In central nervous system (CNS) depressed patients, a sequential approach is necessary to prevent airway obstruction and aspiration of vomitus. Endotracheal intubation is indicated if the lash reflex is absent, response to stimulation is not purposeful, or airway obstruction develops when the patient's neck is flexed. Aspiration may result from CNS depression, abnormal glottic function, or extreme debilitation. It may occur in cannulated patients with improper cuff management or after decannulation while glottic reflexes are ineffective.