You are here: RCJournal.com » Clinical Practice Guidelines

Reprinted from the July 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(7):749–760]

AARC Clinical Practice Guideline

Management of Airway Emergencies

MAE 1.0 PROCEDURE:

Recognition of signs of an impending or actual airway emergency. Initial treatment and continued management of airway emergencies to minimize the likelihood of adverse outcomes, in adults, children, and infants.

MAE 2.0 DESCRIPTION/DEFINITION:

Management of airway emergencies (MAE) for the purpose of this guideline encompasses all care necessary to deal with sudden and often life-threatening events affecting natural and artificial airways and involves the identification, assessment, and treatment of patients in danger of losing or not being able to maintain an adequate airway, including the newborn. This includes (1) identification of the causes of airway emergencies; (2) management of airway emergencies prior to tracheal intubation; (3) use of adjunctive equipment and special techniques for establishing, maintaining, and monitoring effective ventilation; (4) translaryngeal tracheal intubation, including nasal and oral tracheal intubation; (5) transtracheal catheter ventilation, (6) percutaneous dilational cricothyrotomy, and; (7) surgical cricothyrotomy.

MAE 3.0 SETTING:

The guideline applies to a variety of settings including but not limited to hospitals and pre- or interhospital transport.

MAE 4.0 INDICATIONS:

4.1 Conditions requiring management of the airway, in general, are impending or actual (1) airway compromise, (2) respiratory failure, and (3) need to protect the airway. Specific conditions include but are not limited to
4.1.1 Airway emergency prior to endotracheal intubation
4.1.2 Obstruction of the artificial airway
4.1.3 Apnea
4.1.4 Acute traumatic coma(1)
4.1.5 Penetrating neck trauma(2)
4.1.6 Cardiopulmonary arrest and unstable dysrhythmias(3)
4.1.7 Severe bronchospasm(4-8)
4.1.8 Severe allergic reactions with cardiopulmonary compromise(9,10)
4.1.9 Pulmonary edema(11,12)
4.1.10 Sedative or narcotic drug effect(13)
4.1.11 Foreign body airway obstruction(3)
4.1.12 Choanal atresia in neonates(14)
4.1.13 Aspiration
4.1.14 Risk of aspiration
4.1.15 Severe laryngospasm(15)
4.1.16 Self-extubation(16,17)
4.2 Conditions requiring emergency tracheal intubation include, but are not limited to
4.2.1 Persistent apnea
4.2.2 Traumatic upper airway obstruction (partial or complete)(18-20)
4.2.3 Accidental extubation of the patient unable to maintain adequate spontaneous ventilation(16,17)
4.2.4 Obstructive angioedema (edema involving the deeper layers of the skin, subcutaneous tissue, and mucosa)(21-23)
4.2.5 Massive uncontrolled upper airway bleeding(2,24)
4.2.6 Coma with potential for increased intracranial pressure(25)
4.2.7 Infection-related upper airway obstruction (partial or complete)
4.2.7.1 Epiglottitis in children or adults(26,27)
4.2.7.2 Acute uvular edema(28)
4.2.7.3 Tonsillopharyngitis or retropharyngeal abscess(29)
4.2.7.4 Suppurative parotitis(30)
4.2.8 Laryngeal and upper airway edema(31)
4.2.9 Neonatal- or pediatric-specific
4.2.9.1 Perinatal asphyxia(32,33)
4.2.9.2 Severe adenotonsillar hypertrophy(34,35)
4.2.9.3 Severe laryngomalacia(36,37)
4.2.9.4 Bacterial tracheitis(38-40)
4.2.9.5 Neonatal epignathus(41,42)
4.2.9.6 Obstruction from abnormal laryngeal closure due to arytenoid masses(43)
4.2.9.7 Mediastinal tumors(44)
4.2.9.8 Congenital diaphragmatic hernia(45)
4.2.9.9 Presence of thick and/or particulate meconium in amniotic fluid(46-48)
4.2.10 Absence of airway protective reflexes
4.2.11 Cardiopulmonary arrest
4.2.12 Massive hemoptysis(49)
4.3 The patient in whom airway control is not possible by other methods may require surgical placement of an airway (needle or surgical cricothyrotomy).(20,50,51)
4.4 Conditions in which endotracheal intubation may not be possible and in which alternative techniques may be used include but are not limited to
4.4.1 restriction of endotracheal intubation by policy or statute;
4.4.2 difficult or failed intubation in the presence of risk factors associated with difficult tracheal intubations(52) such as
4.4.2.1 Short neck,(53) or bull neck(54)
4.4.2.2 Protruding maxillary incisors(53)
4.4.2.3 Receding mandible(53)
4.4.2.4 Reduced mobility of the atlanto-occipital joint(55)
4.4.2.5 Temporomandibular ankylosis(55)
4.4.2.6 Congenital oropharyngeal wall stenosis(56)
4.4.2.7 Anterior osteophytes of the cervical vertebrae, associated with diffuse idiopathic skeletal hyperostosis(57)
4.4.2.8 Large substernal and/or cancerous goiters(58)
4.4.2.9 Treacher-Collins syndrome(59)
4.4.2.10 Morquio-Brailsford syndrome(60)
4.4.2.11 Endolaryngeal tumors(61)
4.4.3 when endotracheal intubation is not immediately possible

MAE 5.0 CONTRAINDICATIONS:

Aggressive airway management (intubation or establishment of a surgical airway) may be contraindicated when the patient's desire not to be resuscitated has been clearly expressed and documented in the patient's medical record or other valid legal document.(62-64)

MAE 6.0 PRECAUTIONS/HAZARDS AND/OR COMPLICATIONS:

The following represent possible hazards or complications related to the major facets of management of airway emergencies:
6.1 Translaryngeal intubation or cricothyrotomy is usually the route of choice. It may be necessary occasionally to use a surgical airway. Controversy exists as to whether intubation is hazardous in the presence of an unstable injury to the cervical spine. In one series the incidence of serious cervical spine injury in a severely injured population of blunt trauma patients was relatively low, and commonly used methods of precautionary airway management rarely led to neurologic deterioration.(65-67)
6.1.1 Failure to establish a patent airway(68-70)
6.1.2 Failure to intubate the trachea(68,69)
6.1.3 Failure to recognize intubation of esophagus(25,68,71-81)
6.1.4 Upper airway trauma, laryngeal, and esophageal damage(82)
6.1.5 Aspiration(70,74,82,83)
6.1.6 Cervical spine trauma(67,84,85)
6.1.7 Unrecognized bronchial intubation(25,68,72,82,86,87)
6.1.8 Eye injury(70)
6.1.9 Vocal cord paralysis(88)
6.1.10 Problems with ETT tubes
6.1.10.1 Cuff perforation(89)
6.1.10.2 Cuff herniation(89)
6.1.10.3 Pilot-tube-valve incompetence(90)
6.1.10.4 Tube kinking during biting(70,89)
6.1.10.5 Inadvertent extubation(17,25,68,72,86,91-93)
6.1.10.6 Tube occlusion(17,72,82,89,93,94)
6.1.11 Bronchospasm(68,70,74)
6.1.12 Laryngospasm(72)
6.1.13 Dental accidents(70)
6.1.14 Dysrhythmias(94)
6.1.15 Hypotension and bradycardia due to vagal stimulation(94)
6.1.16 Hypertension and tachycardia(94,95)
6.1.17 Inappropriate tube size(89,96-99)
6.1.18 Bleeding
6.1.19 Mouth ulceration(82)
6.1.20 Nasal-intubation specific
6.1.20.1 Nasal damage including epistaxis
6.1.20.2 Tube kinking in pharynx
6.1.20.3 Sinusitis(100-102) and otitis media
6.1.21 Tongue ulceration
6.1.22 Tracheal damage including tracheoesophageal fistula, tracheal innominate fistula, tracheal stenosis, and tracheomalacia(103-107)
6.1.23 Pneumonia(108)
6.1.24 Laryngeal damage with consequent laryngeal stenosis,(82,101,107,109,110) laryngeal ulcer, granuloma, polyps, synechia
6.1.25 Surgical cricothyrotomy or tracheostomy specific(111,112)
6.1.25.1 Stomal stenosis(82,113)
6.1.25.2 Innominate erosion(113)
6.1.26 Needle cricothyrotomy specific(114-118)
6.1.26.1 Bleeding at insertion site with hematoma formation
6.1.26.2 Subcutaneous and mediastinal emphysema(117)
6.1.26.3 Esophageal perforation
6.2 Emergency ventilation
6.2.1 Inadequate oxygen delivery(119-121)
6.2.2 Hypo- or hyperventilation(122-124)
6.2.3 Gastric insufflation and/or rupture(125,126)
6.2.4 Barotrauma(127-129)
6.2.5 Hypotension due to reduced venous return secondary to high mean intrathoracic pressure(130-132)
6.2.6 Vomiting and aspiration(125)
6.2.7 Prolonged interruption of ventilation for intubation(3,126)
6.2.8 Failure to establish adequate functional residual capacity in the newborn(133-135)
6.2.9 Movement of unstable cervical spine (more than by any commonly used method of endotracheal intubation).(136)
6.2.10 Failure to exhale due to upper airway obstruction during percutaneous transtracheal ventilation.(118,136)

MAE 7.0 LIMITATIONS OF PROCEDURE:

Despite adequate management of airway emergencies, desired outcome may not be achieved because of the patient's underlying condition and progression of the process leading to the need for emergency airway management.

MAE 8.0 ASSESSMENT OF NEED:

The need for management of airway emergencies is dictated by the patient's clinical condition. Careful observation, the implementation of basic airway management techniques, and laboratory and clinical data should help determine the need for more aggressive measures. Specific conditions requiring intervention include
8.1 Inability to adequately protect airway (eg, coma, lack of gag reflex, inability to cough) with or without other signs of respiratory distress.
8.2 Partially obstructed airway. Signs of a partially obstructed upper airway include ineffective patient efforts to ventilate, paradoxical respiration, stridor, use of accessory muscles, patient's pointing to neck, choking motions, cyanosis, and distress. Signs of lower airway obstruction may include the above and wheezing.
8.3 Complete airway obstruction. Respiratory efforts with no breath sounds or suggestion of air movement are indicative of complete obstruction.
8.4 Apnea. No respiratory efforts are seen. May be associated with cardiac arrest.
8.5 Hypoxemia, hypercarbia, and/or acidemia seen on arterial blood gas analysis, oximetry or exhaled gas analysis.
8.6 Respiratory distress. Elevated respiratory rate, high or low ventilatory volumes, and signs of sympathetic nervous system hyperactivity may be associated with respiratory distress.

MAE 9.0 ASSESSMENT OF PROCESS AND OUTCOME:

Timely intervention to maintain the patient's airway can improve outcome in terms of survival and level of function. Under rare circumstances, maintenance of an airway by nonsurgical means may not be possible. Despite optimal maintenance of the airway, patient outcomes are affected by patient-specific factors. Lack of availability of appropriate equipment and personnel may adversely affect patient outcome. Monitoring and recording are important to the improvement of the process of emergency airway management. Some aspects (eg, frequency of complications of tracheal intubation or time to establishment of a definitive airway) are easy to quantitate and can lead to improvement in hospitalwide systems. Patient condition following the emergency should be evaluated from this perspective.

MAE 10.0 RESOURCES:

10.1 Personnel: All health professionals should be trained, evaluated at frequent intervals, and retrained as necessary in the skills of emergency clearance of foreign body airway obstruction and airway secretions. Health professionals who are primary members of resuscitation teams in acute care hospitals should be skilled in advanced management of airway emergencies, emergency cardiac care (ECC), and advanced cardiac life support (ACLS).(137)

Emergency response system-a designated resuscitation team should be continuously available (24 hours/day, 7 days/week) to assist with the management of airway emergencies. Team members should be notified simultaneously. All hospital workers must know how to activate the hospital's emergency response system.(137)

10.1.1 Level I
10.1.1.1 Training-all Level I personnel should be trained, evaluated by performance, and retrained as necessary in clearance of foreign-body airway obstruction, emergency airway-secretion evacuation techniques, and basic life support (BLS) at frequent intervals that do not exceed one year. Retraining should focus on identified deficiencies.
10.1.1.2 Responsibilities-Level I personnel are health professionals who assist the primary (Level II) members of the health-care team. They should be capable of assisting Level II personnel by (1) assessing patients for airway emergencies, respiratory, and/or cardiac arrest, (2) activating the resuscitation team, (3) administering BLS, (4) clearing the airway of foreign-body obstruction or material with the potential for obstruction, (5) providing mouth-to-mask ventilation, (6) assisting with tracheal intubation, (7) attaching pulse oximeter and capnograph, (8) moving adjunct airway equipment to the scene, (9) collecting arterial blood for analysis, (10) making a written record of resuscitation efforts.
10.1.1.3 Credentials-Level I health professionals should hold one or more of the following or equivalent credentials: RRT, CRTT, RN, MD, or DO; and have current BLS health-care provider-course completion card from the American Heart Association or a similar equivalent organization. Health professionals and hospital personnel not holding one of these Level I credentials should at a minimum be capable of assessing the patient for foreign-body airway obstruction, activating the resuscitation team, and administering BLS until the team arrives.
10.1.2 Level II
10.1.2.1 Training-Level II personnel should be trained, evaluated by performance, and retrained as necessary in advanced management of airway emergencies-ACLS and/or pediatric advanced life support (PALS) and/or neonatal resuscitation program (NRP)-as appropriate at intervals that should not exceed 1 year. To maintain operator competence, certain procedures (eg, endotracheal intubation) need to be reinforced as often as every 3 months. Retraining should focus on identified deficiencies.
10.1.2.2 Responsibilities-Level II health professionals should be capable of serving as primary members of the resuscitation team. They may respond not only to airway emergency calls in their work areas but also to other areas of the hospital. They are skilled in the use of all adjunctive equipment and special techniques for ECC/ACLS, eg, establishing, maintaining, and monitoring effective ventilation and circulation as described in more detail in the AARC Clinical Practice Guideline: Resuscitation in the Acute Care Hospital.137 They have the skills of Level I personnel and also the following capabilities: (1) advanced ECG monitoring and dysrhythmia recognition, (2) tracheal intubation and airway stabilization; (3) establishing ventilation via transtracheal catheter and cricothyrotomy; (4) emergency treatment of tension pneumothorax or hemothorax with large bore needle; (5) preparing patients for emergency transport; (6) use of continuous and transport mechanical ventilators, (7) evaluating oxygenation, ventilation and acid-base balance from blood gas reports.(138-141)
10.1.2.3 Credentials-Level II health professionals should hold one or more of the following credentials: RRT, RN, MD, or DO; and current ACLS, PALS, and/or NRP course-completion card from the American Heart Association or a similar equivalent association.
10.2 Equipment should be rapidly available and functional. Durability, portability, reliability, and cost should be considered
10.2.1 Ventilation devices should comply with the recommendations made in the AARC Guideline: Resuscitation in the Acute Care Hospital.(137)
10.2.2 Airway management devices should comply with the recommendations made in the AARC Guideline: Resuscitation in the Acute Care Hospital.137 Some other airway devices are available (eg, laryngeal mask airway, esophageal obturator airway, combination esophageal-tracheal tubes) and may be acceptable and useful although they do not provide the airway control and protection afforded by an endotracheal tube.(142)
10.2.2.1 The laryngeal mask airway (LMA) provides a low-pressure seal around the glottis. Although its size effectively prohibits its being inserted into either the trachea or the esophagus, it does not reliably protect the airway from aspirated gastric contents. It may cause less airway trauma than the endotracheal tube and less cardiovascular instability. Available in sizes 1-4, it works in children as well as adults. It may be easier to insert in patients with higher Mallampati classifications.(69,143-151)
10.2.2.2 The esophageal obturator airway/esophageal gastric tube airway (EOA/EGTA) are considered together. Although researchers originally claimed it required less time for training than the endotracheal tube, this may not be the case. It is still widely used, primarily in prehospital care of adults. There have been several reports of the effectiveness of the EOA, but comparison is difficult due to variability in patients and in the medical supervision of the systems. Complications have been reported in many studies. While some believe it to be a useful second-line airway adjunct (for keeping gas out of the stomach and stomach contents out of the pharynx), others feel that the time used for training in EOA insertion would be better spent in training for endotracheal intubation or, failing that, placing more emphasis on basic airway maintenance and ventilation.(152-163)
10.2.2.3 The pharyngeotracheal lumen airway (PTL) is a double-lumen tube that is inserted blindly into the pharynx. After the position of the tube has been assessed, the patient is ventilated through the appropriate lumen. A large pharyngeal balloon seals the airway and a smaller secondary balloon is then inflated. The published complication rate is low, but there has been relatively little evaluation of this device.(164,165)
10.2.2.4 The esophageal tracheal Combitube (ETC) is the newest airway device to be developed. It is similar to the PTL in that it is a double-lumen tube that is inserted blindly into the oropharynx; the position of the tube is assessed; and the patient is ventilated through the appropriate lumen. It has both a low reported rate of complications and few published evaluations.(24,166-172)
10.2.2.5 A 12-16 gauge intravenous catheter-over-the-needle device is used to initiate transtracheal catheter ventilation with the breathing mixture supplied at high pressure (30-50 psi). Because exhalation with this device must occur passively through the upper airway, CO2 excretion is usually inadequate. This technique has potential for providing oxygen to the patient with a partially obstructed airway.
10.2.2.6 Percutaneous dilational cricothyrotomy is performed by making a small vertical incision and advancing a cricothyrotomy tube over a guidewire and dilator.(173) If the catheter is improperly placed or becomes dislodged, ventilation and oxygenation will fail and barotrauma will occur (eg, massive subcutaneous emphysema, pneumomediastinum, pneumothorax, bleeding).
10.2.2.7 Surgical cricothyrotomy requires experience, skill, and specialized equipment and may be facilitated by a tracheal dilator or tracheal hook and a standard tracheostomy or endotracheal tube.

MAE 11.0 MONITORING:

11.1 Patient
11.1.1 Clinical signs-continuous observation of the patient and repeated clinical assessment by a trained observer provide optimal monitoring of the airway. Special consideration should be given to the following:(174)
11.1.1.1 Level of consciousness
11.1.1.2 Presence and character of breath sounds
11.1.1.3 Ease of ventilation
11.1.1.4 Symmetry and amount of chest movement
11.1.1.5 Skin color and character (temperature and presence or absence of diaphoresis)
11.1.1.6 Presence of upper airway sounds (crowing, snoring, stridor)
11.1.1.7 Presence of excessive secretions, blood, vomitus, or foreign objects in the airway
11.1.1.8 Presence of epigastric sounds
11.1.1.9 Presence of retractions
11.1.1.10 Presence of nasal flaring
11.1.2 Physiologic variables-Repeated assessment of physiologic data by trained professionals supplements clinical assessment in managing patients with airway difficulties. Monitoring devices should be available, accessible, functional, and periodically evaluated for function. These data include but are not limited to:(142,175)
11.1.2.1 Ventilatory frequency, tidal volume, and airway pressure
11.1.2.2 Presence of CO2 in exhaled gas
11.1.2.3 Heart rate and rhythm
11.1.2.4 Pulse oximetry
11.1.2.5 Arterial blood gas values
11.1.2.6 Chest radiograph
11.2 Endotracheal tube position-Regardless of the method of ventilation used, the most important consideration is detection of esophageal intubation.
11.2.1 Tracheal intubation is suggested but may not be confirmed bY
11.2.1.1 bilateral breath sounds over the chest, symmetrical chest movement, and absence of ventilation sounds over the epigastrium;(174,175,177)
11.2.1.2 presence of condensate inside the tube, corresponding with exhalation;(174,176,177)
11.2.1.3 visualization of the tip of the tube passing through the vocal cords;
11.2.1.4 Esophageal detector devices may be useful in differentiating esopha-geal from tracheal intubation.(178,179)
11.2.2 Tracheal intubation is confirmed by detection of CO2 in the exhaled gas,(180-182) although cases of transient CO2 excretion from the stomach have been reported.(183)
11.2.3 Tracheal intubation is confirmed by endoscopic visualization of the carina or tracheal rings through the tube.
11.2.4 The position of the endotracheal tube (ie, depth of insertion) should be appropriate on chest radiograph.
11.3 Airway Management Process-a properly managed airway may improve patient outcome. Continuous evaluation of the process will identify components needing improvement. These include response time, equipment function, equipment availability, practitioner performance, complication rate, and patient survival and functional status.

MAE 12.0 FREQUENCY/AVAILABILITY/ DURATION:

Because the need for management of airway emergencies occurs unpredictably, personnel need to be able to respond with the appropriate equipment within 3 minutes, 24 hours/day, 7 days/week.(184) Additionally, a person capable of airway management in the infant should be present at every delivery. A Level-II practitioner should be present at every high-risk delivery.

MAE 13.0 INFECTION CONTROL:

13.1 Implement Universal Precautions including mouth-to-barrier devices and recommendations related to avoidance of the transmission of tuberculosis and other airborne diseases.(185,186)
13.2 Observe all infection control guidelines posted for the patient.
13.3 Disinfect all equipment to be reused on other patients.

Airway Emergencies Guidelines Committee:

Thomas A Barnes EdD RRT, Chairman, Boston MA
Karen M Boudin MA RRT, Stanford CA
Charles G Durbin Jr MD, Charlottesville VA
Robert R Fluck Jr MS RRT, Syracuse NY
Cynthia Malinowski MA RRT, Loma Linda CA

REFERENCES

  1. James HE. Emergency management of acute coma in children. Am Fam Physician 1993;48(3):473-8.
  2. Eggen JT, Jorden RC. Airway management, penetrating neck trauma. J Emerg Med 1993;11(4):381-5.
  3. Emergency Cardiac Care Committee & Subcommittees, American Heart Association. Guidelines for cardio-pulmonary resuscitation and emergency cardiac care. JAMA 1992;268(16):2171-2295.
  4. National Asthma Education Program: Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. U.S. Department of Health and Human Services, Publication No, 91-3042, Aug. 1992, p. 101
  5. Westerman DE, Benatar SR, Potgieter PD, et al. Identification of the high-risk asthmatic patient: experience with 39 patients undergoing ventilation for status asthmaticus. Am J Med 1979;66:565-572.
  6. Darioli R, Perret C. Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir Dis 1984; 129:385-387.
  7. Tuxen DV, Lane S. Effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis 1987;136(4):872-879.
  8. Zimmerman JL, Dellinger RP, Shah AN, Taylor RW. Endotracheal intubation and mechanical ventilation in severe asthma. Crit Care Med 1993;21(11):1727-1730.
  9. Corren J, Schocket AL. Anaphylaxis: A preventable emergency. Postgrad Med 1990; 87(5):167-8,171-8.
  10. Owens VJ, Schuman SH, Caldwell ST. Near death of a woman stung by red imported fire ants: management of anaphylaxis. J Emerg Nurs 1991;17(3):156-61.
  11. Holmes JR, Hensinger RN, Wojtys EW. Postoperative pulmonary edema in young, athletic adults. Am J Sports Med 1991;19(4):365-71.
  12. Halow KD, Ford EG. Pulmonary edema following post-operative laryngospasm: a case report and review of the literature. Am Surg 1993;59(7):443-7.
  13. Mathew JP, Rosenbaum SH, O'Connor T, Barash PG. Emergency tracheal intubation in the postanesthesia care unit: physician error or patient disease? Anesth Analg 1990;71(6):691-7.
  14. Leiberman A, Carmi R, Bar-Ziv Y, Karplus M. Congenital nasal stenosis in newborn infants. J Pediatr 1992; 120(1):124-7.
  15. Quan L. Drowning issues in resuscitation. Ann Emerg Med 1993;22(2 Pt 2):366-369.
  16. Woodmansee VA, Rodriguez A, Mirvis S, Fitzgerald B. Genioglossus hemorrhage after blunt facial trauma. Ann Emerg Med 1992;21(4):440-444
  17. Thaller SR, Beal SL. Maxillofacial trauma: a potentially fatal injury. Ann Plast Surg 1991;27(3):281-283.
  18. Dolin J, Scalea T, Mannor L, Sclafani S, Trooskin S. The management of gunshot wounds to the face. J Trauma 1992;33(4):508-514; discussion 514-515.
  19. Coppolo DP, May JJ. Self-extubations. A 12-month experience. Chest 1990;98(1):165-169.
  20. Black AE, Hatch DJ, Nauth-Misir N. Complications of nasotracheal intubation in neonates, infants and children: a review of 4 years' experience in a children's hospital. J Anaesth 1990;65:461-467.
  21. Roberts JR, Wuerz RC. Clinical characteristics of angiotensin-converting enzyme inhibitor-induced angioedema. Ann Emerg Med 1991;20(5):555-558.
  22. Barna JS, Frable MA. Life-threatening angioedema. Otolaryngol Head Neck Surg 1990;103(5)(Pt 1):795-798.
  23. Thompson T, Frable MA. Drug-induced, life-threatening angioedema revisited. Laryngoscope 1993;103(1)(Pt 1):10-12.
  24. Klauser R, Roggla G, Pidlich J, Leithner C, Frass M. Massive upper airway bleeding after thrombolytic therapy: successful airway management with the Combitube. Ann Emerg Med 1992;21(4):431-433.
  25. Nakayama DK, Gardner MJ, Rowe MI. Emergency endotracheal intubation in pediatric trauma. Ann Surg 1990;211(2):218-23.
  26. Mayo-Smith M. Fatal respiratory arrest in adult epiglottitis in the intensive care unit: implications for airway management. Chest 1993;104(3):964-965.
  27. Andreassen UK, Baer S, Nielsen TG, Dahm SL, Arndal H. Acute epiglottitis-25 years experience with nasotracheal intubation, current management policy and future trends. J Laryngol Otol 1992;106(12):1072-1075.
  28. Goldberg R, Lawton R, Newton E, Line WS Jr. Evaluation and management of acute uvular edema. Ann Emerg Med 1993;22(2):251-255.
  29. Stevenson DS, Webster G, Stewart IA. Acute tonsillectomy in the management of infectious mononucleosis. J Laryngol Otol 1992;106(11):989-991.
  30. Saunders PR, Macpherson DW. Acute suppurative parotitis: a forgotten cause of upper airway obstruction. Oral Surg Oral Med Oral Pathol 1991;72(4):412-414.
  31. Clark WR Jr. Smoke inhalation: diagnosis and treatment. World J Surg 1992;16(1):24-29.
  32. Jacobs MM, Phibbs RH. Prevention, recognition, and treatment of perinatal asphyxia. Clin Perinatol 1989; 16(4):785-807.
  33. Hill A, Volpe JJ. Perinatal asphyxia: clinical aspects. Clin Perinatol 1989;16(2):435-457.
  34. Livesey JR, Solomons NB, Gillies EA. Emergency adenotonsillectomy for acute postoperative upper airway obstruction. Anaesthesia 1991;46(1):36-37.
  35. Shechtman FG, Lin PT, Pincus RL. Urgent adenotonsillectomy for upper airway obstruction. Int J Pediatr Otorhinolaryngol 1992;24(1):83-89.
  36. Marcus CL, Crockett DM, Ward SL. Evaluation of epiglottoplasty as treatment for severe laryngomalacia. J Pediatr 1990;117(5):706-710.
  37. Gonzalez C. Synchronous airway lesions in infancy. Ann Otol Rhinol Laryngol 1987;96:77-80.
  38. Seigler RS. Bacterial tracheitis: recognition and treatment. J S C Med Assoc 1993;89(2):83-87.
  39. Donnelly BW, McMillan JA, Weiner LB. Bacterial tracheitis: report of eight new cases and review. Rev Infect Dis 1990;12(5):729-735.
  40. Tan AK, Manoukian JJ. Hospital croup (bacterial and viral): the role of rigid endoscopy. J Otolaryngol 1992;21(1):48-53.
  41. Catalano PJ, Urken ML. Alvarez M, Norton K, Wedgewood J, Holzman I, Biller HF. New approach to the management of airway obstruction in "high risk" neonates. Arch Otolaryngol Head Neck Surg 1992;118(3):306-309.
  42. Maeda K, Yamamoto T, Yoshimura H, Itoh H. Epignathus: a report of two neonatal cases. J Pediatr Surg 1989;24:395-397.
  43. Ruggins NR, Milner AD. Site of upper airway obstruction in infants following an acute life-threatening event. Pediatrics 1993;91(3):595-601.
  44. Mogilner JG, Fonseca J, Davies MR. Life-threatening respiratory distress caused by a mediastinal teratoma in a newborn. J Pediatr Surg 1992;27(12):1519-1520.
  45. Jain L, Vidyasagar D. Cardiopulmonary resuscitation of newborns. Pediatr Clin North Am 1993;40(2):287-303.
  46. Carson B, Losey R, Bowes W, Simmons M. Combined obstetric and pediatric approach to prevent meconium aspiration syndrome. Am J Obstet Gynecol 1976;126:712.
  47. Falciglia H. Failure to prevent meconium aspiration syndrome. Obstet Gynecol 1988;71:349.
  48. Wiswell TE, Tuggle JM, Turner BS. Meconium aspiration syndrome: have we made a difference? Pediatrics 1990;85:715-721.
  49. Stoller JK. Diagnosis and management of massive hemoptysis: A Review. Respir Care 1992;37(6):564-581.
  50. Xeropotamos NS, Coats TJ, Wilson AW. Prehospital surgical airway management: 1 year's experience from the Helicopter Emergency Medical Service. Injury 1993;24(4):222-224.
  51. De Laurier GA, Hawkins ML, Treat RC, Mansberger AR Jr. Acute airway management: Role of cricothyroidotomy. Am Surg 1990;56(1):12-15.
  52. Atherton GL, Johnson JC. Ability of paramedics to use the Combitube in prehospital cardiac arrest. Ann Emerg Med 1993 Aug;22(8):1263-1268.
  53. Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992;77(1):67-73.
  54. Banyai M, Falger S, Röggla M, Brugger S, Staudinger T, Klauser R, Müller-Spoljaritsch C, et al. Emergency intubation with the Combitube in a grossly obese patient with bull neck. Resuscitation 1993;26(271-276.
  55. Pothmann W; Eckert S; Fullekrug B. [Use of the laryngeal mask in difficult intubation] [Einsatz der Kehlkopfmaske bei schwieriger Intubation.] Anesthetist 1993;42(9):644-7.
  56. Uchiumi R, Itou K, Miyamoto M, Oda S, Taniguchi K, Honda N. [Congenital oropharyngeal wall stenosis: a case of difficult endotracheal intubation] Masui 1993;42(2):292-295.
  57. American Society of Anesthesiologists. Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology 1993;78(3):597-602.
  58. Lacoste L, Gineste D, Karayan J, Montaz N, Lehuede MS, Girault M, Bernit AF, Barbier J, Fusciardi J. Airway complications in thyroid surgery. Ann Otol Rhinol Laryngol 1993;102(6):441-446.
  59. Kovac AL. Use of the Augustine stylet anticipating difficult tracheal intubation in Treacher-Collins syndrome. J Clin Anesth 1992;4(5):409-412.
  60. Tzanova I, Schwarz M, Jantzen JP. Securing the airway in children with the Morquio-Brailsford syndrome] [Die Sicherung der Atemwege von Kindern mit Morquio-Brailsford-Syndrom.] Anesthetist 1993;42(7):477-481.
  61. Ebeling BJ, Straehler-Pohl HJ. [A difficult intubation in a case of endolaryngeal paraganglioma] [Erschwerte Intubation bei endolaryngealem Paragangliom.] Anesthetist 1992;41(4):221-223.
  62. Sachs GA, Miles SH, Levin RA. Limiting resuscitation: emerging policy in the emergency medical system. Ann Intern Med 1991;114:151-154.
  63. Torian LV, Davidson EJ. Fillit HM, Fulop G, Sell LL. Decisions for and against resuscitation in an acute geriatric medicine unit serving the frail elderly. Arch Intern Med 1992;152:561-565.
  64. Stern SG, Orlowski JP. DNR or CPR-the choice is ours. Crit Care Med 1992;20(9):1263-1272.
  65. Wright SW, Robinson GG 2d, Wright MB. Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation. Am J Emerg Med 1992;10(2):104-109.
  66. Kellman R. The cervical spine in maxillofacial trauma: Assessment and airway management. Otolaryngol Clin North Am 1991;24(1):1-13.
  67. Suderman VS, Crosby ET, Lui A. Elective oral tracheal intubation in cervical spine-injured adults. Can J Anaesth 1991;38(6):785-789.
  68. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse events in anesthesia: a closed claims analysis. Anesthesiology 1990;(5):828-833.
  69. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. Anesthesiology 1995;82(2):367-376.
  70. Cheney FW, Posner KL, Caplan RA. Adverse respiratory events infrequently leading to malpractice suits: a closed claims analysis. Anesthesiology 1991;75(6):932-939.
  71. Sum Ping ST, Mehta MP, Symreng T. Accuracy of the FEF CO2 detector in the assessment of endotracheal tube placement. Anesth Analg 1992;74:415-419.
  72. Coté CJ, Rolf N, Liu LMP, Goudsouzian NG, Ryan JF, Ryan JF et al. A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology 1991;74(6):980-987.
  73. Holland R, Webb RK, Runciman WB. Oesophageal intubation: an analysis of 2000 incident reports. Anaesth Intens Care 1993;21(5):608-610.
  74. Williamson JA, Webb RK, Cockings J, Morgan C. The capnograph: applications and limitations-an analysis of 2000 incident reports. Anaesth Intens Care 1993;21(5):551-557.
  75. Leon MA, Räsänen J, Mangar D. Neural network-based detection of esophageal intubation. Anesth Analg 199478:548-553.
  76. Sprung J, Hunter K, Barnas GM, Bourke DL. Abdominal distention is not always a sign of esophageal intubation: cardiac arrest due to "Auto-PEEP." Anesth Analg 1994;78:801-804.
  77. Salem MR, Wafai Y, Baraka A, Taimorrazy B, Joseph NJ, Nimmagadda U. Use of the self-inflating bulb for detecting esophageal intubation after "esophageal ventilation." Anesth Analg 1993;77:1227-1231.
  78. Salem MR, Wafai Y, Joseph NJ, Baraka A, Czinn EA. Efficacy of the self-inflating bulb in detecting esophageal intubation: does the presence of a nasogastric tube or cuff deflation make a difference? Anesthesiology 1994;80(1):42-48.
  79. Zaleski L, Abello D, Gold MI. The esophageal detector device. Anesthesiology 1993;79(2):244-247.
  80. Foutch RG, Magelssen MD, MacMillan JG. The esophageal detector device: a rapid and accurate method for assessing tracheal versus esophageal intubation in a porcine model. Ann Emerg Med 1992;21(9):1073-1076.
  81. Oberly D, Stein S, Hess D, Eiterl D, Simmons M. An evaluation of the esophageal detector device using a cadaver model. Am J Emerg Med 1992;10(4):317-320.
  82. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy: a prospective study of 150 critically ill adult patients. Am J Med 1981;70(1):65-76.
  83. Goodwin SR. Aspiration in intubated premature infants. Pediatrics 1985;75:85-88.
  84. Hastings RH, Marks JD. Airway management for trauma patients with potential cervical spine injuries. Anesth Analg 1991;73:471-482.
  85. Rhee KJ, Green W, Holcroft JW, Mangili JAA. Oral intubation in the multiply injured patient: the risk of exacerbating spinal cord damage. Ann Emerg Med 1990;19(5):511-514.
  86. Rivera R, Tibballs. Complications of endotracheal intubation and mechanical ventilation in infants and children. Crit Care Med 1992;20:193-199.
  87. Owen RL, Cheney FW. Endobronchial intubation: a preventable complication. Anesthesiology 1987;67:255-257.
  88. Smith RB, Schaer WB, Pfaeffle H. Percutaneous transtracheal ventilation for anaesthesia and resuscitation: a review and report of complications. Can Anaesth Soc J 1975;22(5)607-612.
  89. Szekely SM, Webb RK, Williamson JA, Russell WJ. Problems related to the endotracheal tube: an analysis of 2000 incident reports. Anaesth Intens Care 1993;21(5): 611-616.
  90. Heusner JE, Viscomi CM. Endotracheal tube cuff failure due to valve damage (letter). Anesth Analg 1991;72: 262-270.
  91. Franck LS, Vaughan B, Wallace J. Extubation and reintubation in the NICU: identifying opportunities to improve care. Pediatric Nursing 1992;18(3):267-270.
  92. Little LA, Koenig JC, Newth CJ. Factors affecting accidental extubations in neonatal and pediatric intensive care patients. Crit Care Med 1990;18:163-165.
  93. Russomanno JH, Brown LK. Pneumothorax due to ball-valve obstruction of an endotracheal tube in a mechanically ventilated patient. Chest 1992;101(5):1444-1445.
  94. Blanc VF, Tremblay NAG. The complications of tracheal intubation: a new classification with a review of the literature. Anesth Analg 1974;53(2):202-213.
  95. Kaplan JD, Schuster DP. Physiologic consequences of tracheal intubation. Clin Chest Med 1991;12(3)425-432.
  96. Belfort M, Kirshon B, Bowen R, Gouveia C, Hickman R. The cardiovascular and intracranial effects of laryngoscopy and endotracheal intubation in hypercarbic neonatal piglets. S Afr Med J 1993;83(2):117-121.
  97. Davis Kenneth Jr, Branson RD, Porembka D. A Comparison of the Imposed Work of Breathing with endotracheal and tracheostomy tubes in a lung model. Respir Care 1994;39(6):611-616.
  98. Shapiro M, Wilson K, Casar G, Bloom K, Teague RB. Work of breathing through different sized endotracheal tubes. Crit Care Med 1986;14(12)1028-1031.
  99. Bolder PM, Healy TE, Bolder AR, Beatty PC, Kay B. The extra work of breathing through adult endotracheal tubes. Anesth Analg 1986;65(8):853-859.
  100. Bishop MJ. Mechanisms of laryngotracheal injury following prolonged tracheal intubation. Chest 1989; 96(1):185-186.
  101. Holzapfel L, Chevret S, Madinier G, Ohen F, Demingeon G, Coupry A, et al. Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective randomized clinical trial. Crit Care Med 1993;21(8):1132-1138.
  102. Salord F, Gaussorgues P, Marti-Flich J, Sirodot M, Allimant C, Lyonnet D et al. Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route for intubation. Intensive Care Med 1990;16:390-393.
  103. Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Crit Care Med 1991;19(3):352-355.
  104. Gould SJ, Young M. Subglottic ulceration and healing following endotracheal intubation in the neonate: a morphometric study. Ann Otol Rhinol Laryngol 1992; 101(10):815-820.
  105. Kastanos N, Miro RE , Perez AM, Mir AX, Agusti-Vidal A. Laryngotracheal injury due to endotracheal intubation: incidence, evolution, and predisposing factors. A Prospective long-term study. Crit Care Med 1983; 11(5):362-367.
  106. Payne DK, Anderson WMcD, Romero MD, Wissing DR, Fowler M. Tracheoesophageal fistula formation in intubated patients: risk factors and treatment with high-frequency jet ventilation. Chest 1990;98(1):161-164.
  107. Abbey NC, Green DE, Cicale MJ. Massive tracheal necrosis complicating endotracheal intubation (case report). Chest 1989;95(2):459-460.
  108. Hansen M, Poulsen MR, Bendixen DK, Hartmann-Andersen F. Incidence of sinusitis in patients with nasotracheal intubation. Br J Anesth 1988;61:231-232.
  109. Niederman MS, Craven DE, Fein AM, Schultz DE. Pneumonia in the critically ill hospitalized patient. Chest 1991;97(1):170-181.
  110. Benjamin B. Prolonged intubation injuries of the larynx: endoscopic diagnosis, classification, and treatment. Ann Otol Rhinol Laryngol (suppl) 1993;160:1-15.
  111. Bishop MJ, Weymuller EA, Fink BR. Laryngeal effects of prolonged intubation. Anesth Analg 1984;63:335-342.
  112. McGill J, Clinton JE, Ruiz E. Cricothyrotomy in the emergency department. Ann Emerg Med 1982;11(7): 361-364.
  113. Spaite DW, Joseph M. Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome. Ann Emerg Med 1990;19(3):279-285.
  114. Wood DE, Mathisen DJ. Late complications of tracheotomy. Clin Chest Med 1991;12(3)597-608.
  115. Barriot P, Riou B. Retrograde technique for tracheal intubation in trauma patients. Crit Care Med 1988; 16(7):712-713.
  116. Schapera A, Bainton CR, Kraemer R, Lee K. A pressurized injection/suction system for ventilation in the presence of complete airway obstruction. Crit Care Med 1994;22(2):326-333.
  117. Zornow MH, Thomas TC, Scheller MS. The efficacy of three different methods of transtracheal ventilation. Can J Anaesth 1989;36(6):624-628.
  118. Bowes WA, Johnson JO. Pneumomediastinum after planned retrograde fiberoptic intubation. Anesth Analg 1994;78:795-797.
  119. Campbell TP, Stewart RD, Kaplan RM, DeMichiei RV, Morton R. Oxygen enrichment of bag-valve-mask units during positive-pressure ventilation: a comparison of various techniques. Ann Emerg Med 1988;17: 232-235.
  120. Barnes TA, Potash R. Evaluation of five adult disposable operator-powered resuscitators. Respir Care 1989;34:254-261.
  121. Barnes TA, McGarry WP III. Evaluation of ten disposable manual resuscitators. Respir Care 1990;35: 960-968.
  122. Johannigman JA, Branson RD. Oxygen enrichment of expired gas for mouth-to-mask resuscitation. Respir Care 1991;36:99-103.
  123. Hess D, Goff G, Johnson K. The effect of hand size, resuscitator brand, and use of two hands on volumes delivered during adult bag-valve ventilation. Respir Care 1989;34:805-810.
  124. Fluck RR Jr, Sorbello JG. Comparison of tidal volumes, minute ventilation, and respiratory frequencies delivered by paramedic and respiratory care students with pocket mask versus demand valve. Respir Care 1991;36(10): 1105-1112.
  125. Barnes TA, Stockwell DL. Evaluation of ten manual resuscitators across an operational temperature range of -18°ree;C to 50°ree;C. Respir Care 1991;36:161-172.
  126. Nagel EL, Fine EG, Krischer JP, Davis JH. Complications of CPR. Crit Care Med 1981;9:424.
  127. Hargarten KM, Aprahamian C, Mateer J. Pneumoperitoneum as a complication of cardiopulmonary resuscitation. Am J Emerg Med 1988;6:358-361.
  128. Hillman K, Albin M. Pulmonary barotrauma during cardio-pulmonary resuscitation. Crit Care Med 1986; 14(7):606-609.
  129. Madansky DL, Lawson EE, Chernick V, Taeusch HW Jr. Pneumothorax and other forms of pulmonary air leak in newborns. Am Rev Respir Dis 1979;120:729-737.
  130. Primhak RA. Factors associated with pulmonary air leak in premature infants receiving mechanical ventilation. J Pediatr 1983;102:764-768.
  131. Cournand A, Motley HL, Werko L, Richards DW. Physiological studies of the effects of intermittent positive pressure breathing on cardiac output in man. Am J Physiol 1948;15:162-174.
  132. Venus B, Jacobs HK, Mathru M. Hemodynamic responses to different modes of mechanical ventilation in dogs with normal and acid aspirated lungs. Crit Care Med 1980;8:620-627.
  133. Hull D. Lung expansion and ventilation during resuscitation of asphyxiated newborn infants. J Pediatr 1969;75 (1):47-58.
  134. Milner AD, Vyas H, Hopkin IE. Efficacy of face mask resuscitation at birth. Br Med J Clin Res Ed 1984; 289:1563-1565.
  135. Boon AW, Milner AD, Hopkin IE. Lung expansion, tidal exchange, and formation of the functional residual capacity during resuscitation of asphyxiated neonates. J Pediatr 1979;95(6):1031-1036.
  136. Hauswald M, Sklar DP, Tandberg D, Garcia JF. Cervical spine movement during airway management: cinefluoroscopic appraisal in human cadavers. Am J Emerg Med 1991;9(6):535-538.
  137. American Association for Respiratory Care. Clinical Practice Guideline: resuscitation in the acute care hospital. Respir Care 1993;38(12):1179-1188.
  138. American Association for Respiratory Care. AARC Guideline: in vitro pH and blood gas analysis and hemoximetry. Respir Care 1993;38(5):505-510.
  139. American Association for Respiratory Care. AARC Guideline: oxygen therapy in the acute care hospital. Respir Care 1991;36(12):1410-1413.
  140. American Association for Respiratory Care. AARC Guideline: transport of the mechanically ventilated patient. Respir Care 1993;38:1169-1172.
  141. American Association for Respiratory Care. AARC Guideline: Pulse oximetry. Respir Care 1991;36(12): 1406-1409.
  142. Pepe PE, Zachariah BS, Chandra NC, and members of the Invasive Airway Techniques in Resuscitation. Invasive airway techniques in resuscitation. Ann Emerg Med 1993;22(2, Part 2):393-403.
  143. American Association for Respiratory Care. Clinical Practice Guideline: Resuscitation in the acute care hospital. Respir Care 1993;38(1179-1188).
  144. Brain AIJ. The laryngeal mask-a new concept in airway management. Br J Anaesth 1983;55:801-804.
  145. Brain AIJ, McGhee TD, McAteer EJ, Thomas A, Abu-Saad MAW, Bushman JA. The laryngeal mask airway: development and preliminary trials of a new type of airway. Anaesthesia 1985;40:356-361.
  146. Brimacombe J. Laryngeal mask airway: tool for airway management. J Post Anesth Nurs 1993;8(2):88-95.
  147. Mason DG, Bingham RM. The laryngeal mask airway in children. Anaesthesia 1990;45:760-763.
  148. Calder I, Ordman AJ, Jackowski, Crockard HA. The Brain laryngeal mask airway: an alternative to emergency tracheal intubation. Anaesthesia 1990;45:137-139.
  149. Maltby JR, Loken RG, Watson NC. The laryngeal mask airway: clinical appraisal in 250 patients. Can J Anaesth 1990;37(5):509-513.
  150. Martin PD, Cyna AM, Hunter WAH, Henry J, Ranayya GP. Training nursing staff in airway management for resuscitation: a clinical comparison of the face mask and laryngeal mask. Anaesthesia 1993;48:33-37.
  151. Dubreuil M, Laffon M, Benoit P, Penon C, Ecoffey C. Complications and fiberoptic assessment of size 1 laryngeal mask airway . Anesth Analg 1993;76(3):527-529.
  152. Johnston DF. The laryngeal mask airway in paediatric anaesthesia. Anesthesia 1990;45:924-927.
  153. Lavies NG. Use of the laryngeal mask airway in neonatal resuscitation. Anesthesia 1993;48(4):352.
  154. Schofferman J, Oill P, Lewis AJ. The esophageal obturator airway: a clinical evaluation. Chest 1976;69:(1):67-71.
  155. Strate RG, Fischer RP. Midesophageal perforations by esophageal obturator airways. J Trauma 1976;16(6): 503-509.
  156. Grigsby JW, Rottman SJ. Prehospital airway management: esophageal obturator airway or endotracheal intubation? Ann Emerg Med 1981;3(1):25-29.
  157. Bass RR, Allison EJ Jr, Hunt RC. The esophageal obturator airway: a reassessment of use by paramedics. Ann Emerg Med 1982;11(7):358-360.
  158. Donen N, Tweed WA, Dashfsky S, Guttormson B. The esophageal obturator airway: an appraisal. Can Anesth Soc J 1983;30(2):194-200.
  159. Smith JP, Bodai BI, Aubourg R, Ward RE. A field evaluation of the esophageal obturator airway. J Trauma 1983;23(4):317-321.
  160. Smith JP, Bodai BA, Seifkin A, Palder S, Thomas V. The esophageal obturator airway: a review. JAMA 1983; 250(8, Aug 26):1081-1084.
  161. Auerbach PS, Geeher EC. Inadequate oxygenation and ventilation using the esophageal gastric tube airway in the prehospital setting. JAMA 1983;250(22, Dec 9): 3067-3071.
  162. Shea SR, MacDonald JR, Gruzinski. Prehospital endotracheal tube airway or esophageal gastric tube airway: a critical comparison. Ann Emerg Med 1985;14(2):102-112.
  163. Gertler JP, Cameron DE, Shea K, Baker CC. The esophageal obturator airway: obturator or obtundator? J Trauma 1985;25(5):424-426.
  164. Hammargren Y, Clinton JE, Ruiz E. A standard of comparison of esophageal obturator airway and endotracheal tube ventilation in cardiac arrest. Ann Emerg Med 1976; 14(4):953-958.
  165. Goldenberg IF, Campion BC, Siebold CM, McBride JW, Long LA. Esophageal gastric tube airway vs endotracheal tube in prehospital cardiopulmonary arrest. Chest 1986;90(1):90-96.
  166. Niemann JT, Rosborough JP, Myers R, Scarberry EN. The pharyngeo-tracheal lumen airway: preliminary investigations of a new adjunct. Ann Emerg Med 1984; 13(8):591-596.
  167. Bartlett RL, Martin SD, McMahon JM, Schafermeyer RW, Vukich DJ, Hornung CA. A field comparison of the pharyngeotracheal lumen airway and the endotracheal tube. J Trauma 1992;32(3):280-284.
  168. Frass M, Frenzer R, Rauscha F, Weber H, Pacher R, Leithner C. Evaluation of esophageal tracheal Combitube in cardiopulmonary resuscitation. Crit Care Med 1986;15(6)609-611.
  169. Frass M, Frenzer R, Rauscha F, Schuster EE, Glogar D. Ventilation with the esophageal tracheal Combitube in cardiopulmonary resuscitation: promptness and effectiveness. Chest 1988;93(4):781-784.
  170. Frass M, Rodler S, Frenzer R, Ilias W, Leithner C, Lackner F. Esophageal tracheal Combitube, endotracheal airway, and mask: comparison of ventilatory pressure curves. J Trauma 1989;29(11):1476-1479.
  171. Bigenzahn W, Pesau B, Frass M. Emergency ventilation using the Combitube in cases of difficult intubation. Euro Arch Otol Rhino Laryngol 1991;248:129-131.
  172. Eichenger S, Schreiber W, Heinz T, Kier P, Dufek V, Goldin M et all. Airway management in a case of neck impalement: use of the oesophageal tracheal Combitube airway. Br J Anaesth 1992;68:534-535.
  173. Staudinger T, Brugger S, Watschinger B, Röggla M, Dielacher C, Löbl T et al. Emergency intubation with the Combitube: comparison with the endotracheal airway. Ann Emerg Med 1993;22(10):1573-1575.
  174. American Heart Association. Adjuncts for airway control, ventilation, and oxygenation. In: Textbook of advanced cardiac life support. Dallas: American Heart Association 1994:2.12, 2.13.
  175. Birmingham PK, Cheney FW, Ward RJ. Esophageal intubation: a review of detection techniques. Anesth Analg 1986;65(8):886-891.
  176. Stone DJ, Bogdonoff DL. Airway considerations in the management of patients requiring long-term endotracheal intubation. Anesth Analg 1992;74:276-287.
  177. McShane AJ, Martin JL. Preoxygenation and pulse oximetry may delay detection of esophageal intubation. J Natl Med Assoc 1987;79(9):991-992.
  178. Howells TH, Riethmuller RJ. Signs of endotracheal intubation. Anaesthesia 1980;35(10):984-986.
  179. Wee MYK. The oesophageal detector device: assessment of a new method to distinguish oesophageal from tracheal intubation. Anaesthesia 1988;43:27-29.
  180. Andersen KH, Hald A. Assessing the position of the tracheal tube. The reliability of different methods. Anaesthesia 1989;44(12):985-985.
  181. MacLeod BA, Heller MB, Gerard J, Yealy DM, Menegazzi JJ. Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection. Ann Emerg Med 1991;20(3):267-270.
  182. Bhende MS, Thompson AEE, Cook DR, Saville AL. Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children. Ann Emerg Med 1992;21(2):142-145.
  183. Linko K, Paloheimo M. Capnography facilitates blind nasotracheal intubation. Acta Anaesthesiol Belg 1983;34(2):117-122.
  184. Sum-Ping ST, Mehta MP, Symreng T. Reliability of capnography in identifying esophageal intubation with carbonated beverage or antacid in the stomach. Anesth Analg 1991;73(3):333-337.
  185. Eisenberg MS, Hallstrom A, Bergner L. Long-term survival after out-of-hospital cardiac arrest. N Engl J Med 1982;306(22):1340-1343.
  186. Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-382,387-388.
  187. Centers for Disease Control/ Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related tissues. MMWR 1990;39(RR-17):1-29.

Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.

Reprinted from the July 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(7):749–760]

You are here: RCJournal.com » Clinical Practice Guidelines