Airway Management
July 18th, 2020
Overview
Several manoeuvres and devices can be used to restore patency in patients with a threatened airway. This page outlines the basic interventions that can be provided in these patients.
Airway Patency
Before using any airway manoeuvres or adjuncts, first assess whether the airway is patent.
If the patient is talking then this suggests that their airway is patent (however, this is not always the case). Look, listen and feel for movement of air.
Stridor and snoring are both signs of airway compromise.
- Causes of Upper Airway Obstruction
- Soft tissue swelling - anaphylaxis, burns, peritonsillar abscess, epiglottitis, laryngotracheobronchitis (croup)
- Foreign body aspiration
- Deformity - laryngomalacia, laryngeal mass / web, tracheomalacia
- Tongue enlargement / displacement
- Vocal cord lesion / paralysis
Airway Manoeuvres
Airway manoeuvres are used to relieve upper airway obstruction, and maintain a patent airway.
Airway Manoeuvres
- Head tilt and chin lift - tilt the head backward into the sniffing position, opening the airway, and use the index and middle fingers to pull the mandible forward.
- Jaw thrust - use the index and middle fingers on each hand to push the mandible anteriorly, moving the tongue forward.
- Pearls
- Use suction to clear the oral cavity of fluid or foreign body
- If there is concern for c-spine fracture, jaw thrust should be used
- Otherwise, head tilt and chin lift may be used in an attempt to open the airway
Airway Adjuncts
Airway adjuncts are used to relieve upper airway obstruction.
Oropharyngeal Airway
- An oropharyngeal airway is also known as a Guedel airway, and its main role is to move the tongue out of the way.
Measure the airway from the angle of the mandible to the maxillary incisors. First, use suction to ensure that the mouth is clear of secretions. Angle the airway superiorly, toward the palate, and then insert it into the oral cavity. Once the airway reaches the oropharynx, rotate it 180 degrees toward the larynx.
Oropharyngeal airways are contraindicated in conscious patients, and patients who can cough or have an active gag reflex - these patients will not tolerate the airway.
Nasopharyngeal Airway
- A nasopharyngeal airway is inserted into the nose to relive nasal obstruction.
Measure the airway from the tip of the earlobe to the nostril. Point the airway toward the midline, and then insert it backward into the nasal cavity until the flange reaches the nostril.
Lubricant may be used to facilitate insertion of a nasopharyngeal airway.
Nasopharyngeal airways are contraindicated in patients with suspected nasal / base of skull fracture, and patients who are actively bleeding from the nose.
Advanced Airway Interventions
Bag-Valve-Mask
- The bag-valve-mask system is a self-inflating device that is able to deliver high-flow oxygen, expiratory pressure and inspiratory pressure.
A bag-valve-mask system may be used with an oropharyngeal or nasopharyngeal airway in situ, to aid in opening the airway.
Intubation
- If the patient requires intubation, this should be performed by a highly trained member of staff with appropriate planning, monitoring and pre-medication.
- Indications for Intubation
Airway
- Inability to maintain airway patency (upper airway obstruction) - soft tissue swelling, deformity, obesity, tongue displacement
- Inability to protect the airway - sedation (e.g. for procedures), upper airway bleeding, excessive secretions
Breathing
- Inability to ventilate - unconsciousness, sedation, neuromuscular disease, exhaustion
- Inability to oxygenate - severe acute respiratory failure
Circulation
- Cardiac arrest
- The potential complications of intubation are:
During Insertion
- Incorrect placement - oesophagus / bronchus
- Trauma - teeth / oral cavity / pharynx / larynx / trachea
- Hypoxia (due to delayed intubation)
While Intubated
- Mechanical issues - tube obstruction / kinking, loss of cuff integrity
- Infection - ventilator-associated pneumonia
- Self extubation
After Extubation
- Sore throat
- Laryngeal / tracheal pathology - oedema, spasm, stenosis
- Vocal cord paralysis
Cricothyroidotomy
- Cricothyroidotomy can be considered as an emergency airway technique in a patient with a difficult airway. This should be performed by an experienced operator with appropriate equipment and staff available.
Next Page
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------