When EMTs May Consider an SGA
- • The patient is in cardiac arrest.
- • Basic airway maneuvers are ineffective.
- • BVM ventilation is inadequate or difficult.
- • The provider is trained and authorized.
- • Waveform capnography is immediately available.
GrumpyMedic Education Course
BLS Airway & Capnography
EMT-level training covering supraglottic airway use, iGel preparation and insertion, ventilation, continuous waveform capnography, ETCO₂ interpretation, and airway troubleshooting.
EMT-Level CareSupraglottic AirwayiGelWaveform CapnographyCardiac Arrest
Section 01
Learning Objectives
By the end of this course, the learner should be able to:
Identify indications and contraindications for supraglottic airway placement.
Select the appropriate iGel size.
Describe proper iGel preparation and insertion.
Confirm airway placement using waveform capnography.
Interpret common ETCO₂ values and waveform changes.
Troubleshoot ineffective ventilation or failed SGA placement.
Section 02
Scope of Practice
This course focuses on EMT-level airway care during cardiac arrest.
Important Priorities
- • High-quality CPR remains the top priority.
- • Do not delay compressions for airway placement.
- • Continue basic airway care when it is effective.
- • Follow current statewide and local protocols.
Training and Authorization Required
A supraglottic airway may only be used within the provider’s current training, authorization, service policy, medical direction, and statewide scope of practice.
Section 03
What Is a Supraglottic Airway?
A supraglottic airway sits above the vocal cords and provides an alternative method of ventilation.
Placement
The device is inserted through the mouth and rests above the laryngeal opening.
Examples
Common supraglottic airway devices include the iGel, King airway, and laryngeal mask airway.
Purpose
An SGA can provide more consistent ventilation when basic airway maneuvers and BVM ventilation are inadequate.
Section 04
The iGel Airway
The iGel is a supraglottic airway designed for rapid insertion without an inflatable cuff.
Key Features
- • Non-inflatable anatomical cuff
- • Designed to seal around the laryngeal inlet
- • No cuff inflation step
- • Rapid preparation and insertion
- • Available in pediatric and adult sizes
Benefits
- • Fast placement
- • Minimal interruption in compressions
- • Does not require direct laryngoscopy
- • Works with waveform capnography
- • Provides a secure connection for ventilation
Section 05
Indications and Contraindications
Use the device only when the patient and clinical situation meet protocol requirements.
Consider an iGel When
- ✓The patient is in cardiac arrest.
- ✓Basic airway maneuvers are ineffective.
- ✓BVM ventilation is inadequate.
- ✓The patient has no intact gag reflex.
- ✓The provider is trained and authorized.
- ✓Capnography is immediately available.
Do Not Use When
- ✓The patient has an intact gag reflex.
- ✓A foreign-body obstruction has not been relieved.
- ✓The provider lacks training or authorization.
- ✓Severe facial or airway trauma prevents placement.
- ✓BVM ventilation is effective.
- ✓The device cannot be confirmed or ventilated effectively.
Section 06
iGel Size Selection
Select the device using the manufacturer’s weight-based sizing recommendations.
| Size | Weight | Color | Patient Category |
|---|---|---|---|
| 1 | 2–5 kg | Pink | Neonate |
| 1.5 | 5–12 kg | Blue | Infant |
| 2 | 10–25 kg | Gray | Small pediatric |
| 2.5 | 25–35 kg | White | Large pediatric |
| 3 | 30–60 kg | Yellow | Small adult |
| 4 | 50–90 kg | Green | Medium adult |
| 5 | 90+ kg | Orange | Large adult |
Verify Before Use
Always confirm the current manufacturer sizing chart and inspect the device packaging before insertion.
Section 07
Preparation
Prepare the airway device, ventilation equipment, and capnography before attempting placement.
- 1Select the correct iGel size.
- 2Inspect the device for damage or contamination.
- 3Apply water-based lubricant to the posterior surface.
- 4Avoid placing lubricant inside the airway opening.
- 5Prepare the BVM and oxygen source.
- 6Prepare the capnography adapter and sampling line.
- 7Position the patient according to training and protocol.
- 8Continue CPR and minimize interruptions.
Section 08
Insertion Technique
Insert the device smoothly and stop if significant resistance is encountered.
- 1Open the patient’s mouth.
- 2Hold the iGel by the integral bite block.
- 3Insert the device in the midline.
- 4Glide the cuff along the hard palate.
- 5Advance until firm resistance is felt.
- 6Do not force or twist the device.
- 7Connect the BVM and capnography adapter.
- 8Begin ventilation and immediately assess placement.
- 9Secure the airway after confirmation.
- 10Continue uninterrupted compressions.
Never Force the iGel
If the device does not advance normally, stop and reassess the patient’s position, airway, device size, and insertion technique.
Section 09
Confirming Placement
Waveform capnography is the most important method for confirming and continuously monitoring placement.
Continuous waveform capnography
Visible and symmetrical chest rise
Bilateral breath sounds
No sounds over the epigastrium
Improving oxygen saturation
Appropriate ventilation compliance
Confirmation Is Continuous
Continue assessing the waveform, ETCO₂ value, chest rise, breath sounds, device position, oxygen saturation, and ventilation compliance throughout patient care.
Section 10
If the SGA Fails
An ineffective supraglottic airway should not remain in place.
Troubleshooting Priorities
- ✓Check the BVM connection and oxygen source.
- ✓Check the capnography adapter and sampling line.
- ✓Assess chest rise and ventilation compliance.
- ✓Reposition the head and airway when appropriate.
- ✓Check device depth and securement.
- ✓Suction when indicated.
- ✓Remove the device if ventilation remains ineffective.
- ✓Immediately return to BVM ventilation.
- ✓Reattempt only when appropriate and without delaying CPR.
Section 11
What Is Capnography?
Capnography measures exhaled carbon dioxide and displays both a waveform and a numeric ETCO₂ value.
ETCO₂
End-tidal carbon dioxide is the concentration or partial pressure of carbon dioxide measured at the end of exhalation.
ETCO₂ is affected by ventilation, circulation, metabolism, airway integrity, and equipment function.
Waveform
The waveform displays exhaled carbon dioxide breath by breath. A consistent waveform supports proper airway placement and ventilation.
Trends are usually more important than a single isolated number.
Section 12
Why Capnography Matters
Capnography provides real-time information about airway placement, ventilation, circulation, and CPR.
Confirms advanced-airway placement
Continuously monitors ventilation
Helps assess CPR quality
May provide an early indication of ROSC
Detects airway dislodgement or obstruction
Identifies hyperventilation or hypoventilation
Section 13
Understanding the Waveform
A normal waveform has a square-like appearance with a consistent expiratory plateau.
Normal Waveform
A consistent waveform with a clear expiratory upstroke and plateau indicates detected exhaled carbon dioxide.
Irregular Waveform
An irregular waveform may indicate poor seal, movement, obstruction, altered ventilation, or equipment problems.
Flat Line
A flat waveform means no carbon dioxide is detected. Immediately assess the airway, circulation, ventilation, and equipment.
Section 14
Common Capnography Patterns
The waveform and trend often provide more useful information than a single ETCO₂ value.
Normal Waveform
35–45 mmHg
Pattern: Sharp rise, flat plateau, and rapid return to baseline.
What it may mean: Consistent ventilation with a recognizable expiratory plateau.
What to do: Know the patient’s baseline and continue trending.
Shark-Fin Pattern
Obstructive pattern
Pattern: Sloping expiratory rise with no clear flat plateau.
What it may mean: Commonly associated with bronchospasm, asthma, COPD, or expiratory obstruction.
What to do: Assess breath sounds, ventilation resistance, and response to treatment.
Falling ETCO₂
Downward trend
Pattern: The waveform remains present, but the value decreases over time.
What it may mean: May indicate worsening perfusion, shock, excessive ventilation, or declining cardiac output.
What to do: Reassess circulation, ventilation rate, CPR quality, and the patient’s overall condition.
Flat Line
No detected CO₂
Pattern: No measurable waveform is present.
What it may mean: May indicate airway displacement, apnea, absent perfusion, disconnected tubing, or equipment failure.
What to do: Immediately check the airway, patient, ventilation circuit, and monitor.
Low ETCO₂
Below expected range
Pattern: Small waveform with low numeric values.
What it may mean: May be caused by hyperventilation, poor perfusion, shock, pulmonary embolism, or poor-quality CPR.
What to do: Correct excessive ventilation and reassess perfusion and compression quality.
Rising ETCO₂
Upward trend
Pattern: Waveform height or numeric value rises over time.
What it may mean: May indicate hypoventilation, CO₂ retention, respiratory fatigue, rebreathing, or increased metabolism.
What to do: Assess ventilation adequacy, respiratory effort, equipment, and clinical deterioration.
The Power Is in the Trend
A single ETCO₂ number provides limited information. Watch the waveform, compare values over time, and correlate changes with the patient’s airway, ventilation, circulation, treatment response, and overall clinical condition.
Section 15
ETCO₂ Values
Interpret ETCO₂ together with the waveform and the patient’s overall clinical condition.
35–45 mmHg
Typical Normal Range
This is commonly considered a normal ETCO₂ range in a ventilating patient.
Below 10 mmHg During CPR
Poor Perfusion or Compression Concern
Persistently low ETCO₂ may indicate poor perfusion, inadequate compressions, or excessive ventilation.
Sudden Sustained Increase
Possible ROSC
A sudden sustained rise in ETCO₂ during CPR may indicate return of spontaneous circulation.
Above 45 mmHg
Possible Hypoventilation
A high ETCO₂ may indicate inadequate ventilation, rebreathing, or increased carbon-dioxide production.
Low ETCO₂
Possible Hyperventilation or Low Perfusion
Low values may occur with excessive ventilation, poor perfusion, shock, pulmonary embolism, or poor-quality CPR.
Section 16
Ventilation During CPR
Avoid excessive ventilation after an advanced airway has been placed.
Ventilation Rate
Provide approximately one breath every six seconds unless the applicable protocol directs otherwise.
Continuous Compressions
Continue chest compressions without pausing for ventilations after the advanced airway is placed.
Avoid Overventilation
Excessive ventilation can decrease venous return and reduce coronary and cerebral perfusion.
Section 17
Documentation
Document the airway procedure and capnography findings thoroughly.
Include in the Patient-Care Report
- ✓Indication for SGA placement
- ✓Device type and size
- ✓Number of placement attempts
- ✓Placement-confirmation findings
- ✓Initial and trending ETCO₂ values
- ✓Waveform presence and quality
- ✓Ventilation rate
- ✓Patient response
- ✓Troubleshooting or device removal
- ✓ETCO₂ changes associated with possible ROSC
Section 18
Key Takeaways
Remember these priorities during BLS airway management.
High-quality CPR remains the top priority.
Do not delay compressions for airway placement.
Use an SGA only within current training and authorization.
Select the correct iGel size.
Never force the iGel during insertion.
Use waveform capnography for confirmation and monitoring.
Remove the SGA and return to BVM if ventilation is ineffective.
Trend the waveform and ETCO₂ values continuously.
Course Complete
Checking Secure Assessment
Verifying your official BLS Airway & Capnography assessment status.
This course is provided for education and review. Always follow current statewide protocols, manufacturer instructions, local service policies, medical-control direction, and your authorized scope of practice.