Nurse A is a staff nurse on a general medical-surgical ward in a small hospital answering a call light. On arrival, her patient, an elderly woman who has had a minor surgical procedure, is coughing and snoring loudly and her daughter is concerned about her condition.

Using the bedside call light, Nurse A sends for help. This is an uncommon occurrence in the otherwise stable patient recovering from surgery and may be a precursor of more serious problems.

Nurse A then speaks to her patient and determines her level of consciousness. Some patients may respond appropriately and immediately clear their own airway. However, in this case, the patient does not respond to verbal stimuli.

Next, Nurse A places the head of the bed flat and removes the headboard. She gently places her thumb under the center of the patient's chin and displaces her chin upward, toward the ceiling. The tongue is the most likely anatomic structure to occlude the airway, and displacing it from the oropharynx may result in the return of spontaneous respirations. Nurse A's patient begins to breathe, though her respiratory rate is still somewhat low at 8 to 10 breaths per minute.

By now, the help team has begun to arrive, and they bring the emergency cart containing medications and monitoring devices. In the event further equipment is needed, it is now instantly available. Oxygen is administered via a simple mask, and a pulse oximeter is placed on the patient's finger, revealing a blood oxygen level of 90%, which increases over five minutes to 95%.

A review of the record by one of the assisting staff members reveals the patient received an intramuscular dose of an opioid 15 minutes before the call light was pressed. In order to determine if this is the underlying etiology for the problem, a small dose of naloxone is administered. Almost immediately, the patient begins to respond to verbal stimuli. In this case, the patient had an idiosyncratic response to opioid administration.

The only action necessary to re-establish the patient's airway and ventilation was to displace the patient's tongue from her oropharynx. After help arrived, a more in-depth investigation into the cause of the airway problem could be completed, and definitive therapy (narcotic reversal) applied.

Dr. T is the staff psychologist in a multidisciplinary mental health clinic. His next patient has a 50-minute counseling session scheduled. As she is sitting and discussing her concerns, she becomes increasingly restless, squirming in her chair and unable to become comfortable. Dr. T notices her breathing is becoming labored and invites her to lie down. As the patient stands to move to the recliner, she loses consciousness, falling to the floor.

This is a very unusual emergency for the facility's multidisciplinary team, and the patient's condition appears to be rapidly degrading. Dr. T calls out, and when the door opens, he instructs the receptionist to call 911.

Dr. T rolls the patient over and attempts to awaken her, with no response. Her breathing is noisy and labored, so he places her supine and performs a chin-lift technique. Help is on the way, and Dr. T has few tools available, so opening the airway is the easiest and quickest way to possibly improve the situation.

As Dr. T tilts the patient's head back, he notices a rash around her nose and mouth and on her upper chest, which is exposed by a V-neck shirt. She has a bracelet on her right arm that says "PEANUTS" and has a medical symbol beside it. At the same time, the receptionist brings in a large first-aid kit that includes a BVM device. The patient's breathing is now very noisy, and her chest is barely moving. Dr. T begins to ventilate the patient, holding the mask with two hands while an assistant squeezes the bag. Despite opening the airway, the patient is still breathing inadequately and help has not yet arrived. So, the ventilation Dr. T provides is a bridge to the arrival of paramedics.

Paramedics arrive on the scene with oxygen and advanced drugs and equipment. Dr. T relates his findings while they apply oxygen to the BVM device and insert an intravenous line. This patient may need more advanced interventions, and the drugs are best given intravenously. The paramedics note the patient is wheezing and decide to administer epinephrine for a suspected anaphylactic response. Within minutes, the patient's wheezing stops, and she begins to breathe and responds to verbal stimuli.

Paramedics have relieved Dr. T of the care of this patient and provide supplemental oxygen to prepare for transport. Dr. T's prompt interventions provided the necessary bridge to definitive care.

Mr. N is a staff nurse on the night shift in the emergency department. A woman, 70 years of age, with acute shortness of breath and palpitations stumbles toward the triage desk, collapsing into the chair at the vital signs station and gasping for breath. Her blood pressure is low, and her respiratory rate is 35 breaths per minute. She is unable to complete sentences due to her labored ventilations.

Clearly, this patient is in extremis, and Mr. N requires help simply to move her to an emergency treatment room. It seems clear that this patient will need advanced interventions, so additional help is called for.

Airway and ventilation are the first priorities, and Mr. N applies oxygen in a rebreather mask. This patient is significantly short of breath, and oxygen will immediately begin to alleviate this condition in nearly every circumstance.

Mr. N remains at the head of the bed and continues to monitor the patient's ventilatory status, while ensuring the presence of a BVM device and that suction is readily available. The emergency team is present and working to apply monitors and obtain intravenous access; this allows Mr. N to focus all his attention on the patient's ventilatory status and to ascertain the patient's level of consciousness.

The team continues to work and determines the patient is going into respiratory failure. As such, Mr. N begins to prepare for endotracheal intubation. This patient will require mechanical ventilation to allow time for more definitive care. Anesthesia has been summoned to provide advanced airway management. Mr. N begins to review available tools; monitors are already applied, suction is present, and a BVM device (machine) is ready. Mr. N assembles the necessary laryngoscope with straight and curved blades as well as endotracheal tubes with the preferred size (and one size larger and smaller). Finally, Mr. N assembles the drugs and syringes on top of the cart to complete the necessary preparations. The anesthesia care provider arrives, assesses the patient's airway and condition, and is immediately ready to perform endotracheal intubation. Mr. N's preparations have decreased the time between the decision to intubate and the actual performance of the intubation.