What are the principles of airway management for patients at risk of respiratory compromise in rural settings?

Airway Management Principles for Rural Settings

Core Principle: Use Only Techniques You Are Trained In

In rural settings, practitioners must prioritize reliability over sophistication—use only airway techniques in which you have demonstrated competency, as attempting unfamiliar procedures during emergencies significantly increases risk to both patients and providers. 1

Fundamental Framework: Safe, Accurate, and Swift

All airway management in resource-limited settings must follow three principles 1:

• Safe: Protect yourself and your team with appropriate preparation and equipment
• Accurate: Achieve successful airway control on the first attempt whenever possible
• Swift: Act promptly without rushing, avoiding unnecessary delays while maintaining precision

Pre-Event Institutional Preparation

Essential Equipment Stockpile

• Create a dedicated airway management trolley or pack that can be rapidly deployed and contains 1:
  • Equipment for routine airway management
  • Rescue devices for managing difficulty (second-generation supraglottic airways with high seal pressure)
  • Bag-mask ventilation equipment
  • Monitoring equipment (pulse oximetry, capnography if available)
  • Suction apparatus

Personnel Planning

• Identify the most skilled airway manager available in your facility 1
• Establish clear protocols for when to call for help or arrange transfer 2
• Conduct regular in-situ simulation training to identify system gaps before real emergencies occur 1

Immediate Assessment and Stabilization

Recognition of Airway Compromise

Pulse oximetry is a poor and late indicator of airway obstruction—decreasing oxygen saturation represents impending hypoxemia that may progress rapidly to respiratory arrest. 2 Look for:

• Accessory muscle use 3
• Respiratory alkalosis or altered mental status 3
• Increased work of breathing 4

Initial Interventions (Before Definitive Airway Control)

1. Position upright immediately (head-up 35 degrees or higher) to provide mechanical advantage to respiration and reduce aspiration risk 3, 4

2. Administer 100% oxygen with tightly fitting mask to optimize body oxygen stores before any intervention 2, 3

3. Call for help early—getting senior support or arranging transfer is a priority, not a sign of weakness 2, 1

4. Perform basic airway maneuvers (jaw thrust, chin lift) to improve patency of obstructed airway 2

Airway Management Strategy

Team Configuration

Involve the minimum number of staff necessary (typically three) 1:

• One intubator (the most experienced available)
• One assistant
• One person to administer drugs and monitor vital signs

Pre-Procedure Checklist

• Assess for difficult airway using validated tools like MACOCHA score (Malampatti, obstructive sleep apnoea, c-spine movement, mouth opening, coma, hypoxaemia, non-anaesthetist intubator) 1
• Have a clear strategy with primary plan AND rescue plans defined before starting 1
• Pre-oxygenate thoroughly with FiO₂ 1.0, aiming for end-tidal oxygen >0.9 5, 3
• Identify cricothyroid membrane by palpation before induction in case surgical airway becomes necessary 3

Device Selection Based on Training

For practitioners without advanced airway training 1:

• Use airway techniques you are trained in—do not attempt unfamiliar procedures
• Supraglottic airway (SGA) insertion takes priority over facemask ventilation to minimize aerosol generation and improve ventilation success
• Choose second-generation SGAs with high seal pressure when available (i-gel, LMA ProSeal, Ambu Aura Gain)

For practitioners with intubation training 1:

• Videolaryngoscopy improves first-pass success when available and familiar
• Use two-person, two-handed mask ventilation with VE-grip technique if bag-mask ventilation needed
• Limit intubation attempts to maximum of three—repeated attempts increase trauma and risk 3

Critical Rule: First Attempt Optimization

Focus on making the first attempt successful rather than rushing—multiple attempts increase risk to patients and expose more staff to complications. 1 Each attempt should be optimized with:

• Optimal positioning
• Adequate pre-oxygenation
• Best available equipment
• Most experienced operator

Cardiac Arrest Modifications

In cardiac arrest scenarios, airway management principles differ slightly 1:

• Early tracheal intubation with cuffed tube should be the goal when a trained airway manager is present
• Before trained help arrives, insert an SGA rather than continuing facemask ventilation to reduce aerosol generation and improve ventilation
• Use second-generation SGA with high seal pressure when available
• Minimum PPE requirements: FFP3/N95 mask, eye protection, gloves, and apron 1

Post-Intubation Care

Confirmation and Monitoring

• Waveform capnography is mandatory to confirm and continuously monitor tube placement 6
• If capnography unavailable, use multiple confirmation methods (auscultation, chest rise, condensation in tube) 6
• Continue standard monitoring: ECG, blood pressure, pulse oximetry 5

Ongoing Management

• Keep patient nil per os (NPO) as laryngeal competence may be impaired 3, 4
• Monitor respiratory rate, work of breathing, oxygen saturation, and level of consciousness 5, 4
• Arrange transfer to higher level of care if resources for ongoing management are inadequate 3

Common Pitfalls in Rural Settings

Equipment-Related Errors

• Never use single-use equipment of inferior quality simply because it's disposable—use the most reliable equipment available, even if reusable 1
• Ensure all necessary equipment is present before starting—do not begin procedure with incomplete supplies 1

Technique-Related Errors

• Avoid attempting techniques you have not used before or are not trained in—this is not the time to expand your skill set 1
• Do not delay calling for help or arranging transfer while attempting multiple failed interventions 2
• Never leave a patient with respiratory distress unattended 4

Positioning Errors

• Avoid flat or Trendelenburg positioning in patients with respiratory distress—this worsens respiratory mechanics and increases aspiration risk 4
• Do not position patient supine if they can maintain their own airway in upright position 3, 4

When to Arrange Immediate Transfer

Consider immediate transfer to higher-level facility when 3, 2:

• Predicted difficult airway exceeds your training and available equipment
• Multiple failed airway attempts have occurred
• Patient requires ongoing intensive care monitoring unavailable at your facility
• Surgical airway may be needed and expertise is not available locally

Special Consideration: Infectious Disease Precautions

While the evidence provided focuses on COVID-19, principles apply to any high-risk infectious scenario 1:

• Wear appropriate PPE (minimum: N95/FFP3 mask, eye protection, gloves, gown) and have it checked before starting
• Minimize aerosol-generating procedures
• Use smallest necessary team
• Prefer SGA over facemask ventilation when appropriate
• Apply surgical mask over oxygen delivery device post-extubation to reduce contamination risk 5