Airway & Ventilation
The exam's favorite way to end a scenario — and a patient.
High-yield before the exam
- Capnography confirms EVERY tube: no waveform, no airway. Esophageal tubes get pulled, not debated.
- BVM before blade: pre-oxygenate 3+ minutes or 8 vital-capacity breaths before any intubation attempt.
- Suction passes are 15 seconds max in adults — pre-oxygenate before and re-oxygenate after.
- EtCO₂ 35–45 is normal; a sudden drop to near zero means tube dislodgement or arrest, a rise during CPR means ROSC.
- Pediatric airways: big occiput (pad the shoulders), tongue is the #1 obstruction, bradycardia = hypoxia until proven otherwise.
Drug cards3
Dose: 1 mcg/kg IV/IN (typically 50–100 mcg), repeat per protocol.
Indications
- Ischemic chest pain unrelieved by nitrates
- Severe traumatic or burn pain
- Sedation adjunct
Cautions
- Respiratory depression
- Hypotension in the volume-depleted
- Chest-wall rigidity with rapid large doses
SLOW + LOW
- Titrate small and reassess
- Watch the respiratory rate and ETCO₂
- Naloxone and a BVM at the bedside
Pearl: Fentanyl is hemodynamically kinder than morphine in cardiac patients — less histamine, less preload dump.
Dose: Pain: 0.1–0.3 mg/kg IV. Sedation for procedures: 1–2 mg/kg IV. Excited delirium: 4–5 mg/kg IM.
Indications
- Analgesia without blood-pressure collapse
- Sedation for cardioversion or pacing
- Severe agitation / excited delirium
Cautions
- Emergence reactions — keep the room calm
- Increases secretions and heart rate
- Laryngospasm is rare but real
K-HOLE
- K — Keeps respirations and pressure
- Dissociation not deep sleep
- Small doses for pain, big doses for sedation
Pearl: The analgesic for the hypotensive trauma or cardiac patient — it supports blood pressure instead of stealing it.
Dose: Seizures: 5 mg IM/IN or 2.5–5 mg IV. Sedation: 1–2.5 mg IV titrated.
Indications
- Status epilepticus
- Sedation for cardioversion
- Cocaine/stimulant chest pain and agitation
Cautions
- Respiratory depression — bag and ETCO₂ ready
- Synergistic crash with opioids
- Paradoxical agitation in some patients
VERSED
- Versed = very effective sedation
- E — Expect amnesia
- R — Respirations need watching
- S — Seizures stop
- E — ETCO₂ on
- D — Dose small, repeat
Pearl: First-line benzo for stimulant toxicity — it treats the catecholamine storm, not just the behavior.
Field cases3
Mottled, floppy, poor respiratory effort after two days of vomiting and diarrhea.
Vitals: HR 52 · RR 8 and shallow · SpO₂ 82% · cap refill 5 s
Monitor: Sinus bradycardia at 52.
Tripod position, one-word answers, accessory muscle use. Has used her rescue inhaler eight times in an hour.
Vitals: BP 138/86 · HR 128 · RR 34 · SpO₂ 88% on room air · ETCO₂ 58
Monitor: Sinus tachycardia. Chest is nearly silent on auscultation.
Deep rapid respirations, fruity breath, dry mucous membranes. Insulin pump site looks inflamed and has been failing for two days.
Vitals: BP 96/58 · HR 128 · RR 32 deep · SpO₂ 99% · glucose reads HIGH
Monitor: Sinus tachycardia with flattened T waves.
Skills to drill5
BVM ventilation
Mastery: One-person seal with visible chest rise, 10–12 breaths/min, ETCO₂ 30–35 — no bag-squeezing marathons.
Drill: Bag a manikin for 5 minutes solo with a capno line. If ETCO₂ leaves 30–35, slow down.
OPA / NPA placement
Mastery: Sizes and seats an adjunct in under 10 seconds, knows gag = no OPA.
Drill: Blindfold size-and-place drill: measure ear-to-mouth, insert, ventilate, confirm rise.
Supraglottic airway (i-gel/King)
Mastery: Inserts, seals, and confirms with capnography on the first attempt during compressions.
Drill: Time yourself: CPR pause under 10 seconds, waveform present, no gastric sounds.
Endotracheal intubation
Mastery: First-pass success with bougie backup, continuous capno, and a plan B already open.
Drill: Three passes on the manikin weekly; call out your backup plan before every attempt.
Airway suctioning
Mastery: Clears vomit/blood in under 15 seconds per pass, pre-oxygenates, never blinds a tube.
Drill: Simulated emesis scenario: suction, re-bag, reassess — beat the 15-second clock.
Board-style exam questions38
1. Best first indicator that a supraglottic airway is correctly placed?
2. An adult in respiratory failure is being bagged with an advanced airway in place. Target ventilation rate?
3. A COPD patient placed on CPAP becomes hypotensive. Most likely cause?
4. Sudden loss of the ETCO2 waveform in a previously well-placed tube. First action?
5. Severe asthma with a silent chest and rising ETCO2 indicates:
6. Preferred suction technique for a patient with copious emesis?
7. Which finding most strongly predicts a difficult bag-mask seal?
8. Pulse oximetry reads 99% in a confused house-fire victim. Correct interpretation?
9. Pediatric patient with stridor at rest and drooling. Priority action?
10. During RSI, the most important step before laryngoscopy is:
11. A tube is placed and ETCO2 shows 8 mmHg with no waveform in a patient with a pulse. Most likely:
12. Which patient is the best candidate for CPAP?
13. Nasopharyngeal airway is relatively contraindicated with:
14. Tidal volume goal when bagging an average adult?
15. Anaphylaxis with rapidly worsening stridor after IM epinephrine. Next best step?
16. Best position to improve oxygenation in an obese patient before intubation?
17. A tension pneumothorax is developing in a ventilated patient. Earliest ventilator/BVM sign?
18. Suspected complete foreign body obstruction in a responsive adult. First maneuver?
19. A tension pneumothorax is suspected in a ventilated trauma patient. First intervention?
20. Normal adult end-tidal CO2 range?
21. Rising ETCO2 during CPR most likely means:
22. Which adjunct is contraindicated with suspected basilar skull fracture?
23. Anaphylaxis with stridor and hypotension. First drug?
24. Apneic oxygenation during intubation means:
25. Flail chest impairs ventilation primarily because of:
26. Pediatric ventilation rate with an advanced airway in place during CPR?
27. Best position for an awake patient in severe respiratory distress?
28. A shark-fin capnography waveform indicates:
29. Cricothyrotomy is indicated when:
30. Carbon monoxide poisoning treatment in the field?
31. A 2-year-old child has a barking cough and inspiratory stridor that improves with cool night air. Best prehospital management?
32. An infant with severe bronchiolitis has a respiratory rate of 80 that suddenly drops to 20 with head bobbing. This means:
33. Correct bag-mask technique for a pediatric patient?
34. Adult with a complete foreign body obstruction becomes unresponsive. Next action?
35. During ventilation of an intubated asthmatic, the patient becomes hypotensive with rising peak pressures. First action?
36. A newborn is not breathing after drying and stimulation. First intervention?
37. Best indicator of adequate ventilation in a child you are bagging?
38. Which airway adjunct is sized from the corner of the mouth to the angle of the jaw?
Keep going
Educational review only — always follow your local protocols and medical direction. Not affiliated with or endorsed by the NREMT.