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Category: Airway

Topic: Advanced Airway Management

Level: AEMT

Next Unit: Assessing Difficult Airways

16 minute read

Blind Insertion Airway Devices (BIAD's)

With the importance of maintaining the airway and the sheer number of patients who experience airway compromise, several companies have created devices to ease the process of obtaining a "definitive airway." A definitive airway is one that cannot be easily compromised by vomit, secretions, or swelling. (e.g. a tube of plastic that maintains a path for air at all costs).

This role was traditionally played by intubation and placement of an endotracheal tube in the past. However, the complexity of this procedure lead to frequent failures in the uncontrolled EMS environment. BIAD's are tools that simplify this process, per the name, they can be inserted blindly; without visualization of the vocal cords to confirm placement. 

This section will review the indications for BIAD use, the two most common types, and the usage of BIADS in general.


Indications, Contraindications, and Complications

INDICATIONS: BIAD's are used when a definitive/advanced airway is required and intubation is either unsuccessful or unrealistic to perform. The indications for an advanced airway are as follows:

  • An unresponsive patient who is hypoxic despite adequate BVM ventilation
  • Patient with trauma to the face/neck who is experiencing confirmed or suspected swelling.
  • Penetrating injury to the head or neck 
  • More routine injuries with suspected long transport times

CONTRAINDICATIONS: The contraindications to BIAD are focused around causing vomiting, bleeding, or potentially perforating the larynx/esophagus. They are as follows:

  • an intact gag reflex
  • known esophageal disease (cancer, varices, stricture)

Cancer tissue is very fragile--you can easily perforate the esophagus (or trachea in laryngeal or tracheal cancer) without even feeling the breach of resistance! 

  • laryngectomy with a stoma
  • caustic ingestion or airway burns
  • stature < 4 feet

COMPLICATIONS: The complications of BIAD use surround the nature of pushing a rigid tube into relatively soft tissue and inflating a balloon within it (trauma/compression) along with the risk of inflating the stomach.

  • Inflation of the stomach leading to regurgitation and aspiration of gastric contents
  • compression of vascular structures in the neck
  • trauma to the airway/esophagus
  • nerve injury to the "laryngeal nerves" that control the vocal cords.
  • Hypotension due to positive pressure ventilation and/or stimulation of the vagus nerve.



The Combitube is the most common BIAD and has many trade names, the most common being "KING airway device." These tubes are "dual lumen devices" their tube has two channels within, one channel ends at the end of the tube like a traditional ET tube, the other ends between the two inflatable balloons.

The goal of this device is an insertion into either the larynx or esophagus. Since the esophagus is much easier to access the lower balloon generally seals off the esophagus, then the upper balloon will naturally seal off the bottom of the pharynx. This allows air to be sent through the secondary lumen, exiting between the two balloons and entering the larynx! This is confirmed by listening for breath sounds and watching for chest rise.

In the rare case that the tube is inserted into the larynx, the primary lumen can be used to ventilate just like a traditional ET tube. This is suspected when ventilation of the secondary lumen does not result in breath sounds or chest rise.

The time usage of this tube becomes complicated is if the patient has a bilateral pneumothorax, in which case auscultation is not a reliable method of confirming placement.

Laryngeal Masks

The laryngeal mask airway (LMA) is essentially an ET tube that goes over the larynx as opposed to into it. These devices are less common than combitubes outside the hospital but may be used in patients who are being transferred between facilities. 

The LMA is placed blindly, after measuring the patient it is pushed into the oropharynx until resistance is met, then the cuff is inflated. If placed correctly, it will sit atop the glottis and protect the airway from vomit/blood/secretions. Like a combitube, auscultation for breath sounds is the preferred method of confirming placement. 


Usage of BIADS

To place any BIAD:

  1. make sure the patient is being pre-oxygenated with 100% O2 for at least 30 seconds.
  2. assemble your equipment: Suctioning, lubricant, oxygen, BVM, and at least two full correctly-sized BIAD devices.
  3. Check the equipment to ensure it is in working order.
    (If the BIAD of choice is the King LTD airway or the Combitube, ensure the cuffs will inflate to the proper pressure.)
  4. Lubricate the distal tip of the BIAD and open the patient’s airway.
  5. Remove any adjunct (OPA, NPA) present and suction airway of any secretions.
  6. Insert the BIAD at a 90º angle (pointing to the right or left corner of the mouth) with the distal tip sliding back over the patient's tongue.
  7. Rotate the BIAD to be in line with the patient's airway.
  8. Continue to advance the device until the phalange rests against the patient’s teeth.
  9. Inflate the pilot balloon with air from the included syringe to the manufacturer-indicated pressure.
  10. To confirm correct placement, connect to capnography or capnometry and then to the BVM, and auscultate over the abdomen as a breath is delivered
  • If no breath sounds are heard in the abdomen, move up to auscultate the L lung first, then the R (right main stem placement is rare but possible.)
  • If breath sounds are heard in the abdomen, deflate the front (pilot) balloon some and withdraw the BIAD a few centimeters, remembering to re-inflate the balloon when finished. Auscultation over the stomach should produce no breath sounds.
  • If no breath sounds are auscultated in the L lung but are present in the R lung, perform the same method as was described for abdominal breath sounds and reassess until equal sounds are auscultated in the L and R lung.

11. Secure the device with a commercial tube holder or by other protocol-indicated means and monitor SPO2 and ETCO2 for changes.


  • Be aware that a pneumothorax could prevent bilateral breath sounds even with correct placement.
  • Always use a water-based lubricant when necessary, e.g., KY jelly, Trachjell. Never petroleum based, e.g., Vaseline.
  • Combitubes are contraindicated in children < 16 years of age or under 5' tall.