Managing the Airway (Advanced)

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Week 2

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Without a patent airway, you patient will not survive. Look at the Assessing The Airway section for the first steps in airway assessment and management. Remember you cannot move onto Breathing in the assessment without assessing and managing the Airway. 

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Airway Obstruction

So you are unsure about the patient’s airway, what are you unsure of from your assessment? Here are some of the signs that might demonstrate that their airway is partially obstructed and is not patent:

  • Respiratory noises – wheezing, snoring, stridor
  • Patient unable to talk, or gasping for air
  • Signs of cyanosis 
  • Changes to the respiratory pattern

A completely obstructed airway will be diagnosed by the following signs on initial assessment: 

  • When looking to the chest, listening and feeling for breathing over ten seconds there will be an absence of air movement
  • Lack of breath signs on auscultation
  • Retraction of the sternum and rib cage
  • Rocking motion of the chest which is not synchronised with respiratory effort.

What might cause an airway obstruction?

There are numerous causes for an airway obstruction, but a few examples are listed below: 
The patient's tongue falling back

  • Allergic reaction / anaphylaxis
  • Burns –chemical and fire related
  • Epiglottitis
  • Foreign bodies – inhaled food, peanuts etc
  • Infection of the upper airway, peritonsular abcess, 
  • Injury to the upper airway
  • Laryngeal cancer
  • Tracheomalacia

act-now11.gifWhatever the cause or the symptoms of upper airway obstruction, you need to act fast. Upper airway obstruction is a life threatening emergency that requires immediate attention. Firstly, go back to the basics; ensure that the patient’s airway is open. When the muscles of the mouth and tongue relax, usually in a patient with altered consciousness, the tongue will lie close to the back wall of the oropharynx and cause an obstruction. So, the basic technique to apply first in all instances is one of the following:

Head tilt-chin lift manoeuvre. Place one hand on the patients forehead and tilt the head backwards carefully. Using your fingers on the patient’s chin, lift the chin to open the airway 

The Jaw thrust – this is the only option for the patient with suspected C-Spine injury and involves moving the tongue forward with the mandible reducing the tongue's ability to obstruct the airway. Standing at the head of the bed, the middle finger of the right hand is placed at the angle of the patient's jaw on the right. The middle finger of the left hand is similarly placed at the angle of the jaw on the left. An upward pressure is applied to elevate the mandible which will lift the tongue from the posterior pharynx.

If the above manoeuvre is unsuccessful and the patient is still showing signs of partial or complete airway obstruction, the next step is to consider the use of airway adjuncts.

Airway Adjuncts

There are a number of airway adjuncts available to healthcare workers, depending on the patient assessment and background. A quick assessment is required before insertion to ensure that you are using the right equipment. Be aware of your limitations and level of competence before proceeding. Those of you working in healthcare organisations must also be aware of your policies and procedures around airways management.


Oro-pharyngeal Airways

guedel.jpgOro-pharyngeal airways (sometimes known as Guedel airways) are used to prevent the tongue from blocking the airway. They come in a variety of different sizes and are usually indicated for unconscious patients who do not have a gag reflex. If used in semi conscious patients the airway could stimulate the gag reflex and cause the patient to vomit and potentially aspirate. Note that oro-pharyngeal airways cannot be used in patients with any oral trauma. 

The correct size airway is chosen by measuring against the patients head. Place the flange of the airway against the centre of the patients lips and the tip to the centre of the jaw. Once you have ascertained the correct size, insert the airway upside down into the patients mouth until you make contact with the back of the throat, when you need to then rotate the airway 180 degrees until it is in place.

Naso-pharyngeal airways

nasopharangealairway.jpgThese simple less-frequently used airways are suitable for semi-conscious patients that have a gag reflex and a variety of different circumstances. However these airways are NOT suitable for patients that may have sustained a head injury with a possibility of a basal skull fracture. In addition they cannot be used on patients with nasal injury or nosebleed. As the name depicts, the airway is inserted into the nostril. As with all airways you must make an assessment of the appropriate size before insertion. Sizing should be undertaken by measuring from the patient’s nose to their ear lobe. Before inserting the airway use a water-based lubricant on the tip of the airway and insert with the bevel towards the septum, ideally in the right nostril.

Laryngeal Mask Airway (LMA)

lma.jpgA laryngeal mask airway is a supraglottic airway device and is an important device in the emergency management of the difficult airway. It is a good alternative to bag-valve-mask ventilation, is fairly easy to use and quick to insert. It is shaped like a large endotracheal tube on the proximal end that connects to a elliptical mask on the distal end. It sits in the patient’s hypopharnyx, covering the supraglottic structures, isolating the trachea. The mask can be used as a temporary alternative to an endotracheal (ET) tube but does not completely prevent risk of aspiration. It is inserted usually under sedation to prevent laryngospasm.

I-Gel

igel.jpgThe Igel airway is another supraglottic airway device made of a medical grade thermoplastic elastomer, which is soft, gel-like and transparent. The i-gel is designed to create a non-inflatable anatomical seal of the pharyngeal, laryngeal and perilaryngeal structures whilst avoiding the compression trauma that can occur with inflatable supraglottic airway devices. The i-gel does not have an inflatable cuff and it has features designed to separate the gastrointestinal and respiratory tracts allowing an NG tube to be passed, reducing the overall risk of aspiration.

Endotracheal (ET) Tubes

ET-tube-cuffed-800.jpgEndotracheal intubation is an advanced airway procedure where an orotracheal tube is placed under direct vision through the larynx into the trachea. Insertion of a endotracheal tube is a specialised technique that can only be undertaken by trained and competent healthcare professionals. Endotracheal tubes are utilised in critically ill patients requiring sedation or who are unable to protect their airway. The semi-rigid tube ensures airway patency, allows introduction of anaesthetic gases, facilitates oxygenation and suctioning and prevents aspiration of gastric contents They are measured according to their internal diameter and the tube size depends on the size of the patient. They can be cuffed or uncuffed and there are a variety of types available.

 

tab_thumb.png References and Further Reading

Resuscitation Council UK 2015 Resuscitation Guidelines https://www.resus.org.uk/pages/Guide.htm Links to an external site. 

Ellis, D.Y., Lambert, C. and Shirley, P. 2006. Intracranial placement of nasopharyngeal airways: is it all that rare? Emergency Medicine Journal 23: 661.

Higginson, Ray; Parry, Andy. Emergency Airway management: common ventilation techniques British Journal of Nursing22.7 (April 11, 2013): 366-371

Jevon, P. Maintaining an airway Nursing Standard22.26 (March 5, 2008): 35-37. 

Simpson, T. 2010 Airway management skills and knowledge for nurses British Journal of Nursing19.22 (December 9): 1388