Airway management is a critical aspect of the practice of emergency medicine and the emergency department (ED) presents a unique and challenging environment for airway management. The undifferentiated nature of the patients demands proficiency on the part of the clinician as well as familiarity with a wide range of equipment and procedures as well as adherence to best practices that have been identified for emergency airway management.

Patients arriving at the ED in extremis are often unannounced and many times have little accompanying history or clinical information. This challenge is quite different from the elective surgical patient from whom a complete history can be acquired and a physical examination can be conducted in a low-stress environment to develop a plan for operative airway management.

In an ED one of the primary issues when evaluating a patient is the decision to intubate. Clinical indications requiring emergency airway management are diverse but revolve around the need to protect the airway of the patient who is otherwise unable to maintain a patent airway, or to provide invasive positive- pressure oxygenation, ventilation, or both to the critically ill.

Patients presenting with pathology such as allergic reactions, respiratory distress, cardiac arrest, burns, decreased levels of consciousness, and multisystems traumatic injury are common in the nearly 120 million ED visits that occur annually in the United States alone. It is estimated that 67% of intubations are performed for medical emergencies and 26% for traumatic emergencies (Fig. 50-1).¹

Select populations of patients are candidates for noninvasive positive- pressure ventilation (see Chapter 3). This technology is contraindicated in patients who are unable to protect their airway, have a cardiac arrest, severely impaired consciousness, facial deformities secondary to trauma or surgery, high aspiration risk, and recent esophageal anastomosis. However, in patients with chronic obstructive pulmonary disease (COPD), asthma, hypoxemic respiratory failure, or cardiogenic and noncardiogenic pulmonary edema without the above contraindications, it can be a useful adjunct to preventing intubation. A Cochrane database review of 14 studies showed that the use of noninvasive positive- pressure ventilation in patients with COPD decreased mortality, need for intubation, respiratory rate, length of hospital stay, and complications with treatment.²

When intubation is deemed necessary in the ED, it is prudent to decide that every airway is going to be a difficult airway and plan accordingly (see Chapter 12). It is estimated that up to 20% of ED intubations can be classified as difficult.³