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By Gary DiLorenzo, CRT, CHS
Breathe Deep Institute
When clinicians discuss medical emergencies, attention often focuses on cardiac rhythms, medications, or advanced procedures. Yet one reality remains unchanged: if a patient cannot oxygenate or ventilate, nothing else matters for long.
Airway emergencies can develop rapidly and without warning. A patient who appears stable may suddenly develop airway swelling, aspiration, excessive secretions, laryngospasm, or respiratory fatigue. Within minutes, oxygen levels fall, carbon dioxide rises, and the risk of cardiac arrest increases dramatically.
Respiratory therapists occupy a unique position during these events. While physicians may perform intubation and nurses administer medications, respiratory therapists are often the professionals most focused on maintaining oxygenation and ventilation throughout the crisis.
Successful emergency airway management is not simply about placing an endotracheal tube. It is about recognizing trouble before it occurs, maintaining oxygenation during difficult situations, understanding rescue airway options, and using physiologic monitoring tools to guide clinical decisions.
Understanding these principles can mean the difference between a controlled intervention and a life-threatening emergency.
Why Airway Management Matters
The human body can survive for extended periods without food or water, but oxygen deprivation causes irreversible damage within minutes.
Every organ depends on adequate oxygen delivery. The brain is particularly vulnerable, with permanent neurological injury possible after only a few minutes of severe hypoxia. Cardiac tissue, kidneys, and other vital organs are similarly affected when oxygen delivery is compromised.
For respiratory therapists, airway management represents one of the most important responsibilities in patient care.
Airway emergencies occur in virtually every healthcare setting:
Many cardiac arrests begin as respiratory events. Patients frequently experience hypoxia, respiratory fatigue, airway obstruction, or ventilatory failure before circulatory collapse occurs.
The best airway emergency is the one prevented through early recognition and preparation.
Recognizing the Difficult Airway Before It Becomes a Crisis
One of the most valuable skills a respiratory therapist can develop is the ability to identify a potentially difficult airway before intervention becomes necessary.
Many airway catastrophes are predictable.
Several patient characteristics should immediately raise concern:
Clinical signs may also indicate impending airway failure:
A patient struggling to maintain oxygenation despite escalating oxygen therapy deserves immediate attention.
Respiratory therapists should continuously ask themselves:
Waiting until complete airway collapse occurs significantly reduces available options.
Most difficult airways provide warning signs. The challenge is recognizing them before the emergency begins.
Bag-Mask Ventilation: The Most Underrated Airway Skill
Modern airway management often emphasizes advanced equipment and intubation techniques. Yet one of the most important lifesaving skills remains effective bag-mask ventilation.
Many patients can be adequately oxygenated and ventilated with proper bag-mask technique, buying valuable time for definitive airway management.
Common problems include:
The two-person bag-mask ventilation technique frequently provides superior results compared to a single-operator approach.
In this method, one clinician maintains a secure mask seal using both hands while a second clinician delivers ventilations. Airway positioning improves, leaks are reduced, and oxygen delivery is often more effective.
Airway adjuncts such as oral and nasal airways can further improve ventilation.
Equally important is avoiding hyperventilation.
Excessive ventilation may:
Excellent bag-mask ventilation can save lives and often determines whether an airway emergency remains controlled.
Failed Intubation: What Happens Next?
Despite preparation and expertise, not every intubation attempt succeeds.
When intubation becomes difficult, team members may focus intensely on placing an endotracheal tube while oxygen saturation continues to fall.
This is where respiratory therapists provide critical value.
The primary goal is not tube placement.
The primary goal is oxygenation.
If oxygenation can be maintained, additional options remain available.
Rescue airway strategies may include:
Examples of rescue devices include:
These devices can rapidly restore oxygenation while definitive plans are developed.
The most dangerous scenario is often the “cannot intubate, cannot oxygenate” situation. Fortunately, early recognition and preparation significantly reduce the likelihood of reaching that point.
The objective is oxygen delivery—not winning an intubation contest.
Tracheostomy Emergencies Every Respiratory Therapist Should Understand
Patients with tracheostomies present unique challenges.
Common tracheostomy emergencies include:
A mucus plug may produce sudden respiratory distress with increased airway pressures and reduced airflow.
Respiratory therapists should rapidly evaluate:
Suctioning may resolve the problem quickly. If obstruction persists, tube replacement may become necessary.
Accidental decannulation can be particularly dangerous in patients with immature tracheostomy tracts. Rapid assessment and prompt intervention are essential.
Tracheostomy emergencies often deteriorate quickly, making early recognition and decisive action critical.
The Value of Waveform Capnography During Airway Emergencies
Few technologies have improved airway management as dramatically as waveform capnography.
Capnography provides real-time information regarding ventilation and airway status that pulse oximetry alone cannot offer.
For respiratory therapists, waveform capnography assists with:
A sudden increase in ETCO₂ during CPR may indicate improving perfusion and possible ROSC.
Many of these airway management principles are explored in greater depth within the RT-ACLS™ curriculum developed through Breathe Deep Institute.
Waveform capnography is one of the most valuable monitoring tools available to respiratory therapists.
Case Study
A 62-year-old ICU patient is extubated after several days of mechanical ventilation.
Initially, the patient appears stable. Thirty minutes later, the respiratory therapist notices increasing work of breathing, rising oxygen requirements, mild stridor, and increasing anxiety.
Although oxygen saturation remains acceptable, several warning signs suggest impending airway failure.
The therapist immediately notifies the care team, prepares difficult airway equipment, and develops a contingency plan.
Within minutes, the patient's condition worsens. Because the team anticipated the problem, intervention occurs in a controlled manner rather than during a crisis.
This case highlights an important lesson:
Airway emergencies are often won or lost before the first laryngoscope is ever picked up.
Frequently Asked Questions
What is considered a difficult airway?
A difficult airway is any situation in which ventilation, oxygenation, or intubation may be challenging because of anatomy, trauma, swelling, obesity, secretions, or other patient factors.
Why is bag-mask ventilation so important?
Effective bag-mask ventilation can maintain oxygenation while definitive airway plans are developed. In many emergencies, it is the most important intervention performed.
Why is waveform capnography important?
Capnography helps verify airway placement, monitor ventilation, evaluate CPR effectiveness, and identify airway complications early.
What should a respiratory therapist do during a failed intubation?
The priority is maintaining oxygenation while assisting with rescue airway strategies, optimizing ventilation, and supporting team communication.
Can airway failure lead to cardiac arrest?
Yes. Many cardiac arrests begin with respiratory failure, severe hypoxia, or airway compromise.
Conclusion
Successful emergency airway management is rarely the result of a single heroic intervention.
Instead, success comes from preparation, anticipation, communication, and mastery of fundamental respiratory care skills.
Respiratory therapists play a critical role in recognizing airway deterioration, maintaining oxygenation, supporting ventilation, and helping teams navigate high-stakes emergencies safely.
Whether managing a difficult airway, assisting with a failed intubation, responding to a tracheostomy emergency, or interpreting waveform capnography, the respiratory therapist often serves as the clinical expert most focused on the patient's ability to breathe.
And when the airway fails, that expertise can make all the difference.
Continue Your Airway Education
Emergency airway management is one of the most critical responsibilities of the respiratory therapist. RT-ACLS™ was developed to provide respiratory-focused training that goes beyond traditional ACLS and emphasizes airway management, ventilation, capnography, and real-world code response.
To learn more about RT-ACLS™ and other respiratory education opportunities, visit A&T Respiratory Lectures and Breathe Deep Institute.
References
About the Author
Gary DiLorenzo, CRT, CHS, is a respiratory therapist with more than 25 years of experience in critical care, aviation medicine, hyperbaric medicine, emergency response, and respiratory education. He is the creator of RT-ACLS™ and founder of Breathe Deep Institute, dedicated to advancing respiratory therapist education through practical, physiology-driven training.
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