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The Physiologically Difficult Airway

Learn the 4Ps & Avoid Peri-Intubation Arrest

There’s a dangerous intersection between critically ill physiology and intubation. If you don’t want to crash and burn, you must pay attention to the number one rule of the road “resuscitate before you intubate.” In this learning installation we ask you to expand your conception of the difficult airway into the physiologic space so that you can protect your patients using the 4 P’s of peri-intubation resuscitation.

Sara Murphy DO – Director of the Physiologically Difficult Airway Installation


For In Person Learning – Preview Materials & Map Your Journey

The Protected Airway is designed to break the one size fits all conference mold. Each airway installation has a landing page like this one so we can integrate the digital and physical space in new ways to help you learn.

Start here to get a preview of the in person learning opportunities at course, and to help you map your airway learning journey through the installation.

You can visit before, during and after your in person learning experience for continuous review, and deeper dives into all the bonus content on this site.

For Remote Learning – Virtual Installations & Live Online Training Events

By merging digital and physical space at PAC we can provide airway learning when you need it regardless of your physical location. Use this page to explore the virtual version of our learning installations. When you’re done exploring all the online content make sure to sign up for scheduled live events online. The PAC team is creating innovative ways to learn online with remote simulations, faculty discussion groups and deliberate practice tools.



Created by our Protected Airway Course faculty, this online master class on the physiologically difficult airway covers all the critical concepts and skills you need to navigate this space in the sickest of patients. Our experts will teach you the tricks of the trade they rely on in their practice. When you’re done, you will be able to take your skills to the bedside. Start with the content here, learn at your own pace, and then join us for live online events as well as virtual and in person PAC events to complete your training.

If “resuscitate before you intubate” is the meme of the physiologically difficult airway, then the four P’s of peri-intubation resuscitation are its organizing principle.

Sara Murphy DO – Director of the Physiologically Difficult Airway Installation
pressure – focus on hypotension

1 Peri-intubation hypotension is an Independent Risk Factor for cardiac arrest, longer ICU stays, and in-hospital mortality. Vasodilation, loss of intrinsic sympathetic surge, and increased intrathoracic pressure from positive pressure ventilation are all potential hazards of intubation. Learn how to avoid these risks and protect your patients from peri-intubation hypotension

preox – Focus On Hypoxia

2 Safe apnea time is a cornerstone of safe airway management, but the rate at which oxygen is consumed increases substantially in the critically ill, and shunt physiology and will need more advance pre-oxygenation techniques to provide a safe level of oxygenation during intubation.

ph – Focus On acidemia

3 Severe acidosis, puts the patient at risk of postintubation cardiac arrest due to the rapid rise of pCO2 during the apneic period. This station will cover the basics of both metabolic and respiratory acidosis and give you a strategy to prevent post-intubation cardiac arrest and death by hydrogen ion.

the PUMP – Focus On rv failure

4 During intubation,  positive pressure ventilation rapidly increases the RV’s afterload while simultaneously decreasing the preload. This leads to decreased LV filling, decreased cardiac output, and eventually, cardiovascular collapse.  This section of the installation will teach you how to assess and mitigate the risks of RV dysfunction.

Schedule of Virtual Live Events

Our team has designed a series of remote discussions, training simulations and deliberate practice exercises for this virtual installation. Our virtual live events allow you to hone your clinical interactions as well as your skills to make them more effective.

Build Your Own Learning Installations with the PAC Poster Series

The PAC posters used in the course are available to you, so you can build these essential emergency airway installations at your shop. Just download and print our interactive posters, and you will have access to all the embedded digital airway content that will walk learners through all the core concepts and skills for this topic. Set them up in any pop up spac, then keep them up as long as you like, use them over and over! Just add your own equipment and faculty for hands on learning.

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