earning your RRT credentials.
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Airway Management Tips for the TMC Exam
- Understand how to establish an airway
- Understand pharyngeal airways
- Master endotracheal intubation
- Understand tracheostomy care
- Understand extubation
Watch this video or keep reading to learn essential tips and tricks for mastering the airway management section of the TMC Exam.
1. Understand How to Establish an Airway
Proper airway management is a fundamental skill for respiratory therapists and is essential during intubation. The goal is to ensure a clear and patent airway to facilitate ventilation and oxygenation.
Two primary techniques are used depending on the patient’s condition and the presence of contraindications:
Preferred Airway Technique
The head-tilt/chin-lift is the preferred method for establishing an airway during routine intubation. It works by tilting the head back and lifting the chin, which prevents the tongue from falling back and obstructing the upper airway. This technique is highly effective for opening the airway in patients without spinal or neck injuries.
- How It Works: Tilting the head and lifting the chin moves the tongue away from the oropharynx, creating a clear passage for airflow.
- Contraindications: Suspected cervical spine injury or neck fracture. Performing this maneuver in such cases could exacerbate spinal damage.
Alternative Technique
In scenarios where a neck injury is suspected, the jaw thrust or modified jaw thrust is recommended instead. This technique allows for airway clearance without moving the neck, thus minimizing the risk of spinal cord damage.
- How It Works: The maneuver involves grasping the angles of the patient’s lower jaw and lifting it forward. This motion brings the chin and tongue forward, effectively relieving the obstruction without extending the neck.
- When to Use: The jaw thrust should be the go-to method for patients with suspected cervical spine trauma, multi-trauma, or any condition where maintaining neutral spinal alignment is critical.
Key Takeaway
- Head-Tilt/Chin-Lift: Use for patients without suspected neck injury.
- Jaw Thrust/Modified Jaw Thrust: Use for patients with suspected cervical spine injuries to prevent exacerbation of spinal trauma.
Note: Knowing when to use each technique is crucial for safe airway management and will help you provide the best possible care in emergency situations. Familiarize yourself with these procedures, as they are frequently tested on the TMC Exam and essential in clinical practice.
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2. Understand Pharyngeal Airways
Pharyngeal airways are small tubes used to maintain a patent airway by preventing upper airway obstructions. They extend only into the pharynx and are designed to keep the tongue from falling back and blocking the airway.
There are two primary types of pharyngeal airways: oropharyngeal and nasopharyngeal. For the TMC Exam, you must know the indications, contraindications, and proper use of each type.
Oropharyngeal Airway
An oropharyngeal airway is a curved plastic device inserted through the mouth into the oropharynx to prevent the tongue from obstructing the airway. It is specifically designed for unconscious or sedated patients.
- Indication: Oropharyngeal airways are used in unconscious patients to prevent airway obstruction caused by the tongue. They are also effective in facilitating bag-mask ventilation by maintaining a clear airway.
- Contraindication: Never use an oropharyngeal airway in a conscious or semi-conscious patient, as it can trigger gagging, vomiting, and increase the risk of aspiration.
- Additional Use Case: When a patient is orally intubated and bites down on the endotracheal tube, an oropharyngeal airway can be used as a bite block to protect the tube and maintain a patent airway.
Nasopharyngeal Airway
A nasopharyngeal airway is a soft, flexible tube inserted through the nose into the nasopharynx, creating a passage for airflow. Unlike the OPA, a nasopharyngeal airway can be used in patients who are conscious and have an intact gag reflex.
- Indication: Nasopharyngeal airways are recommended for patients who require frequent nasotracheal suctioning, such as those with copious secretions or upper airway obstructions. They can be used in both conscious and semi-conscious patients without causing a gagging reflex.
- Benefits: NPAs are less likely to cause discomfort compared to OPAs and can be safely used in patients who cannot tolerate an oropharyngeal airway.
Note: Understanding these differences will help you confidently identify the correct airway choice based on the patient’s condition and the clinical scenario presented on the TMC Exam.
3. Master Endotracheal Intubation
Understanding the nuances of intubation and endotracheal (ET) tube management is critical for both clinical practice and the TMC Exam. This topic often appears in exam questions, so mastering the key details will help you navigate these scenarios with confidence. Here are some essential tips to remember:
An orally inserted ET tube is generally preferred over the nasal route for adult intubation. Why? It allows for the use of a larger diameter tube, which reduces airway resistance and decreases the patient’s peak, plateau, and mean airway pressures. This results in improved ventilation and oxygenation.
Proper ET Tube Sizes for Oral Intubation
- Men: Size 7.5 or 8
- Women: Size 7 or 7.5
Confirming Proper Tube Placement
Proper placement of the endotracheal tube is essential to ensure effective ventilation and to avoid complications such as mainstem intubation or inadequate ventilation.
- Through the Vocal Cords: The ET tube should be inserted 3–4 cm past the vocal cords in adults.
- Lip Marking: The tube should be positioned at 21–24 cm at the patient’s lip, as indicated by the markings on the side of the tube.
- Above the Carina: The tube should be 1.5 inches (or 3–6 cm) above the carina. This can be verified using a chest x-ray.
After intubation, it’s crucial to confirm that the ET tube is correctly positioned in the trachea. Here are the methods you should use:
- Auscultation: Check for bilateral breath sounds to confirm equal lung inflation.
- SpO2 Monitoring: Improving oxygen saturation is a positive indicator of proper tube placement.
- Condensation in the ET Tube: Presence of moisture or condensation inside the tube indicates airflow.
- CO2 Detector: Look for a color change on exhalation. (e.g., “Gold is good, yellow is mellow”).
- Symmetric Chest Expansion: Symmetrical chest rise during inspiration indicates correct placement.
- Capnography: Verify exhaled CO2 with a capnography device.
- Chest X-Ray: A chest radiograph should show the tip of the tube between the T2 and T4 thoracic vertebrae, which is also the superior border of the aortic knob.
How to Correct Tube Position
You will likely see a question about when to adjust or pull back an endotracheal tube. Consider the following scenario:
After orally intubating an adult patient in the ICU, you are asked to confirm that the tube is in the correct position. Upon auscultation, you note that the breath sounds are absent on the patient’s left side. Which of the following is the most appropriate action to take at this time?
A. Obtain a stat chest radiograph
B. Withdraw the endotracheal tube by 1–2 cm
C. Reintubate the patient
D. Insert a large-bore needle in the left upper chest
The absence of breath sounds on the left side suggests right mainstem intubation, meaning the tube has been inserted too far into the right bronchus. The appropriate action is to withdraw the ET tube by 1–2 cm and reassess for bilateral breath sounds.
Correct Answer: B. Withdraw the endotracheal tube by 1–2 cm
While a chest x-ray is useful for confirming placement, it is not the first intervention in this case. There is no need to reintubate if the issue can be resolved by repositioning the tube. A large-bore needle is used for tension pneumothorax, not for correcting tube placement.
Note: By mastering these concepts, you’ll be equipped to answer any intubation-related questions on the TMC Exam with confidence and accuracy.
4. Understand Tracheostomy Care
A tracheostomy is a surgical opening created in the neck and trachea that allows for the insertion of a tracheostomy tube—an artificial airway used to facilitate breathing or provide long-term ventilatory support.
For the TMC Exam, understanding the purpose, indications, and care of tracheostomies is essential for success. Here are some key concepts to remember:
Indications for a Tracheostomy
- Long-Term Ventilation: Tracheostomies are recommended for patients who require long-term mechanical ventilation. If a patient is expected to need ventilatory support for 21 days or longer, the endotracheal tube should be replaced with a tracheostomy tube to minimize complications and improve patient comfort.
- Inability to Use the Oral or Nasal Route: When oral or nasal intubation is not feasible due to anatomical abnormalities, trauma, or other medical conditions, a tracheostomy provides a more secure and stable airway.
Since a tracheostomy involves a direct opening in the trachea, sterile technique is crucial during trach care and suctioning to prevent infections and complications. Always follow aseptic procedures when cleaning the site, changing dressings, and suctioning the tracheostomy tube.
Tracheostomy Tube Features
- Cuffed Tracheostomy Tubes: Similar to endotracheal tubes, many tracheostomy tubes have a cuff that should be inflated when the patient is receiving mechanical ventilation. This cuff seals the airway and prevents air leaks, ensuring effective ventilation.
- Inner Cannula: Some tracheostomy tubes have an inner cannula that can become obstructed by secretions. Regular cleaning and maintenance of the inner cannula are required to ensure patency and prevent respiratory distress.
- Fenestrated Tracheostomy Tubes: A fenestrated tracheostomy tube has a hole on the side, allowing air to pass through the vocal cords. This enables patients to speak and communicate while the tracheostomy is in place, making it ideal for patients in the weaning process or those who require speech capabilities.
If you see a scenario where a patient is expected to remain on mechanical ventilation for 21 days or longer, the correct recommendation is to replace the endotracheal tube with a tracheostomy tube to reduce airway trauma, improve patient comfort, and facilitate better long-term care.
Note: By understanding these concepts and mastering the nuances of tracheostomy care, you’ll be better prepared for questions on the TMC Exam related to artificial airways and ventilatory support.
5. Understand Extubation
For most patients, intubation and mechanical ventilation are temporary measures to support breathing during critical illness or surgery. Once the underlying issue is resolved and the patient is stable, it’s time to consider extubation—the process of removing the artificial airway.
Successful extubation depends on several factors to ensure that the patient can maintain their airway and breathe independently. Understanding the criteria, steps, and complications associated with extubation is crucial for both clinical practice and the TMC Exam.
Criteria for Extubation
Before proceeding with extubation, the patient must meet the following criteria:
- Ability to Protect Their Airway: The patient must be alert and able to cough and clear secretions effectively.
- Adequate Respiratory Function: The patient should have a stable respiratory rate and sufficient tidal volume without the support of the ventilator.
- Ability to Manage Secretions: The patient must be able to cough up and clear secretions without excessive suctioning.
- Adequate Oxygenation: SpO2 and PaO2 levels should be within acceptable ranges on minimal oxygen support.
- Stable Hemodynamic Status: Blood pressure and heart rate should be stable without requiring high doses of vasopressors or other medications.
- Ability to Cooperate with the Medical Team: The patient should be responsive, able to follow commands, and exhibit no signs of severe anxiety or agitation.
Steps for Extubation
Extubation is a multi-step process that requires careful preparation and monitoring. The general steps are as follows:
- Pre-Oxygenate the Patient: Ensure adequate oxygenation prior to removing the tube to prevent hypoxemia during the procedure.
- Suction the Airway: Suction both the mouth and trachea to clear any secretions that could obstruct the airway after the tube is removed.
- Deflate the Cuff: Gently deflate the cuff while ensuring the patient is prepared to have the tube removed.
- Remove the Tube: Instruct the patient to take a deep breath, then swiftly remove the tube during expiration to minimize trauma and coughing.
- Suction the Upper Airway: Immediately suction the mouth and throat to clear any remaining secretions.
- Monitor and Assess: Closely observe the patient’s respiratory effort, oxygen saturation, and overall status for signs of distress.
Common Complications After Extubation
Even if a patient meets the extubation criteria, complications can arise. It’s essential to be aware of the common issues and how to manage them:
- Aspiration: Occurs when secretions or gastric contents enter the lungs, increasing the risk of infection and respiratory compromise.
- Laryngospasm: A sudden closure of the vocal cords, which can obstruct the airway and cause severe respiratory distress.
- Hoarseness: Common after extubation due to irritation or trauma to the vocal cords.
- Laryngeal Edema: Swelling of the larynx can narrow the airway, leading to difficulty breathing.
If a patient develops inspiratory stridor—a high-pitched, noisy breathing sound—it’s a sign of laryngeal edema, which can compromise the airway. In this case, you should administer humidified oxygen therapy to improve oxygenation. You should also administer racemic epinephrine via a nebulizer to reduce airway swelling and alleviate stridor.
If the patient shows signs of severe respiratory distress, hypoxemia, or hemodynamic instability after extubation, you should immediately consider reintubation and placing the patient back on mechanical ventilation. Early intervention is critical to prevent respiratory failure and further complications.
Note: Understanding the criteria, performing a safe procedure, and managing post-extubation complications will help you handle related questions on the TMC Exam and ensure the best outcomes for your patients.
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Final Thoughts
The airway management section of the TMC Exam can be challenging, but with the right preparation and understanding of key concepts, you can master this topic with confidence.
Focus on the indications, contraindications, and techniques for each types of airway management, and be prepared to handle any scenario presented during the exam.
If you found these tips helpful, be sure to check out our TMC Exam Hacks video course for more insider advice, proven strategies, and expert insights to help you succeed. Best of luck on your journey to becoming a registered respiratory therapist (RRT).
Written by:
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
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- Pilbeam’s Mechanical Ventilation. Cairo, JM. Physiological and Clinical Applications. 8th Edition. Saunders, Elsevier. 2023.
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