Understanding Basic, Intermediate, and Advanced Airway Adjuncts in Prehospital Care

/ Delta Emergency Support Training/

Securing and maintaining a patient’s airway is the cornerstone of prehospital medicine. Whether you are an Emergency Medical Responder (EMR), Primary Care Paramedic (PCP), or Advanced Care Paramedic (ACP), understanding the range of airway adjuncts—and when to use them—is critical for optimal patient outcomes. Airway adjuncts are commonly grouped into three categories: basic, intermediate, and advanced.

1. Basic Airway Adjuncts

These devices are non-invasive and require minimal training, yet they can be lifesaving.

  • Oropharyngeal Airway (OPA)
    Use: Unconscious patients without a gag reflex to keep the tongue from obstructing the airway.
    Key Points: Measure from the corner of the mouth to the angle of the jaw; insert upside down then rotate 180° (or sideways with a tongue depressor in children).

  • Nasopharyngeal Airway (NPA)
    Use: Patients with an intact gag reflex or trismus (jaw clenching).
    Key Points: Lubricate well; size from nostril to earlobe. Contraindicated in suspected basilar skull fractures.

  • Suction Equipment
    Use: Clears secretions, blood, or vomit to maintain a patent airway.

Clinical Pearl: Basic adjuncts buy time. Always reassess and be ready to escalate if ventilation or oxygenation remains inadequate.

2. Intermediate Airway Adjuncts

These devices provide more definitive control without requiring endotracheal intubation skills.

  • Supraglottic Airway Devices (SADs) such as:

    • Laryngeal Mask Airway (LMA)

    • King LT or i-gel

    Use: For unconscious patients when bag-valve-mask (BVM) ventilation is inadequate or prolonged transport is expected.
    Key Points: Rapid insertion, minimal training compared to intubation, and useful when laryngoscopy is not feasible.

3. Advanced Airway Adjuncts

These procedures require specialized training and are often reserved for paramedics with advanced certification or physicians.

  • Endotracheal Intubation (ETI)
    Use: To provide definitive airway protection and control ventilation.
    Key Points: Requires laryngoscopy, confirmation of tube placement (capnography is gold standard), and ongoing monitoring for dislodgement.

  • Surgical Airway (Cricothyrotomy or Needle Cricothyrotomy)
    Use: “Cannot ventilate, cannot intubate” scenarios such as severe facial trauma or airway obstruction.
    Key Points: High-stakes, last-resort procedure with strict indications.

Airway Decision-Making in the Field

When deciding which airway adjunct to use, consider:

  • Level of provider certification and local protocols.

  • Patient condition: Consciousness, gag reflex, trauma, and potential for rapid deterioration.

  • Environment: Limited space, lighting, or access may guide your choice.

Tip: Airway management is dynamic. Start with the least invasive method and escalate as needed while continually reassessing breathing and oxygenation.

Training and Maintenance

  • Regular Practice: Skills such as BVM ventilation and intubation degrade quickly without use.

  • Equipment Checks: Verify availability, integrity, and proper sizes of adjuncts at the start of every shift.

Bottom Line

From OPAs and NPAs to supraglottic devices and endotracheal tubes, airway adjuncts form a spectrum of tools for professional responders. Mastery of their indications, insertion techniques, and limitations ensures that you can match the right device to the right patient, improving survival and reducing complications in the prehospital setting.