Basic Airway Management
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Introduction
Assessment
Assess a patient's breathing clinically in three ways: look, listen, and feel:
- look for the chest rising and falling, and at the patient's colour
- listen for air escaping from the mouth or nose
- feel for air against your cheek
When considering difficulty in ventilating a patient, the acronym BOOTS is helpful for identifying challenging features:
- beard: use vaseeline or cream to improve seal
- obese: place blankets between shoulder blades to expand chest
- older: head/neck position
- teeth: keep dentures in
- snores/stridor (obstruction)
Opening the Airway
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.
If trauma is suspected, use a jaw thrust instead. 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.
ILCOR no longer advocates use of the jaw thrust by lay rescuers, 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.
Mouth-to-Mouth
Bag-Valve-Mask
The Bag-Valve-Mask (BVM) is a foundational method of ventilating patients in need of respiratory support.
Filmed at the Dalhousie Learning Resource Centre
used with permission
Stand behind the victim for maximum effectiveness. Look just below the clavicles for chest rise.
The E-C grip can be used to ensure a tight seal. Assess for chest rise. When starting ensure you have a good head tilt to ensure open-airway.
A jaw thrust can intially be done with two hands, and then held in position with just one.
An underhand grip on the bag is easiest for ergonomics and to prevent fatigue.
Avoid excesive ventilation - either too frequent or too large a volume. Hyperventilation can lead to increased thoracic pressure, decreasing cardiac output and venous return to the heart. Air can also enter the stomach, potentially leading to vomiting and aspiration. These can cause serious complications.
Airway Adjuncts
Airway adjuncts - oropharyngeal or nasopharyngeal airways - can also be used to prevent the tongue from blocking the airway. When these airways are inserted properly, the rescuer does not need to manually open the airway with a head tilt/chin lift or jaw-thrust maneuver. Aspiration of blood, vomitus, and other fluids can still occur with these two adjuncts.
- oropharyngeal airway
- nasopharyngeal airway
Oropharyngeal airway
An OPA should be measured against the side of the face. With the tip of the OPA at the corner of the mouth, the opening should be at the angle of the mandible.
Insert upside down, rotating as it reaches the pharynx.
Suction as needed.
Nasopharyngeal airway
An NPA is a soft rubber tube that protects airflow from the nose to the pharynx.
they may be used in conscious or semiconscios patients.
Size: The tube should be similar in size to the interior aperture of the nares. The patient's smallest finger can also be used as an estimate.
Lubricate the tube, with anesthetic used as appropriate.
Suction as needed.
Moving Beyond Basic Airway Management
In some cases, basic airway management is either inaequate to sustain ventilation. In others, it is clear that respiratory support will be necessary for extended time. In both these situations, proceeding to secure an advanced airway is recommended; as described in this topic.
Resources and References
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