Airway management
Encyclopedia
In cardiopulmonary resuscitation
, anaesthesia, emergency medicine
, intensive care medicine
and first aid
, airway management is the process of ensuring that:
In nearly all circumstances airway management is the highest 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. Getting oxygen to the lungs is the first step in almost all clinical treatments. The ‘A’ is for ‘airway’ in the ‘ABC’ of cardiopulmonary resuscitation
.
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.
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.
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.
, 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 airways (OPAs) 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 — 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.
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
, anaesthesia, emergency medicine
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
, intensive care medicine
Intensive care medicine
Intensive-care medicine or critical-care medicine is a branch of medicine concerned with the diagnosis and management of life threatening conditions requiring sophisticated organ support and invasive monitoring.- Overview :...
and first aid
First aid
First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...
, airway management is the process of ensuring that:
- there is an open pathway between a patient’s lungLungThe lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
s and the outside world, and - the lungs are safe from aspirationPulmonary aspirationPulmonary aspiration is the entry of material from the oropharynx or gastrointestinal tract into the larynx and lower respiratory tract...
.
In nearly all circumstances airway management is the highest 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. Getting oxygen to the lungs is the first step in almost all clinical treatments. The ‘A’ is for ‘airway’ in the ‘ABC’ of cardiopulmonary resuscitation
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
.
Head-tilt chin-lift
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
First aid
First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...
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 supineSupine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...
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
Glasgow Coma Scale
Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment...
< 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
Vertebrate trachea
In tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
, 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.
Cervical spine immobilization
Cervical spine immobilization — Most airway maneuvers are associated with some movement of the cervical spine (c-spine). Even though collars for holding the head in-line can cause problems maintaining an airway and maintaining a blood pressure, it is unrecommended to remove the collar without adequate personnel to manually hold the head in place.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 positionRecovery position
The recovery position refers to one of a series of variations on a lateral recumbent or three-quarters prone position of the body, in to which an unconscious but breathing casualty can be placed as part of first aid treatment.An unconscious person The recovery position refers to one of a series of...
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.
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 tracheaVertebrate trachea
In tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
, 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
Laryngeal mask airway
The laryngeal mask airway is a supraglottic airway device invented by Archie Brain, a British anaesthetist.-Description:Laryngeal masks consist of a tube with an inflatable cuff that is inserted into the pharynx. Laryngeal mask airways come in a variety of sizes ranging from large adult to infant...
(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
Laryngoscopy
Laryngoscopy is a medical procedure that is used to obtain a view of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation or for procedures on the larynx or other parts of the upper...
or even bronchoscopy
Bronchoscopy
Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for...
may be performed in order to visualise and remove the blockage.
Oropharyngeal airway — Oropharyngeal airways (OPAs) 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 — 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.
See also
- Tracheal intubationTracheal intubationTracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
- Endotracheal tube
- Laryngeal mask airwayLaryngeal mask airwayThe laryngeal mask airway is a supraglottic airway device invented by Archie Brain, a British anaesthetist.-Description:Laryngeal masks consist of a tube with an inflatable cuff that is inserted into the pharynx. Laryngeal mask airways come in a variety of sizes ranging from large adult to infant...
- Oropharyngeal airwayOropharyngeal airwayAn oropharyngeal airway is a medical device called an airway adjunct used to maintain a patent airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing...
- Nasopharyngeal airwayNasopharyngeal airwayIn medicine, a nasopharyngeal airway, also known as an NPA or a nasal trumpet because of its flared end, a type of airway adjunct, is a tube that is designed to be inserted into the nasal passageway to secure an open airway. When a patient becomes unconscious, the muscles in the jaw commonly relax...
- VentilationVentilation (physiology)In respiratory physiology, ventilation is the rate at which gas enters or leaves the lung. It is categorized under the following definitions:-Sample values:...
- CardioversionCardioversionCardioversion is a medical procedure by which an abnormally fast heart rate or cardiac arrhythmia is converted to a normal rhythm, using electricity or drugs. Synchronized electrical cardioversion uses a therapeutic dose of electric current to the heart, at a specific moment in the cardiac cycle...