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Strategies for Airway

Management in Patients
Encountered in Atypical
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Situations: The Floor Airway

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CHRISTOPHER W. ROOT, MD, NRP

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Emergency Medical Services Fellow

Department of Emergency Medicine
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University of New Mexico Health Science Center

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Albuquerque
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JAMES DUCANTO, MD
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Staff Anesthesiologist
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Advocate Health Care

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Clinical Adjunct Professor

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University of Wisconsin–Madison
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School of Medicine and Public Health

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Root reported no relevant financial disclosures.

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DuCanto is the developer of the DuCanto Catheter

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(SSCOR Inc.), the SEADUC Suction Easy (EM Innovations)

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and the Life/form S.A.L.A.D. Simulator (Nasco).

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uccessful resuscitation and airway
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management in an atypical environment

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require a deliberate approach and

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careful clinical decision making.

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Introduction management during routine perioperative practice are

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Airway management is a central component of the prac- exceedingly low, adverse event rates as high as 39%
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tice of anesthesiology. Anesthesia providers are most often have been reported when an anesthesiologist intubates a
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responsible for airway management in the perioperative
and periprocedural setting; however, resuscitative airway
management is also a critically important skill. Depending
on their practice setting, an anesthesia provider may be
called upon to perform airway management on inpatient
wards, the emergency department, the ICU and anywhere
else within a hospital.
Practicing in an unfamiliar environment carries sig-
nificant risks. Although complication rates of airway
patient outside of the OR.1
In rare circumstances, an anesthesia provider may
be required to manage the airway of a patient who has
decompensated in a nonclinical setting. The approach to
airway management in a patient found down on the floor
presents a number of distinct challenges. While these
events are uncommon for hospital-based anesthesia pro-
viders, they are routine in the world of prehospital medi-
cine and emergency medical services (EMS).

A N E S T H E S I O L O G Y N E W S A I R W AY M A N A G E M E N T 2 0 2 3 31
 In many European and Australasian countries, anesthe-
siologists are one of the primary groups of physicians who
practice in the prehospital setting.2 In the United States,
physician involvement in the prehospital setting is rare,
and few programs involve anesthesia providers.3 In this
article, we share techniques and expertise from the world
of prehospital medicine and discuss strategies for manag-
ing the airway of a critically ill patient who requires airway
management outside of the typical anesthesia environ-
ment—specifically, patients who require resuscitation and
airway management on the floor.
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Initial Assessment
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The concept of the “scene size-up” is a foundational
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component of training new EMS clinicians. The initial com-
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ponents of a scene size-up typically include the application
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of appropriate personal protective equipment and asking
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the question, “Is the scene safe?”4 This may sound pecu-
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liar in the setting of a healthcare institution. However, there
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are recent examples in which healthcare institutions have
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been affected by catastrophes ranging from natural disas-
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ters to mass shootings, leading hospitals to be evacuated
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or locked down and even necessitating the management of
critically ill patients in the setting of complete loss of electri-
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cal power. If the power fails in the building and entire areas
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of a hospital become uninhabitable or inaccessible, we may
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find ourselves asking the question, “Is the scene safe for
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performance of resuscitation and airway management?”
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In the prehospital setting, scene safety considerations
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may include appropriate stabilization of a motor vehicle
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crash for rescue and resuscitation of a patient entrapped in
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the vehicle, or shutting down the high-voltage third rail for
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a patient trapped beneath a subway car. In-hospital exam-
ples of scene safety considerations might include precau-
tions for use of certain medical equipment in an MRI suite
(defibrillators, metal carts and laryngoscopes not designed
for the MRI environment), donning appropriate personal
protective equipment prior to entering the room of a
patient with an airborne transmissible illness, or decontam-
ination of a patient exposed to dangerous chemicals in a
medical laboratory setting.
The fundamental goal of assessing scene safety is to
ensure the rescuers do not become victims themselves.
Other key components of the scene size-up include iden-
tifying the total number of patients (such as in a mass casu-
alty incident), considering any additional resources that
may be needed, and identifying safe ingress and egress
for the team and the patient.
After the scene size-up and a primary survey assessing
the patient’s level of responsiveness as well as the patient’s
airway, breathing and circulation, the patient’s position within
the space should be considered. If a patient has collapsed in
an elevator or bathroom, the confined space will make effec-
tive resuscitation and airway management extremely diffi-
cult. If feasible, based on the location, the size of the patient
and the number of team members available, the patient
should be moved from the confined space into a more open
area. Ideally, the patient should be positioned in a space
to allow for 360 degrees of access to the patient by team
32 ANESTHESIOLOGYNEWS.COM
members.5,6 Care should be taken to limit manipulation of the
cervical spine if there is concern for cervical spine injury.
The patient’s position in the space should be reassessed
dynamically throughout the resuscitation. Consider a hypo-
thetical patient who has collapsed and is found in cardiac
arrest in a single-occupancy bathroom just off the hospital
lobby. It may be necessary to initiate cardiopulmonary resus-
citation (CPR) in the confined space of the bathroom as a
single rescuer, but once additional resources and adequate
personnel are available, in order to effect an expedient
move with minimal interruption in CPR, the patient should be
dragged out of the bathroom into the lobby to allow for bet-
ter access for interventions as the resuscitation progresses.
Beyond the initial scene size-up, scene management is
a critical ongoing consideration throughout any resuscita-
tion. Prehospital clinicians hone this skill set through years of
experience managing resuscitations in atypical environments.
Campeau described the “space control theory of paramedic
scene management.”7 Using data collected through struc-
tured interviews, the author found that paramedics control a
scene through a delicate interplay of clinical decisions and
social interactions. Manipulating the physical space is actu-
ally only a small component of resuscitating a patient in an
atypical environment. The ability to form social connections
quickly in order to lead an ad hoc team with varying levels of
clinical knowledge is a far greater factor.
Bag-Mask Ventilation
Mask ventilation is a central component of anesthetic
practice. The fundamentals of good mask ventilation of a
patient on the floor are the same as a patient on an oper-
ating table or a hospital bed. Any successful airway man-
agement strategy starts with deliberate positioning of the
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patient’s airway. In the case of a patient lying on the floor,
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the clinician responsible for airway management will not be
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able to simply raise or lower the head of the bed. Stacked
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sheets or towels, pillows, or commercially available devices
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can be used to elevate the head and achieve an ear to ster-
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nal notch position for airway patency and ventilation.8,9
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Anesthesia providers are accustomed to utilizing one-
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handed mask seal techniques when performing face mask
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ventilation. Depending on the situation and access to the
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patient’s airway, the anesthesia provider may need to lead
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the resuscitation and delegate face mask ventilation to a
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less experienced team member. The patient may also be
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lying in such a way that there is no space for a clinician to
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kneel above the head to deliver normal single-rescuer face
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mask ventilation.
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In cases such as this, if team composition and space
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allow, using two rescuers to deliver face mask ventila-
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tion may be superior.10 One team member holds the mask
seal with two hands and opens the airway while the other
squeezes the bag to deliver ventilation. In cardiac arrest,
the team member providing ventilation can also deliver
chest compressions when a 30:2 ratio is being utilized
before insertion of an advanced airway. This technique has
been shown in simulation to lead to higher tidal volumes
without compromising chest compressions.11,12
Supraglottic Airways
Supraglottic airways (SGAs) have a number of distinct
advantages when a patient requires airway management
in an atypical environment. Positioning the patient and cli-
nician for effective laryngoscopy and endotracheal intuba-
tion (ETI) is challenging and is discussed below. An SGA
can be inserted without needing to instrument the airway
or visualize any airway structures. This allows a clinician
to rapidly protect the airway and initiate ventilation, even
if the patient is entrapped or access to the airway is other-
wise limited.13 This ability to be easily inserted in cramped,
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The subjects were asked to intubate or place an SGA in
a manikin in three scenarios: supine under a table with its
head against a wall, sitting upright accessible from behind
and lying on its side. In all scenarios the time to ventilate
the manikin was faster using an SGA, and in the supine and
rear-approach scenarios the paramedics demonstrated sig-
nificantly faster ventilation times. The performance of the
paramedic group was superior despite reporting less intu-
bation experience than the physicians.
Even though paramedics are likely more accustomed to
intubating in atypical environments with suboptimal posi-

suboptimal environments is part of the reason these tioning, a cadaveric study found that their success rates
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devices have become so popular in the prehospital setting. improved when they were able to intubate on a stretcher at
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SGAs have been shown to have comparable if not supe- waist height compared with being positioned on the floor.18
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rior performance when compared with ETI in the setting of If face mask ventilation or an SGA is not providing ade-
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out-of-hospital cardiac arrest.14,15 In a manikin study evaluating quate ventilation or is not readily available and the patient
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experienced prehospital physicians, both SGA placement and has to be intubated, then there are several techniques
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ETI were more difficult in cases where access was restricted, that can be utilized. Confined spaces and floor intubations
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but SGA placement was faster and universally successful on make it difficult to achieve the necessary angles for visu-
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the first attempt.16 Given the ease of rapid insertion, place- alization of the glottic opening with direct laryngoscopy.
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ment of an SGA should be the first-line strategy for establish- Given that geometry, these are situations in which video
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ing a resuscitative airway in a patient whose positioning will laryngoscopy likely confers a significant advantage.
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make conventional laryngoscopy and ETI difficult or infeasible. The following techniques can be employed whether the
intubator is using direct or video laryngoscopy. If there is
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Intubation adequate space above the patient’s head, the intubating

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As we have taken care to outline above, the first rule of clinician can lie prone along the same axis as the patient
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intubating on the floor is: Do whatever you can to avoid (Figure 1). The intubator supports their upper body weight
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intubating on the floor. Many physician-led prehospital ser- and positions themselves using their elbows, in order to
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vices advocate that rapid sequence induction should only perform laryngoscopy and ETI. This positioning typically
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be performed with the patient on an ambulance stretcher allows for decent visualization; however, it requires an area
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at waist height with 360 degrees of access to the patient.5,6 of free space above the patient’s head that’s roughly equal
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A number of different techniques that can be employed in to the height of the intubator, and is not ideal if the ground
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order to perform laryngoscopy and ETI on a patient on the around the patient is soiled with bodily fluids or other sub-
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floor, but the clinician should carefully consider their use if stances the intubator would need to avoid while lying prone.
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they have never practiced them before. If the space above the patient’s head is limited, an alter-
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A study by Hoyle et al underscores the difficulty of intu- native approach is for the intubator to kneel at the patient’s
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bation in situations that are unfamiliar or atypical for phy- head (Figure 2). This positioning creates a challenge in that
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sicians.17 They studied simulated airway management the angle between the patient’s mouth and intubator’s eyes
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performed by paramedics, emergency medicine resident will be extremely acute, assuming direct laryngoscopy is
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physicians and emergency medicine attending physicians. the technique utilized. This positioning would be analogous
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Figure 1. Intubating a supine patient on the Figure 2. Intubating a supine patient on the
ground while lying prone. floor while kneeling.

A N E S T H E S I O L O G Y N E W S A I R W AY M A N A G E M E N T 2 0 2 3 33
to standing at the patient’s head in the OR with the table
height several inches below your waist. In order to visual-
ize the glottis in this situation, the intubator typically has to
hunch forward or lean backward significantly in order to
achieve an appropriate angle during direct laryngoscopy.
Similarly, the intubator can sit at the patient’s head with
their legs extended down over the patient’s shoulders. In
this position the patient’s head is more or less in the intu-
bator’s lap (Figure 3). Finally, the intubator can lie on their
side at the patient’s head at an angle perpendicular to the
patient. This positioning can be useful if there is limited
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space above the patient’s head but sufficient space to the
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side of the patient (Figure 4).
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Less traditional intubation techniques could be consid-
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ered depending on access to the patient’s airway and clini-
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cian familiarity. A “face-to-face” approach can be employed
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by standing over the patient or straddling the patient’s
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chest and inserting the laryngoscope in an overhand fash-
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ion.19 This is obviously not feasible in the setting of cardiac
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arrest, as it would likely lead to significant interruptions in
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chest compressions.
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Another technique that has been advocated when tra-
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ditional laryngoscopy is not feasible is the blind digital
intubation.20 Blind digital intubation requires no visualiza-
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tion and is performed with the intubator positioned to the
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patient’s side, which makes it an appealing technique
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when access to the area above the head is limited. How-
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ever, unless the patient is fully unresponsive or chemically
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paralyzed, there is the potential for significant injury to the
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intubator’s fingers from an unanticipated bite. This tech-
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nique is likely not in the armamentarium of most of today’s
or
U.S.-trained anesthesiologists, and would not be consid-
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ered safe without the immediate presence of a waveform
capnography monitor, but is included here to provide a
comprehensive discussion of the topic.
The final alternative approach to ETI, if none of the
above techniques is feasible, would be an invasive air-
way technique, also referred to as front-of-neck access
(FONA). 21 This access can be accomplished with an
open surgical technique or a percutaneous technique,
Figure 3. Intubating a supine patient on the
floor while in a seated position.
34 ANESTHESIOLOGYNEWS.COM
depending on the clinician’s experience and the available
equipment. FONA is typically considered a last resort in
difficult airway algorithms.22 However, there are situations
where the patient’s position and available equipment may
make surgical airway the most appropriate initial airway
strategy. Consider a patient with significant facial trauma
who is morbidly obese and entrapped in such a position
that leaves no access to the area above the head, leaving
intubation impossible. FONA to the airway may be the only
viable option for such a patient.
Extrication
When the patient’s airway has been secured and ongo-
ing resuscitation efforts allow, they should be extricated
from their position on the floor and moved to a more con-
ventional clinical environment. If the patient is on the floor,
lifting them onto a bed for transfer should be done care-
fully and deliberately. Depending on the size of the patient,
the space and the team members available, a number
of techniques can be employed. First, the stretcher the
patient is being moved to should be placed at the lowest
level. Then the team member at the patient’s head should
direct efforts, maintain control of the airway and stabilize
the cervical spine, if clinically indicated. The best approach
to lift the patient from the floor will involve a lifting device
of some type. The patient can be log-rolled onto a hospi-
tal sheet, a commercial lifting device or a long spinal board
before lifting. This allows for uniform, coordinated move-
ment of the patient off the floor and onto the stretcher,
and minimizes the risk for inadvertent airway dislodgment,
injury to the patient and injury to team members. Commer-
cial devices designed to facilitate patient evacuation from
the hospital may be useful tools for patient repositioning.
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Conclusion
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Patients requiring resuscitation and airway manage-
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ment will not always be presented on a waist-high table in
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a brightly lit OR. Successful resuscitation and airway man-
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agement in an atypical environment require a deliberate
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approach and careful clinical decision making. The initial
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Figure 4. Intubating a supine patient on the
floor while lying in a lateral position.
assessment must include a scene size-up followed by a
conservative approach to airway management.
It is in the patient’s best interest to use the simplest and
least invasive technique that provides effective ventilation.
SGAs are likely superior to ETI for airway management in
these situations. If an SGA cannot provide adequate ven-
tilation, then ETI can be performed using one of several
techniques. It is worth considering practicing these tech-
niques in simulation if you think you may find yourself in a
position where you will have to employ them in vivo. Finally,
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once the airway is secured, it must remain secure as the
patient is extricated to a conventional clinical environment
for ongoing resuscitation.
Note: Root spent nine years working as a paramedic in New York City,
including working through medical school and the initial phases of
the COVID-19 pandemic. He is now an emergency physician pursuing
fellowship training in emergency medical services with a special
interest in advanced airway management.
The authors thank paramedic Kathryn Chadason for demonstrating
various intubation techniques and Kyle Burns for his photography.

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