Airway Management Procedure Note

(If any core metadata element is unknown, document "Unknown/Not recorded" rather than leaving blank. Use concise, factual language. Convert times to local format consistently.)

Procedure: [Endotracheal Intubation / Supraglottic Airway Placement / BVM Ventilation with Adjuncts / Basic Airway Adjunct(s) Placement / Other: specify]

Date/Time: [Start date/time] | [Airway secured date/time (if applicable)]

Location: [ED / ICU / OR / Ward / Transport / Other: specify]

Operators: [Primary airway operator] | [Assistant(s) and roles]

Urgency: [emergent / urgent / non-emergent]

Patient Position: [sniffing / ramped / head-up / neutral / C-spine precautions / Other: specify]

Indication

[Primary indication: failure to oxygenate / failure to ventilate / inability to protect airway / airway obstruction / anticipated clinical deterioration / procedural or anesthetic need / cardiac arrest / severe agitation preventing oxygenation / Other: specify]. [Relevant clinical context and risk factors, including aspiration risk, physiologic instability, or trauma with C-spine precautions if present]. Post-procedure status: [Airway secured with ETT/SGA / Airway supported with BVM and adjuncts].

Consent and Time-Out

• Consent: [verbal / written / not obtained: emergent and life-threatening / not obtained: patient incapacitated]
• Team brief/Time-out: [performed / not performed / not feasible due to emergency] (If performed, note that patient identity, planned approach, backup plan, and roles were confirmed. If completed under separate institutional workflow, reference that documentation.)

Pre-Procedure Assessment

• Access: [IV/IO access and adequacy]
• Pre-intubation vitals: SpO2 [value]% | HR [value] bpm | BP [value] mmHg
• Positioning: [Patient positioning prior to attempts]
• Monitoring and readiness: [SpO2 / ECG / NIBP / arterial line / waveform capnography] | Suction ready: [yes / no] | Oxygen source confirmed: [yes / no]
• Airway difficulty screening: Anticipated difficulty: [yes / no / uncertain] | Key predictors if present: [limited mouth opening / neck immobility / facial trauma / obesity / airway contamination / prior difficult airway / other: specify]
• Pre-oxygenation: Method: [NRB / BVM with PEEP / NIV-CPAP / HFNC / ventilator / other] | Duration or adequacy: [e.g., 3 minutes tidal breathing / until SpO2 ≥94% / unable due to crashing airway] | Apneic oxygenation: [used / not used]

Medications

(Include when medications were used. If none used, state "No medications used" with reason such as cardiac arrest or crash airway.)

• Technique: [RSI / modified RSI / sedation-only / awake intubation / crash airway / cardiac arrest airway]
• Induction/sedation: [Medication name, dose, route, time] (Add additional agents as needed.)
• Neuromuscular blocker: [Medication name, dose, route, time] (Add additional agents as needed.)
• Adjuncts: [Vasopressor / topicalization / antisialagogue / analgesic / other: medication name, dose, route, time] (Include only if used.)

Attempt Log

(Document every airway attempt chronologically, even if only one. Add additional attempt subsections as needed. Include only fields relevant to the device used.)

Attempt 1

• Operator: [Name/role]
• Device category: [BVM / Basic adjunct / SGA / ETT]
• Approach: [oral / nasal] | [awake / post-induction] (Include for ETT/SGA.)
• Laryngoscopy method: [direct / video] | Blade: [type, size] (Include for ETT.)
• Airway view grade: [Cormack-Lehane grade I-IV / POGO %] (Specify system used. Include for ETT.)
• Adjuncts used: [Bougie / Stylet / External laryngeal manipulation / Cricoid pressure / None]
• SGA details: Type: [type] | Size: [size] | Insertion approach: [approach] (Include for SGA.)
• ETT details: ID: [size] mm | Depth at [teeth / lip]: [depth] cm | Cuff inflated: [yes / no] (Include for ETT.)
• BVM/adjunct details: [OPA size / NPA size / two-person technique / jaw thrust / PEEP valve setting] | Ventilation effectiveness: [chest rise present/absent, SpO2 response] (Include for BVM.)
• Result: [successful / unsuccessful: poor view / secretions / inability to advance / desaturation / other: specify]
• Optimization before next attempt: [repositioning / additional suction / device change / bougie / external manipulation / release of cricoid / other] (Include if unsuccessful.)

Attempt [number]

(Repeat structure above for each additional attempt.)

Confirmation of Placement

(Required. Primary confirmation should be waveform capnography when available. Do not document tube as confirmed based solely on SpO2 improvement, chest radiograph, or auscultation.)

• Primary confirmation: Waveform capnography: [persistent waveform present / absent / unavailable: reason] | ETCO2: [value] mmHg
• Additional confirmation methods: [Direct visualization through cords / Bilateral breath sounds with absent epigastric sounds / Visible chest rise / Condensation in tube / Ultrasound / Bronchoscopy]
• Chest radiograph: [ordered / not ordered]

Post-Procedure Status

• Oxygenation/Ventilation: SpO2 [value]% | ETCO2 [value] mmHg | Breath sounds: [findings] | Chest rise: [symmetric / asymmetric / absent]
• Hemodynamics: BP [value] mmHg | HR [value] bpm | Rhythm: [rhythm] | Vasopressor: [none / agent and dose]
• Ventilator settings: Mode: [mode] | FiO2: [value]% | PEEP: [value] cmH2O | Rate: [value]/min | TV or pressure: [value] (Include if mechanically ventilated.)
• Sedation/analgesia plan: [Agent(s), dosing strategy, and titration plan]
• Airway device security: Secured with: [holder / tape] | Bite block: [yes / no]
• Reassessment plan: [Continuous waveform capnography / Depth recheck after transfer / Chest radiograph / Repeat blood gas / Other]

Complications

[No immediate complications noted] OR [Complications as follows:]

(If complications occurred, document type, timing relative to induction, severity, and treatment provided. Include: hypoxemia with lowest SpO2, hypotension or arrhythmia, esophageal intubation recognized and corrected, aspiration or regurgitation, dental or oropharyngeal trauma, laryngospasm or bronchospasm, airway edema, rescue airway required, or equipment failure.)

[Complication details and management]

Handoff and Difficult Airway Summary

(Include when applicable.)

• Handoff recipient: [Name/role] | Key information communicated: [Device and depth, confirmation method, complications and treatments, ventilator settings, sedation plan]
• Difficult airway summary: Difficulty with: [ventilation / intubation / both] | What worked: [successful technique] | Recommended future approach: [recommendations] (Include if airway was difficult or high-risk.)
• Team debrief: [performed / not performed]

Attestation

I performed or directly supervised this airway management procedure as documented above.

Proceduralist: [Name, credentials] | Date: [Date] | Time: [Time]

Signature: ______________________________