Airway management

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Airway management is the medical process of ensuring there is an open pathway between a patient’s lungs and the outside world, as well as ensuring the lungs are safe from aspiration. Airway management is a primary consideration in cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.

Cardiopulmonary resuscitation

Airway management is a high priority for clinical care. This is because if there is no airway, there can be no breathing, hence no oxygenation of blood and therefore circulation (and hence all the other vital body processes) will soon cease. The ‘A’ is for ‘airway’ in the ‘CAB’ (chest compressions-airway-breathing) of cardiopulmonary resuscitation according to the 2010 American Heart Association and International Liaison Committee on Resuscitation CPR guidelines.

Airway maneuvers

Head-tilt chin-lift

The head-tilt chin-lift is the most reliable method of opening the airway.

Head-tilt chin-lift — The head-tilt chin-lift is the primary maneuver used in any patient in whom cervical spine injury is not a concern. The simplest way of ensuring an open airway in an unconscious patient is to use a head tilt chin lift technique, thereby lifting the tongue from the back of the throat. This is taught on most first aid courses as the standard way of clearing an airway.

Jaw-thrust maneuver

Jaw-thrust maneuver — The jaw-thrust maneuver is an effective airway technique, particularly in the patient in whom cervical spine injury is a concern. The jaw thrust is a technique used on patients with a suspected spinal injury and is used on a supine patient. The practitioner uses their thumbs to physically push the posterior (back) aspects of the mandible upwards - only possible on a patient with a GCS < 8 (although patients with a GCS higher than this should also be maintaining their own patent airway). When the mandible is displaced forward, it pulls the tongue forward and prevents it from occluding (blocking) the entrance to the trachea, helping to ensure a patent (secure) airway.

The International Liaison Committee on Resuscitation no longer advocates use of the jaw thrust by lay rescuers,^[1] even for spinal-injured victims, although health care professionals still maintain the technique for specific applications. Instead, lay rescuers are advised to use the same head-tilt for all victims.

Cervical spine immobilization

Cervical spine immobilization — Most airway maneuvers are associated with some movement of the cervical spine (c-spine).^[2][3] Even though collars for holding the head in-line can cause problems maintaining an airway and maintaining a blood pressure,^[4] it is unrecommended to remove the collar without adequate personnel to manually hold the head in place.^[5]

Invasive airway management

ProSeal Laryngeal Mask Airway inflated 001

Tracheal intubation

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction. The most widely used route is orotracheal, in which an endotracheal tube is passed through the mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea.

Cricothyrotomy

In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage

A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma.^[6] A cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications.^[7]

Adjuncts to airway management

There are a variety of artificial airways which can be used to keep a pathway between the lungs and mouth/nose. The most commonly used in long term or critical care situations is the endotracheal tube, a plastic tube which is inserted through the mouth and into the trachea, often with a cuff which is inflated to seal off the trachea and prevent any vomit being aspirated into the lungs. In some cases. a laryngeal mask airway (LMA) is a suitable alternative to an endotracheal tube, and has the advantage of requiring a lower level of training than that of an ET tube.

In the case of a choking patient, laryngoscopy or even bronchoscopy may be performed in order to visualise and remove the blockage.

Oropharyngeal airway

Oropharyngeal airway — Oropharyngeal airways (OPA) are plastic curved devices used to hold tissue (such as the tongue) away from the airway to keep it open. An OPA should only be used in a deeply unresponsive patient who is unable to maintain his or her airway. In responsive patients, they can cause vomiting and aspiration.

Nasopharyngeal airway

Nasopharyngeal airway — The nasopharyngeal airway (NPA) (also known as nasal trumpet) is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx. Patients tolerate NPAs more easily than OPAs, so NPAs can be used when the use of an OPA is difficult, such as when the patient's jaw is clenched or the patient is semiconscious and cannot tolerate an OPA.^[8]

Removal of vomit and regurgitation

In the case of a patient who vomits or has other secretions in the airway, these techniques will not be enough. Suitably trained clinicians may elect to use suction to clean out the airway, although this may not always be possible. A unconscious patient who is regurgitating stomach contents should be turned into the recovery position when there is no suction equipment available, as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea.

See also

• Tracheal intubation
• Endotracheal tube
• Laryngeal mask airway
• Ventilation
• Cardioversion

References

1. ^ Part 2: Adult Basic Life Support - 112 (22 Supplement): III-5 - Circulation
2. ^ Donaldson WF, Heil BV, Donaldson VP, Silvaggio VJ (1997). "The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study.". Spine (Phila Pa 1976) 22 (11): 1215–8. PMID 9201858. 
3. ^ Brimacombe J, Keller C, Künzel KH, Gaber O, Boehler M, Pühringer F (2000). "Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers.". Anesth Analg 91 (5): 1274–8. PMID 11049921. 
4. ^ Kolb JC, Summers RL, Galli RL (1999). "Cervical collar-induced changes in intracranial pressure.". Am J Emerg Med 17 (2): 135–7. PMID 10102310. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10102310. 
5. ^ Mobbs RJ, Stoodley MA, Fuller J (2002). "Effect of cervical hard collar on intracranial pressure after head injury.". ANZ J Surg 72 (6): 389–91. PMID 12121154. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12121154. 
6. ^ Mohan, R; Iyer, R; Thaller, S (2009). "Airway management in patients with facial trauma". Journal of Craniofacial Surgery 20 (1): 21–3. doi:10.1097/SCS.0b013e318190327a. PMID 19164982. 
7. ^ Katos, MG; Goldenberg, D (2007). "Emergency cricothyrotomy". Operative Techniques in Otolaryngology 18 (2): 110–4. doi:10.1016/j.otot.2007.05.002. 
8. ^ Roberts K, Whalley H, Bleetman A (2005). "The nasopharyngeal airway: dispelling myths and establishing the facts.". Emerg Med J 22 (6): 394–6. doi:10.1136/emj.2004.021402. PMC 1726817. PMID 15911941. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1726817. 

Emergency Medical Responder (Second Canadian Version). Brady. 2006. pp. 92–97. ISBN 0-13-127824-X.