Oxygenation is the primary aim of all airway management. The shape of the oxyhaemoglobin dissociation curve determines onset of hypoxaemia and means that when it occurs it can progress rapidly and severely. Hypoxaemia causes rapid damage to living tissues, most importantly the brain. Oxygenation strategies are required including delivering oxygen before, during and after airway management. Low flow oxygenation techniques are traditionally employed and apnoeic oxygenation has been rarely used. Newer high flow oxygen delivery systems enable effective pre-oxygenation and apnoeic oxygenation and can be used both during complex airway management or as an alternative to instrumenting the airway during surgery.

Pre-hospital airway management is an essential skill for every pre-hospital clinician and should be performed to the same standards as would be expected in the emergency department. This chapter recommends tailored pre-hospital airway management in terms of clinical care delivered to the patient, skills of the clinician and the infrastructure of emergency medical system to achieve this. The importance of having a standardised, well-rehearsed approach, using aids to reduce cognitive load, articulating a clear airway management plan and having a structured way of handling airway management difficulties is highlighted. The concept of the physiologically difficult airway is discussed and the significance of excellent pre-oxygenation, peroxygenation, first-pass success and post-intubation care is discussed. Backup equipment in the form of second generation supraglottic airway devices, a videolaryngoscope with both standard and hyperangulated blades and equipment for an emergency front of neck airway should be available when advanced pre-hospital airway management is provided. When delivering airway management to trauma patients, an awareness of potential anatomical difficulties combined with careful management of physiological derangement is necessary to deliver safe, high quality care.