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The Airway Assistant



The Airway Assistant

If intubation is not part of your scope of practice, the whole procedure may feel foreign. This is especially true if you work in a crew configuration that does not include a paramedic. Perhaps you’ve experienced a situation like this: you call for an ALS intercept, the crew arrives, performs what seems like a thousand tasks quickly, intubates the patient, and then they’re gone. These situations might leave you with at least a few questions:

  •  How do they know which patients need an advanced airway?

  •  How do they prepare for and perform the procedure?

  •  What are the critical red flags to watch out for?

  •  And, most relevant to this blog, how can you assist in a meaningful way?


Who needs an advanced airway?

If a patient fails to do two things, they are likely in need of an advanced airway (Brown et al., 2018; Walz et al., 2016). Those two things are:

  1. Phonation (making purposeful sounds)

  2. Clearing their secretions (swallowing/clearing the throat)


There are other indications, such as a poor predicted clinical course. If they’re sick and seem to be getting sicker (including not oxygenating or ventilating well), an advanced airway may be in the patient’s future if the condition is not reversible (Alvarado & Panakos, 2023).


As for preparation and performing the intubation procudre, doesn’t always happen in a strict linear fashion, and some parts may occur simultaneously; however, we can break it down into rough phases. 


The phases:

Positioning and Opening the Airway

As long as there are no spinal precautions, the patient should be placed into a head-elevated sniffing position (Whitten, 2013). This has several advantages for the entire intubation procedure, including improving lung volume and facilitating any necessary ventilation. With the head of the bed elevated at 15-30º, in the ear-to-sternal notch (sniffing) position, and the face flat against the ceiling, the patient is in an optimal position to oxygenate, ventilate, and intubate (Whitten, 2013).


Running Checklist:

  1. -> Positioned in a head-elevated sniffing position.

  2. -> A simple airway is in place if needed.



Pre-oxygenation and ‘de-nitrogenation’ 

The basic principle of this phase is to get as much of the lung filled with pure oxygen, and as little nitrogen as possible. If the patient is breathing adequately on their own, this can be performed with a nasal cannula set to high flow and a mask placed over the top (or possibly even CPAP) (Oliveira et al., 2017). If the patient has inadequate respiratory rate or tidal volume, a good two-hand seal with a BVM is recommended. The nasal cannula is the foundation, since this should stay in place throughout the intubation process for apneic-oxygenation (‘Ap-Ox’).


Running Checklist: 

  1. Positioned in a head-elevated sniffing position.

  2. A simple airway is in place if needed.

  3.   -> If respiratory effort is adequate, NC at high-flow + mask.

  4.   -> If inadequate: BVM (with PEEP+ETCO2) and NC under mask (2-hand seal).


Equipment Preparation

Depending on your ambulance configuration, the amount of necessary equipment at your disposal will vary. At a minimum, have suction on and ready for use, tucked under the pillow (especially if the patient is receiving BVM ventilation) (Higgs et al., 2018; Whitten, 2013). If you have any supraglottic airway and any securing device for it, set that out as well. If it’s within your scope, place an IV or IO, if not already done, as this will be needed for induction medications. If you’re able to set up IV/IO access, start a maintenance infusion and prepare some medication supplies, such as needles, syringes of various sizes, and ETOH/scrub hubs, in anticipation of the induction medications.


Essential equipment to set out (if not already on/in the patient):

  • Simple airways

  • Suction on and ready

  • SGA and a securing device

  • IV/IO access


Complete equipment list if configuration allows (in addition to the above):

  • Endotracheal tubes of various sizes and a securing device around the patient’s neck ready for use

  • 10mL syringe (attached to the tube to be used)

  • Stylet and Bougie (inside of the tube or other configuration per request of the intubating clinician)

  • Laryngoscope and blades

  • Knowledge of the location of the surgical airway kit as a secondary backup


Running Checklist: 

  1. Positioned in a head-elevated sniffing position.

  2. A simple airway is in place if needed.

  3. If respiratory effort is adequate, NC at high-flow + mask.

  4. If inadequate: BVM (with PEEP+ETCO2) and NC under mask (2-hand seal).

  5.   -> Equipment is set out, organized, and kept clean.


Medication Preparation

Depending on how your service operates, medications outside of your scope of practice may be off-limits for handling. Regardless of who handles the medications, having an accurate weight and height will be very helpful for the person administering them. Weight helps with weight-based dosing, and height provides the ability to figure out an ideal body weight (based on height and sex) if a ventilator will be used. Even if you’re not the person drawing up and administering the medications, you want to be competent with basic medication math so that you can be used as a reliable second set of eyes. A common case would be confirming a medication such as ketamine:


500mg in 5mL would equal 100mL per mL (500 / 5 = 100). If the patient weighs 80 kg and is receiving 2 mg per kg, how much volume should they receive? 80 × 2 = 160, and there is 100 mg per mL. This means they would need 1.6 mL (160 mg) of ketamine.


Having a dosing chart, calculator, or protocol to fact-check these doses is considered best practice; however, you should at least be familiar with how to double-check another clinician’s medication math. Basic math is not outside of anyone’s scope of practice.


Another integral skill closely related to confirming dosing is knowing how to label syringes correctly (Alvarado & Panakos, 2023). All medications should be clearly labeled to prevent confusion (confusing the sedative syringe for the paralytic syringe would be a very poor misstep). Building on our ketamine example, the syringe would be labeled with the name of the medication and the concentration from the vial: “KETAMINE 100mg/mL”. Tape and a Sharpie work great for this; just be sure not to obscure the graduations on the vial when labeling the syringe.


Running Checklist: 

  1. Positioned in a head-elevated sniffing position.

  2. A simple airway is in place if needed.

  3. If respiratory effort is adequate, NC at high-flow + mask.

  4. If inadequate: BVM (with PEEP+ETCO2) and NC under mask (2-hand seal).

  5. Equipment is set out, organized, and kept clean.

  6.   -> Medications are prepared, labeled, and doses are carefully confirmed.


Final Checks

At this stage, everything under the control of the crews is essentially ready to go, and this is usually where an Airway Checklist is enacted to ensure nothing has been missed. If you’re handed a list, start at the top, read it out loud, and ensure someone responsible for that item responds affirmatively.


However, the patient may not have ‘read the textbook’ and may be too unstable for intubation. ‘Unstable’ may refer to their oxygenation saturation or their blood pressure.


On oxygenation: As a general rule, the patient should be saturating at or above 93% for several minutes before induction (Oliveira et al., 2017). If this isn’t the case, non-invasive oxygenation/ventilation should be stepped up until this threshold is reached. This may mean increasing the PEEP on the BVM or increasing the flow through the cannula or mask.


On blood pressure: The combination of sedatives, paralytics, and positive pressure in the patient’s chest may drop their blood pressure post-intubation (it may even cause them to lose their pulse - it’s a risky procedure) (George, 2015). Crystalloids, blood, and/or something like epinephrine may need to be administered to the patient before induction.


As a non-intubating clinician, you are freed up to monitor these vital signs closely, and reporting on them can significantly reduce the cognitive load on clinician(s) placing the ETT. Watch for:

 

  1. SPO2 <93%

  2. MAP hovering around 65 mmHg

  3. SBP <90 mmHg

  4. Shock Index (HR/SBP) >0.9


If you’re not familiar with Shock Index, it can be a predictor of hypotension post-intubation (the switch to invasive positive pressure and exposure to sedatives and muscle relaxants) (Heffner et al., 2012). You don’t necessarily need to get out your calculator; just note if the heart rate is approaching or has surpassed the SBP. For example, a heart rate of 95 BPM and a SPB of 95 would equal a shock index of 1.0, and is something that should be brought to everyone’s attention before induction, especially since it’s typically not a metric that the monitor displays. A heart rate of 140 BPM and SBP of 70 mmHg is a shock index of 2.0, and a very concerning indicator that induction may lead to severe cardiovascular decline.


Running Checklist: 

  1. Positioned in a head-elevated sniffing position.

  2. A simple airway is in place if needed.

  3. If respiratory effort is adequate, NC at high-flow + mask.

  4. If inadequate: BVM (with PEEP+ETCO2) and NC under mask (2-hand seal).

  5. Equipment is set out, organized, and kept clean.

  6. Medications are prepared, labeled, and doses are carefully confirmed.

  7.   -> Final checks are performed with a checklist, and vitals are reassessed for concerning markers.


Medication administration (and waiting)

On par with the actual intubation, medication administration may be the most stressful part of the entire procedure. All non-critical communication should be halted, and all attention should be on the timing and administration of the induction agents and monitoring vital signs. Let's use Ketamine and Rocuronium as examples.


Ketamine must be given slowly, since rapid administration can lead to hypersalivation and laryngeal spasm. Once the ketamine is administered over ~2 minutes into a running line, the crew should allow time for it to work (at least 60 seconds). 


After the ketamine has taken effect, a paralytic like rocuronium should be given. This, too, should be given at least 60 seconds to take effect before a laryngoscope is inserted across the teeth (sometimes longer in hypotensive patients with poor muscle perfusion).


The airway assistant should note the time of each medication administration and call out time intervals as they approach and are crossed. Allowing time for the paralytic to take effect is the countdown to when the intubating clinician will begin intrumentation:


“Ketamine completed at 1400”

 “1401 - we’re 60 seconds post Ketamine”

“Rocuronium completed at 1402”

“30 seconds post roc” 

“45 seconds post roc”

“We’re 60 seconds post roc” (the point where the BVM will likely come off - an important marker in time)


Of note, sometimes you may hear the term “DSI” for Delayed Sequence Intubation. This is where Ketamine is given much earlier in the stream of events to facilitate the preparation process. Ketamine, when administered correctly, should not depress the respiratory drive, allowing it to dissociate the patient and make them compliant with the pre-oxygenation process. In these scenarios, the patient will already be sedated, and during the ‘medication administration’ phase, a paralytic like rocuronium will be administered to ease the intubation process. 


Running Checklist: 

  1. Positioned in a head-elevated sniffing position.

  2. A simple airway is in place if needed.

  3. If respiratory effort is adequate, NC at high-flow + mask.

  4. If inadequate: BVM (with PEEP+ETCO2) and NC under mask (2-hand seal).

  5. Equipment is set out, organized, and kept clean.

  6. Medications are prepared, labeled, and doses are carefully confirmed.

  7. Final checks are performed with a checklist, and vitals are reassessed for concerning markers.

  8. -> Medications administered and tracked.


Intubation

During the countdown to the full effect of paralysis, the two key players should be in their respective positions. There are a couple of configurations that may occur, but the position of the airway assistant remains unchanged. Here are a couple of examples:


Example 1:

Player 1: Intubating clinician: at the head of the bed holding a two-handed seal on the BVM.

Player 2: Airway Assistant: on their right-hand side, squeezing the BVM. 


In this example, the airway assistant would take the BVM and hand the intubating clinician the instruments they have made clear they require. This will always include a laryngoscope in their left hand, and either a suction or tube+bougie in their right hand. If they choose to lead with suction, be prepared to take it back from them and hand them the tube+bougie when they’re ready. Here is a blog on tube+bougie configurations.


Example 2:

Player 1: Intubating clinician: Has tools in hand already.

Player 2: Airway: at the head of the bed holding a two-handed seal on the BVM.

Player 3: Player 2: Airway Assistant: on their right-hand side, squeezing the BVM. 


In this example, the person holding the two-handed seal and the intubating clinician will quickly trade places, and the intubator will already have their initial desired tools in hand. As the assistant, you’ll still want to be prepared to swap out anything necessary, such as removing the suction and providing a dressed endotracheal tube (ETT). This requires an organized work area, similar to that of a surgical assistant assisting a surgeon.


Regardless of the configuration, one key skill is handling the BVM during the intubation process. Remove the mask from the BVM (don't lose it), but ensure that the waveform ETCO2 remains - the waveform ETCO2 will be vital for tube confirmation. 


If the intubation is clearly unsuccessful, the mask should be placed back onto the BVM, and everything resets.


It’s essential to note that there's a delay in pulse oximetry, meaning the reading displayed on the monitor is not ‘live.’ During the intubation, be watchful for readings that reach 93%. This signals it’s time to let the intubating clinician know it’s time to re-oxygenate the patient, since the SPO2 is lower than what it’s displaying. The lower an SPO2 level goes, the faster it decreases, and the more difficult it becomes to increase.


Running Checklist: 

  1. Positioned in a head-elevated sniffing position.

  2. A simple airway is in place if needed.

  3. If respiratory effort is adequate, NC at high-flow + mask.

  4. If inadequate: BVM (with PEEP+ETCO2) and NC under mask (2-hand seal).

  5. Equipment is set out, organized, and kept clean.

  6. Medications are prepared, labeled, and doses are carefully confirmed.

  7. Final checks are performed with a checklist, and vitals are reassessed for concerning markers.

  8. Medications administered and tracked.

  9. -> Airway assistant on the right-hand side of the patient, assisting the intubating clinician.

Confirmation

The cuff is inflated, either by the intubator or the assistant (plan for who will perform this task). An intubation is not officially successful until there are two methods of confirmation. Your first method should be attaching the waveform ETCO2 to the ETT and delivering breaths while the intubating clinician manually holds the ETT in place (Hendrix & Regunath, 2025; Higgs et al., 2018). As for the second method:

  •  Direct visualization: especially if the intubating clinician is using a video laryngoscope, the laryngoscope can be left in place during other confirmation methods.

  •  Auscultation: listening to the belly to assess for gastric sounds, and then both lungs to evaluate for bilateral lung sounds.

  •  Ultrasound: Sliding sign present on both hemithorax.


In addition to proper placement, depth is also a key consideration. For an adult, the depth of the ETT should be 3x its size (8.0 x 3 = 24 at the teeth). If the patient only has lung sounds on the right, and the depth is considerably deeper than 3x the tube size, the tube may be in the right lung, and the intubating clinician may need to back the tube out slightly until both lungs are being ventilated.


After two methods confirm the ETT placement, the tube should be secured, and the confirmation methods monitored to ensure it has not migrated (including the depth at the teeth). Some clinicians may choose to partially immobilize the head/neck with various means to ensure the tube does not become displaced.


Now that the airway is secure, reassess the vital signs and ensure you hear talk of post-intubation sedation. Rocuronium (the paralytic) will outlast any push-dose sedatives given for induction. 


Running Checklist: 

  1. Positioned in a head-elevated sniffing position.

  2. A simple airway is in place if needed.

  3. If respiratory effort is adequate, NC at high-flow + mask.

  4. If inadequate: BVM (with PEEP+ETCO2) and NC under mask (2-hand seal).

  5. Equipment is set out, organized, and kept clean.

  6. Medications are prepared, labeled, and doses are carefully confirmed.

  7. Final checks are performed with a checklist, and vitals are reassessed for concerning markers.

  8. Medications administered and tracked.

  9. Airway assistant on the right-hand side of the patient, assisting the intubating clinician.

  10. -> Airway placement in the trachea confirmed x2 and ETT secured.

  11.   -> Reassess vital signs and make mention of ‘post-intubation sedation’ on the checklist.



Red Flag

If you see something, say something.


🚩SPO2 <93% or a fast downward trend despite oxygenation.

🚩Shock Index ≥ 1 (heart rate ≈ or > systolic BP), or SBP <90 mmHg / MAP <65 mmHg.

🚩Absent or very low ETCO2 after two or three positive-pressure breaths post-intubation.

🚩Poor BVM compliance (stiff lungs, minimal chest rise, or sudden high airway pressures).

🚩Unilateral chest rise or gastric gurgling after tube placement (possible right-mainstem or esophageal intubation).



Summary

Even if the actual skill of intubation is not within your scope of practice, nearly every skill surrounding the procedure is. A skilled airway assistant is worth their weight in gold, and knowing the flow of the procedure is the first step to proficiency. No doubt, this was a lot to take in. If you’re struggling to understand the process as a whole and how you can assist, take the phases we've outlined here one at a time. Start by understanding positioning, then determining who needs help with a BVM versus who does not, and next, how to maintain a good two-hand BVM seal.


After that, familiarize yourself with the equipment involved, and so on. Taken as a whole, intubation is daunting, even for those assisting with it. However, if you break the procedure into pieces that make sense to you, they’ll be easy to put together when the time comes.


If it’s your aim to sit in the driver’s seat of an intubation one day, learning to be a proficient airway assistant will put you well ahead of the pack!


Thanks for reading!



References

Alvarado, A. C., & Panakos, P. (2023, July 10). Endotracheal tube intubation techniques. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560730/

Brown, C. A., III, Sakles, J. C., & Mick, N. W. (Eds.). (2018). The Walls manual of emergency airway management (5th ed.). Wolters Kluwer.

George, N. (2015, February 12). Post‑intubation hemodynamic collapse in the critically ill patient. Airway, Critical Care, Clinical. EM Resident. Retrieved from https://www.emra.org/emresident/article/post-intubation-hemodynamic-collapse-in-the-critically-ill-patient/

Heffner, A. C., Swords, D. S., Nussbaum, M. L., Kline, J. A., & Jones, A. E. (2012). Predictors of the complication of postintubation hypotension during emergency airway management. Journal of Critical Care, 27(6), 587–593. (https://www.perrlacomplete.com/App/#)

Higgs, A., McGrath, B., Goddard, C., Rangasami, J., Suntharalingam, G., Gale, R., & Cook, T. (2018). Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia, 120(2), 323–352. (https://www.perrlacomplete.com/App/#)

Hendrix, J. M., & Regunath, H. (2025, January 19). Intubation endotracheal tube medications. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459276/

Oliveira J. e Silva, L., Cabrera, D., Barrionuevo, P., Johnson, R. L., Erwin, P. J., Murad, M., & Bellolio, M. (2017). Effectiveness of apneic oxygenation during intubation: A systematic review and meta-analysis. Annals of Emergency Medicine, 70(4), 483–494.e11. (https://www.perrlacomplete.com/App/#)

Walz, J. M., Kaur, S., & Heard, S. O. (2016, September 5). Airway management and endotracheal intubation. Anesthesia Key. https://aneskey.com/airway-management-and-endotracheal-intubation-3/

Whitten, C. E. (2013). Anyone can intubate (5th ed.): A step-by-step guide to intubation & airway management (whitten's step-by-step guides) (4th ed.). Mooncat Publications. (https://www.perrlacomplete.com/App/#)

 
 
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