Advanced Airway Assessment and Strategy Selection - NREMT Paramedic Level

SECTION 1

Historical Context & Motivation

The management of the human airway has always been at the center of emergency medicine, yet the idea that prehospital providers should perform advanced airway assessment before selecting a device is surprisingly modern. For much of the twentieth century, endotracheal intubation was considered the default—often the only—advanced airway option in the field. Early paramedic curricula emphasized technique repetition over patient-specific decision-making, and success was measured by tube placement rather than patient-centered outcomes. As research accumulated showing that failed or prolonged intubation attempts increased morbidity and mortality, the profession shifted toward a strategy-based model that begins with a rigorous anatomical and physiological assessment before any device is chosen.

1960s • Birth of Modern EMS

The National Academy of Sciences publishes "Accidental Death and Disability," galvanizing the development of prehospital care systems. Endotracheal intubation is adopted from the operating room with minimal adaptation for field conditions.

1988 • ASA Difficult Airway Algorithm

The American Society of Anesthesiologists introduces the first structured difficult airway algorithm, emphasizing systematic assessment before intervention. This framework eventually influences prehospital protocols.

2001 • Introduction of the King LT and i-gel

Supraglottic airway devices gain traction as viable alternatives to endotracheal intubation in the prehospital arena, enabling strategy selection rather than a one-size-fits-all approach.

2010 • AHA Guideline Shift

The American Heart Association de-emphasizes early intubation during cardiac arrest, citing equivalent outcomes with supraglottic airways and bag-valve-mask ventilation when performed competently.

2019–Present • Evidence-Based Airway Bundles

Major EMS agencies adopt first-pass success bundles, bougie-assisted intubation, and video laryngoscopy protocols, all grounded in pre-procedure assessment of difficulty predictors.

The central question this lesson addresses is deceptively simple: how does a paramedic decide which airway strategy is best for a given patient, in a given clinical scenario, at a given moment? The answer requires integrating anatomy, physiology, predictive assessment tools, and situational awareness into a coherent decision framework—a skill the NREMT expects at the paramedic level.

SECTION 2

Core Principles of Airway Assessment

Advanced airway assessment is built on a layered evaluation that moves from the general to the specific. Before reaching for any device, the paramedic must determine whether the patient can be ventilated with basic maneuvers, whether the anatomy suggests a difficult intubation, and whether clinical conditions—such as trauma, edema, or obesity—introduce additional risk. The assessment is not a single checklist but rather a dynamic, iterative process that continues throughout resuscitation.

Predict Difficulty Before Intervening

Use validated screening tools—LEMON, MOANS, RODS, SHORT—to anticipate challenges with intubation, bag-valve-mask ventilation, supraglottic airways, and surgical airways before the first attempt.

Oxygenation Takes Priority Over Intubation

The primary goal is maintaining oxygen delivery. A patent airway with effective BVM ventilation is always superior to a prolonged, failed intubation attempt that results in hypoxia.

Have a Plan A, B, and C

Strategy selection means identifying a primary device, a backup device, and a rescue/surgical pathway before sedation or paralysis. This tiered approach minimizes cognitive load during a crisis.

Reassess Continuously

Airway status can change rapidly—edema can progress, blood can accumulate, and medications can wear off. Post-placement confirmation (waveform capnography) and ongoing monitoring are non-negotiable.

Context Matters

Entrapment, lighting, provider experience, transport time, and available equipment all shape strategy. A technically correct choice in the ED may be impractical on a hillside at night.

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KEY TAKEAWAY

Think of airway strategy selection like a pilot's pre-flight checklist. A pilot never simply starts the engine and hopes for the best; they systematically inspect each critical system, identify potential hazards (weather, runway length, fuel load), and have alternate airports plotted before taxiing. Similarly, a paramedic must evaluate the patient's anatomy, physiology, and scene conditions—then map out primary, backup, and rescue strategies—before committing to an airway intervention.

SECTION 3

Visual Explanation — The Airway Assessment Decision Pathway

This flowchart illustrates the decision pathway from initial ventilation assessment through Plan A, Plan B, and ultimately Plan C (surgical airway). The green confirmation box on the right applies after any successful placement—waveform capnography is the gold standard for confirming correct positioning.

The flowchart above captures the fundamental logic of strategy selection. The first branch—can you ventilate with a bag-valve-mask?—is the most critical decision point. If the answer is no, you bypass the standard assessment pathway entirely and move to an immediate rescue device or surgical airway. When BVM ventilation is possible, the next task is evaluating intubation difficulty using tools like the LEMON mnemonic. Low-difficulty patients proceed to endotracheal intubation as Plan A, whereas high-difficulty patients are better served with a supraglottic airway (SGA) as the primary device. Notice that every pathway converges on the same confirmation step: waveform capnography (ETCO₂). Regardless of which device secures the airway, placement must be verified quantitatively.

SECTION 4

Assessment Mnemonics and Predictive Tools

Paramedic-level airway assessment relies on structured mnemonics that organize dozens of anatomical and physiological variables into rapid, memorable frameworks. While no single tool is perfectly sensitive or specific, using several in combination dramatically improves the ability to predict difficulty and select the optimal device before the first attempt. The four key mnemonics every paramedic must know are LEMON (difficult intubation), MOANS (difficult BVM ventilation), RODS (difficult SGA placement), and SHORT (difficult surgical airway).

LEMON — Predicting Difficult Intubation

Letter	Factor	What to Assess
L	Look Externally	Facial trauma, large tongue, obesity, short neck, facial hair, dental abnormalities
E	Evaluate 3-3-2 Rule	Mouth opening ≥ 3 finger-breadths; hyoid-to-chin ≥ 3 finger-breadths; thyroid notch-to-floor of mouth ≥ 2 finger-breadths
M	Mallampati Score	Class I–II = favorable view; Class III–IV = likely difficult. Assess visibility of uvula, soft palate, and faucial pillars
O	Obstruction / Obesity	Epiglottitis, peritonsillar abscess, tumors, angioedema, morbid obesity with excess pharyngeal tissue
N	Neck Mobility	Cervical spine immobilization, rheumatoid arthritis, ankylosing spondylitis, or any condition limiting atlanto-occipital extension

LEMON mnemonic for predicting difficult endotracheal intubation

MOANS — Predicting Difficult BVM Ventilation

Letter	Factor	Clinical Significance
M	Mask Seal	Beards, facial burns, blood/secretions, and unusual facial anatomy compromise mask seal
O	Obesity / Obstruction	BMI > 30 significantly increases ventilation resistance; upper airway masses or foreign bodies block flow
A	Age > 55	Loss of tissue elasticity, edentulous jaws, and reduced pharyngeal muscle tone
N	No Teeth	Edentulous patients have collapsed oral structures, making mask seal and jaw support more difficult
S	Stiffness / Snoring	Reactive airway disease (asthma, COPD), pulmonary edema, and late-pregnancy diaphragm splinting increase resistance

MOANS mnemonic for predicting difficult bag-valve-mask ventilation

RODS — Predicting Difficult SGA Placement

R — Restricted mouth opening: Trismus, angioedema, or temporomandibular joint dysfunction may prevent device insertion.
O — Obstruction: Supraglottic masses, laryngeal tumors, or severe peritonsillar abscess can block SGA seating.
D — Disrupted or Distorted airway: Trauma, hematoma, or post-radiation changes alter anatomy enough to prevent proper SGA seal.
S — Stiffness: Severe bronchospasm or reduced pulmonary compliance may negate the benefit of an SGA, as high airway pressures overwhelm the low-pressure seal.

SHORT — Predicting Difficult Surgical Airway

S — Surgery / Scarring: Previous neck surgery or radiation fibrosis distorts landmarks.
H — Hematoma: Expanding neck hematoma from trauma or vascular injury obscures the cricothyroid membrane.
O — Obesity: Excess subcutaneous tissue increases the depth to the airway and makes landmark palpation difficult.
R — Radiation distortion: Prior radiation therapy to the neck causes dense fibrosis and vascularity changes.
T — Tumor: Thyroid masses, goiter, or anterior neck tumors displace or obscure the cricothyroid membrane.

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Clinical Pearl

When multiple mnemonics flag the same patient as "difficult," the risk compounds. A patient who scores high on both LEMON and MOANS is telling you that neither intubation nor BVM ventilation will be straightforward—prepare your surgical airway kit before you begin.

SECTION 5

Detailed Anatomical Landmarks and Device Classification

Successful airway strategy selection requires an intimate understanding of the anatomy through which each device must pass. The airway is conventionally divided into the upper airway (nasal cavity, oral cavity, pharynx) and the lower airway (larynx, trachea, bronchi). Devices are classified by where they terminate relative to the glottis: basic adjuncts (OPA, NPA) maintain the upper airway, supraglottic airways seat above or around the glottic opening, endotracheal tubes pass through the glottis into the trachea, and surgical airways access the trachea below the glottis via the cricothyroid membrane.

This schematic sagittal view maps the four device categories to their anatomical zones. Dashed lines connect each device class to its target region. Note that the glottis (vocal cords) is the key anatomical dividing line: devices above it are supraglottic, those passing through it are infraglottic, and the surgical airway bypasses it entirely.

The diagram clarifies why strategy selection is fundamentally an anatomical decision. When a patient's upper airway is obstructed at the level of the oropharynx—by a tumor, hematoma, or angioedema—a supraglottic device may be unable to achieve a seal, and an endotracheal tube may be impossible to visualize. In that scenario, the anatomy itself dictates that a surgical airway may be the only viable option. Conversely, a patient with a straightforward upper airway but significant lower airway disease (e.g., severe bronchospasm) may intubate easily but require careful ventilator management post-placement. The assessment must account for the entire airway, not just the glottic view.

SECTION 6

Worked Example — Field Airway Assessment

Consider the following scenario: You are called to a 58-year-old male found unresponsive in his home. He weighs approximately 130 kg (BMI ≈ 42), has a thick beard, and his wife reports he has a history of obstructive sleep apnea. He has sonorous respirations at 6 breaths per minute with an SpO₂ of 82% on room air. There is no evidence of trauma, and his cervical spine is mobile.

Systematic Airway Assessment and Strategy Selection

1
Step 1 — Immediate Assessment and BVM Viability (MOANS)

Begin by assessing whether BVM ventilation will be effective while you prepare for a definitive airway. Apply the MOANS mnemonic: M — the thick beard will compromise mask seal (positive). O — morbid obesity with BMI 42 (positive). A — age 58, over 55 (positive). N — teeth present (negative). S — history of OSA suggests pharyngeal tissue redundancy and possible stiffness (positive). Four of five factors are positive.

BVM ventilation predicted to be DIFFICULT. Plan for two-person BVM technique; preoxygenate aggressively.
2
Step 2 — Evaluate Intubation Difficulty (LEMON)

L — external look reveals obesity, short thick neck, and beard (positive). E — 3-3-2 evaluation: mouth opening appears adequate (≈3 FB), but hyoid-to-chin distance is reduced due to obesity (approximately 2 FB), and thyroid notch distance is borderline. M — patient is unresponsive so formal Mallampati cannot be obtained, but the wife confirms loud snoring and diagnosed OSA, suggesting Class III–IV. O — morbid obesity (positive). N — neck mobility is intact (negative).

Intubation predicted to be DIFFICULT (4/5 LEMON factors positive).
3
Step 3 — Evaluate SGA Viability (RODS)

R — mouth opening is adequate (negative). O — no fixed obstruction noted (negative). D — no disrupted anatomy (negative). S — no significant lower airway stiffness (negative). All four factors are negative.

SGA placement predicted to be FAVORABLE. This becomes Plan A.
4
Step 4 — Evaluate Surgical Airway (SHORT)

Although not the planned primary device, assess the surgical pathway as a safety net. S — no prior neck surgery (negative). H — no hematoma (negative). O — obesity is significant; landmarks may be palpable but difficult (positive). R — no radiation (negative). T — no tumor (negative).

Surgical airway feasible but may be moderately difficult due to obesity. Prepare kit proactively.
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Step 5 — Formulate the Strategy

Integrating all four assessments, the strategy is: preoxygenate with two-person BVM technique using an OPA/NPA and ramped positioning (head of bed elevated 25°). Plan A: Supraglottic airway (King LT or i-gel, size selected by patient weight). Plan B: Video laryngoscopy-assisted endotracheal intubation with a bougie (VL improves glottic view in obese patients). Plan C: Surgical cricothyrotomy with kit at bedside. Confirm all placements with waveform capnography.

Final Strategy: SGA → VL-ETI → Surgical. All equipment staged before first attempt.

SECTION 7

Strengths and Limitations of Advanced Airway Devices

No single airway device is ideal for every patient or every scenario. Understanding the relative strengths and limitations of each device class allows the paramedic to match the tool to the clinical situation. The table below compares the three primary advanced airway categories across dimensions that matter most in the prehospital environment.

Dimension	Supraglottic Airway (SGA)	Endotracheal Tube (ETT)	Surgical Airway (Cric)
Ease of Placement	High — blind insertion, minimal training needed for basic competency	Moderate — requires visualization of cords, significant training and ongoing practice	Low — invasive, rarely performed, high-stress situation
Aspiration Protection	Partial — low-pressure seal does not fully isolate trachea	Excellent — inflated cuff provides direct tracheal seal below the glottis	Good — cuffed surgical tubes seal below vocal cords
Ventilation Efficacy	Good at normal pressures; may leak at high pressures (> 20–25 cmH₂O)	Excellent — tolerates high pressures, allows precise PEEP and volume control	Adequate — smaller tube diameter increases resistance; limited by tube size
First-Pass Success (EMS)	≈ 85–95%	≈ 70–85% (varies widely by experience and use of VL)	≈ 90% in trained hands (limited field data)
Complications	Gastric insufflation, aspiration, incomplete seal, airway edema if left in place too long	Esophageal intubation, right mainstem, vocal cord injury, prolonged attempt → hypoxia	Hemorrhage, false passage, subcutaneous emphysema, posterior tracheal wall injury
Best Indications	Cardiac arrest, predicted difficult intubation, limited provider experience, short transport	Need for definitive airway, aspiration risk, prolonged transport, need for precise ventilation	Cannot intubate / cannot ventilate (CICV) scenario, complete upper airway obstruction

Comparative analysis of advanced airway device classes for prehospital use

✦

KEY TAKEAWAY

Selecting an airway device is like choosing the right tool in a mechanic's toolbox. A wrench is versatile and easy to use (SGA), a torque wrench gives you precise control but requires calibration and skill (ETT), and a cutting torch is your last resort when nothing else works (surgical airway). The best mechanic—and the best paramedic—knows which tool fits the job before picking one up, and always has a backup plan if the first tool doesn't work.

SECTION 8

Connection to Advanced Theory — RSI and Drug-Assisted Airway

The assessment principles discussed in this lesson form the foundation for more advanced airway interventions, most notably rapid sequence intubation (RSI). RSI involves the near-simultaneous administration of an induction agent (e.g., ketamine, etomidate) and a neuromuscular blocking agent (e.g., succinylcholine, rocuronium) to render the patient unconscious and paralyzed, creating optimal intubating conditions. However, RSI commits the paramedic to securing an airway—once the patient is paralyzed, there is no voluntary breathing to fall back on. This makes pre-RSI assessment using LEMON, MOANS, RODS, and SHORT not just recommended but absolutely critical. A failed RSI with no viable backup plan is among the most dangerous situations in prehospital medicine.

Concept	Basic Strategy Selection (This Lesson)	RSI-Level Decision-Making (Advanced)
Assessment Tools	LEMON, MOANS, RODS, SHORT	Same tools + Cormack-Lehane grading, thyromental distance ratio, physiologic assessment (pH, hemodynamics)
Pharmacology	Not applicable — patient is either unconscious or airway managed without sedation	Induction agent selection, paralytic choice, pretreatment medications, post-intubation sedation
Risk Level	Moderate — failed attempts allow return to BVM ventilation in most cases	High — paralysis eliminates the patient's ability to breathe spontaneously; failure = apnea
Decision Consequence	Device can usually be removed and alternative attempted	Committed once medications given; must succeed with Plan A, B, or C within the apnea window
Post-Placement Mgmt	Confirmation with ETCO₂, ongoing SpO₂ monitoring	Same + continuous sedation, ventilator management, peri-intubation arrest prevention

Progression from basic strategy selection to RSI-level airway management

As you advance in your paramedic training, you will build upon the assessment framework presented here to incorporate pharmacologic decision-making, hemodynamic optimization prior to intubation, and post-intubation management strategies. The key insight is that RSI does not change the assessment—it raises the stakes of the assessment. The same LEMON, MOANS, RODS, and SHORT evaluations that guide device selection in this lesson become life-or-death prerequisites when paralytic agents are involved.

SECTION 9

Practice Problems

Question 1: CONCEPTUAL

A paramedic student states: "If I can see the vocal cords, I should always intubate." Explain why this reasoning is incomplete from an advanced airway assessment perspective.

Show answer

Visualizing the vocal cords addresses only one component of the airway assessment—the glottic view during laryngoscopy. Advanced airway strategy selection requires evaluation of the entire clinical picture, including whether BVM ventilation is possible (MOANS), whether a backup device will work (RODS), whether a surgical airway is feasible (SHORT), and whether the patient's physiologic status can tolerate the attempt. Additionally, contextual factors such as provider experience, available equipment, transport time, and the patient's underlying condition must inform the decision. A visible glottis does not guarantee successful tube passage (e.g., anterior larynx, subglottic stenosis), nor does it mean intubation is the best strategy for a particular patient at that moment.

Question 2: BASIC CALCULATION

You are assessing a 45-year-old female using the LEMON mnemonic. She has a mouth opening of 2 finger-breadths, a hyoid-to-chin distance of 3 finger-breadths, and a thyroid notch-to-floor of mouth distance of 2 finger-breadths. Her neck has full range of motion, and no external abnormalities are noted. Which component(s) of the 3-3-2 rule does she fail, and what does this predict?

Show answer

The 3-3-2 rule requires: (1) mouth opening ≥ 3 finger-breadths, (2) hyoid-to-chin ≥ 3 finger-breadths, and (3) thyroid notch-to-floor of mouth ≥ 2 finger-breadths. This patient fails the first measurement with only 2 finger-breadths of mouth opening. The hyoid-to-chin distance (3 FB) and thyroid notch distance (2 FB) both meet the minimum thresholds. A reduced mouth opening (< 3 FB) predicts difficulty with both laryngoscope blade insertion and endotracheal tube passage. This finding, scored under the 'E' in LEMON, should prompt the paramedic to consider a supraglottic airway as Plan A or to have a video laryngoscope with a hyperangulated blade immediately available, as well as to verify that a surgical airway is feasible as an ultimate backup.

Question 3: INTERMEDIATE

You respond to a 72-year-old male in cardiac arrest. He is edentulous (no teeth), has a BMI of 35, and his family reports a history of neck radiation therapy for throat cancer three years ago. His anterior neck has palpable fibrotic tissue changes. Perform a complete multi-mnemonic assessment (MOANS, LEMON, RODS, SHORT) and propose a tiered strategy.

Show answer

MOANS assessment: M — edentulous jaw complicates mask seal (positive); O — obesity BMI 35 (positive); A — age 72 (positive); N — no teeth (positive); S — unknown lung stiffness but age and body habitus suggest possible (borderline). MOANS = 4/5 positive → BVM will be difficult. LEMON assessment: L — edentulous, obese (positive); E — may have reduced distances due to obesity and radiation changes (positive); M — cannot assess Mallampati in arrest, but radiation history suggests tissue changes (positive); O — obesity and possible post-radiation narrowing (positive); N — radiation fibrosis may limit neck extension (positive). LEMON = 5/5 → intubation predicted very difficult. RODS assessment: R — mouth opening may be limited by radiation fibrosis (potentially positive); O — possible residual tumor or stenosis (potentially positive); D — radiation-distorted anatomy (positive); S — unknown (neutral). RODS = 2–3/4 → SGA may also be challenging. SHORT assessment: S — no prior surgery but radiation (borderline); H — no hematoma (negative); O — obesity (positive); R — prior neck radiation with fibrosis (positive); T — history of throat cancer, possible residual or recurrent mass (positive). SHORT = 3/5 → surgical airway will be difficult. This patient has predicted difficulty across all four modalities—a true "can't intubate, might not ventilate" risk. Strategy: maximize BVM with two-person technique, oral and nasal airways, and ramped positioning. Plan A: SGA (attempt despite moderate difficulty prediction, as it has the highest first-pass success rate). Plan B: video laryngoscopy with bougie-assisted ETI. Plan C: surgical cricothyrotomy with kit pre-opened at bedside. Consider early notification of the receiving facility for an awake surgical airway or fiberoptic-assisted approach if ROSC is achieved.

Question 4: APPLIED

You are treating a 28-year-old female with severe facial burns and progressive stridor following a house fire. She is conscious and anxious, with singed nasal hairs, carbonaceous sputum, and visible facial edema that is worsening. Her SpO₂ is 94% on 15 L non-rebreather. She has a normal body habitus and full neck mobility. Transport time to the nearest burn center is 35 minutes. Describe your airway assessment, explain why timing is critical, and outline your strategy.

Show answer

This patient has classic signs of inhalation injury with progressive upper airway edema: singed nasal hairs, carbonaceous sputum, stridor, and worsening facial swelling. The critical time pressure here is that airway anatomy is changing in real-time—what may be an achievable intubation now could become impossible in 15–20 minutes as edema progresses. MOANS: facial burns and edema will impair mask seal (positive); no obesity, age, dental, or stiffness issues (negative × 4). BVM is currently feasible but may deteriorate. LEMON: L — facial burns and edema (positive); E — currently adequate but narrowing (positive and worsening); M — likely Class I–II now but worsening (borderline); O — progressive airway edema is the dominant concern (positive); N — neck mobile (negative). Intubation is feasible now but difficulty is increasing rapidly. RODS: currently all negative, but edema could compromise SGA seal. SHORT: normal neck anatomy, no complicating factors (all negative). Strategy: This is a time-sensitive situation that demands early, elective intubation rather than watchful waiting. Plan A: endotracheal intubation via video laryngoscopy (which provides the definitive airway protection needed for a 35-minute transport with worsening edema). Use the largest ETT that will pass, anticipating that post-intubation edema may make reintubation impossible if the tube is dislodged. Plan B: SGA as a temporizing measure. Plan C: surgical cricothyrotomy. The key clinical decision is to intubate now while anatomy is favorable rather than waiting until the airway has swollen shut. A smaller ETT (6.0–6.5) should be immediately available if the standard size cannot pass through edematous tissues.

Question 5: CRITICAL THINKING

A rural EMS system is debating whether to equip its paramedics with video laryngoscopes (VL) in addition to direct laryngoscopes (DL). The medical director argues that VL improves first-pass success rates in difficult airways but is more expensive and requires additional training. The EMS chief argues that SGAs achieve equivalent patient outcomes in cardiac arrest with less training burden. Using the airway assessment and strategy selection framework from this lesson, construct an evidence-informed argument that reconciles both positions. Address which patient populations and clinical scenarios would benefit most from VL availability, and which would be adequately served by SGA-first protocols.

Show answer

Both positions have merit, and the airway assessment framework actually provides the reconciliation. The strategy selection model teaches that device choice should be driven by patient assessment, not by a one-size-fits-all protocol. For cardiac arrest—which constitutes the majority of prehospital advanced airway encounters—evidence from the AIRWAYS-2 and PART trials demonstrates that SGAs achieve non-inferior neurologic outcomes compared to ETI, with higher first-pass success and fewer interruptions in compressions. In these patients, LEMON and MOANS scores are often moot because the goal is rapid airway control without interrupting CPR. An SGA-first protocol is well-supported here. However, there are specific patient populations where VL-assisted ETI offers clear advantages: patients with progressive airway edema (burns, anaphylaxis) who need a definitive seal before anatomy worsens; patients at high aspiration risk (active vomiting, GI hemorrhage) where the superior seal of a cuffed ETT is clinically meaningful; patients requiring prolonged transport where SGA complications (leak, gastric insufflation) compound over time; and patients with LEMON scores suggesting moderate difficulty where VL's improved Cormack-Lehane view can convert a Grade III to a Grade I. The optimal system-level solution is therefore a tiered approach: equip all units with SGAs as the default Plan A for cardiac arrest and predicted-difficult-intubation patients, invest in VL for situations where the assessment framework indicates ETI is the better primary strategy, and ensure all paramedics maintain surgical airway competency as Plan C. Training should emphasize the assessment-first philosophy, teaching providers when to reach for which tool rather than defaulting to one device for all scenarios. This approach honors both cost-effectiveness and patient-centered care.

SUMMARY

Lesson Summary

Summary

Advanced airway assessment and strategy selection is the systematic process of evaluating a patient's anatomy, physiology, and clinical context to choose the safest and most effective airway management strategy before any intervention begins. The four core mnemonics—LEMON (difficult intubation), MOANS (difficult BVM), RODS (difficult SGA), and SHORT (difficult surgical airway)—provide structured, rapid assessments that predict difficulty across all four airway modalities. The results guide a tiered strategy with a Plan A, Plan B, and Plan C determined before the first attempt.

Key principles include prioritizing oxygenation over intubation, choosing devices based on patient-specific assessment rather than protocol default, and confirming every placement with waveform capnography (ETCO₂). Supraglottic airways offer high first-pass success and are ideal for cardiac arrest and predicted-difficult-intubation scenarios. Endotracheal intubation provides the most definitive airway protection but demands greater skill and carries higher risk of failed attempts. Surgical cricothyrotomy is reserved for cannot-intubate, cannot-ventilate emergencies and should always be prepared as the ultimate rescue. This assessment-first philosophy forms the foundation for all advanced airway interventions, including rapid sequence intubation (RSI), where the stakes of a failed plan are highest.