Airway management: Difference between revisions

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==Overview==
==Overview==
''Airway management'' is the process of ensuring that there is an open pathway between a patient’s [[lung]]s and the outside world, and the [[lungs]] are safe from [[Pulmonary aspiration|aspiration]]. [[Airway]] loss is a major cause of preventable prehospital death in [[trauma]] patients. Airway management complications are common, especially in [[trauma]] patients because of associated [[pathology]], lack of complete evaluation before [[intubation]]. Additionally, [[trauma]] [[patients]] are at increased risk of [[airway obstruction]], aspiration, [[hypoxia]] and [[hypotension]], and [[vital sign]] instability. The providers must have skillset related to working with a variety of tools and techniques used in airway management and knowledge of the important [[anatomical]], [[physiological]], and [[pathological]] features related to the airway. They also should know the differences between the adult versus pediatric and neonatal airways as these [[anatomical]] and physiological differences are critical, impactful on patients lives and knowing these leads to effective control of the airway. Some of the indications for managing the [[airway]] in patients include [[respiratory failure]], a reduced level of consciousness ([[Glasgow Coma Scale]] less than or equal to 8), rapid deterioration of [[mental status]], [[airway]] injury or compromise, injuries causing a high risk for [[aspiration]], which includes all penetrating injuries to the [[abdomen]] or [[chest wall]]. Inadequate airway management may lead to [[cardiovascular]] arrest and compromise life-saving interventions in a trauma patient. Several airway control devices and techniques are available to assist [[healthcare]] providers in order to maintain ventilation and oxygenation. These include [[bag valve mask]] ([[Bag valve mask|BVM]]) [[ventilation]], direct [[laryngoscopy]] with [[endotracheal intubation]] (ETI) and adjunct supraglottic [[airway]] devices such as the [[laryngeal]] mask airway.
''Airway management'' is the process of ensuring that there is an open pathway between a patient’s [[lung]]s and the outside world, and the [[lungs]] are safe from [[Pulmonary aspiration|aspiration]]. [[Airway]] loss is a major cause of preventable prehospital death in [[trauma]] patients. Airway management complications are common, especially in [[trauma]] patients because of associated [[pathology]], lack of complete evaluation before [[intubation]], unanticipated difficulty during ventilation and [[intubation]]. Additionally, [[trauma]] [[patients]] are at increased risk of [[airway obstruction]], aspiration, [[hypoxia]] and [[hypotension]], and [[vital sign|other unstable vital]] The providers must have skillset related to working with a variety of tools and techniques used in airway management and knowledge of the important [[anatomical]], [[physiological]], and [[pathological]] features related to the airway. They also should know the differences between the adult versus [[pediatric]] and [[neonatal]] airways as these [[anatomical]] and physiological differences are critical, impactful on patients lives and knowing these leads to effective control and management of the [[airway]]. Some of the indications for managing the [[airway]] in patients include [[respiratory failure]], altered sensorium([[Glasgow Coma Scale]] less than or equal to 8), rapid deterioration of [[mental status]], [[airway]] injury or compromise, injuries causing a high risk for [[aspiration]]-which includes all penetrating injuries to the [[abdomen]] or [[chest wall]]. Inadequate [[airway]] management may lead to [[cardiovascular]] arrest and compromise life-saving interventions in a [[trauma]] patient. Several [[airway]] control devices and techniques are available to assist [[healthcare]] providers in order to maintain the airway by [[ventilation]] and [[oxygenation]]. These include [[bag valve mask]] ([[Bag valve mask|BVM]]) [[ventilation]], direct [[laryngoscopy]] with [[endotracheal intubation]] (ETI) and adjunct [[Supraglottitis|supraglottic]] [[airway]] devices such as the [[laryngeal]] mask airway.


==Functional anatomy of the upper airway==
==Functional anatomy of the upper airway==
For a successful approach to [[airway]] management, health care providers must have knowledge of important [[anatomical]], physiological, and pathological features related to the airway as well as knowledge of the various equipment and methods that can be utilized for this purpose. Also, the difference between airway management in adults, [[pediatrics]], and [[neonates]] is very critical.<ref name="pmid3056703">{{cite journal |vauthors=Morris IR |title=Functional anatomy of the upper airway |journal=Emerg. Med. Clin. North Am. |volume=6 |issue=4 |pages=639–69 |date=November 1988 |pmid=3056703 |doi= |url=}}</ref>
For a successful approach to [[airway]] management, [[health care providers]] must have knowledge of important [[anatomical]], [[physiological]], and [[pathological]] features related to the airway as well as knowledge of the various equipment and methods that can be utilized for this purpose. Also, the difference between airway management in adults, [[pediatrics]], and [[neonates]] is very critical.<ref name="pmid3056703">{{cite journal |vauthors=Morris IR |title=Functional anatomy of the upper airway |journal=Emerg. Med. Clin. North Am. |volume=6 |issue=4 |pages=639–69 |date=November 1988 |pmid=3056703 |doi= |url=}}</ref>


* The [[upper airway]] is consists of the [[pharynx]] and [[nasal]] cavities, the [[larynx]] and [[trachea]] may be included, and the oral cavity provides an alternate air entry into the [[respiratory system]].  
*The [[upper airway]] is consists of the [[pharynx]] and [[nasal]] cavities, the [[larynx]] and [[trachea]] may be included, and the [[oral cavity]] provides an alternate air entry into the [[respiratory system]].
* The nose is a bony and [[cartilage]] structure attached to the facial [[skeleton]] and is divided into the two [[nasal]] cavities. The nose functions as a heater and humidifier of inspired gas, it is also helping in [[phonation]] and [[vocal resonation]] and houses the [[olfactory]] receptors. The [[paranasal sinuses]] drain into the nasal cavities.
*The nose is a bony and [[cartilage|cartilaginous]] structure attached to the facial [[skeleton]] and is divided into the two [[nasal]] cavities. The nose functions as a heater and humidifier of inspired air, it is also helps in [[phonation]] and [[vocal resonation]] and houses the [[olfactory]] receptors. The [[paranasal sinuses]] drain into the nasal cavities.
* An [[endotracheal tube]] passes through the [[nose]] or mouth into the trachea to protect the [[airway]] and achieve positive-pressure ventilation. The mouth opens posteriorly into the [[oropharynx]] and becomes part of the [[gastrointestinal system]], helps the digestion and also plays a role as an alternate pathway for [[respiration]]. It is also involved in [[phonation]].  
*An [[endotracheal tube]] passes through the [[nose]] or mouth into the [[trachea]] to protect the [[airway]] and achieve positive-pressure [[ventilation]]. The mouth opens posteriorly into the [[oropharynx]] and becomes part of the [[gastrointestinal system]], helps the [[digestion]] and also plays a role as an alternate pathway for [[respiration]]. It is also involved in [[phonation]].
* [[Orotracheal intubation]] can be used as an alternative to [[nasal]] [[intubation]] to achieve [[airway]] protection and maintain [[ventilation]]; but depending upon position of patient who is arriving and difficulty that is due to [[anatomical]] shape of [[upper airway]], this route may not be doable, for instance in supine unconscious persons, the backward movement of the [[tongue]] and lower [[jaw]] may cause [[airway obstruction]] and performing [[orotracheal intubation]] may not be the optimal way of managing airway.
*[[Orotracheal intubation]] can be used as an alternative to [[nasal]] [[intubation]] to achieve [[airway]] protection and maintain [[ventilation]]; but depending upon the condition of the [[patient]] and difficulty due to [[anatomical]] shape of [[upper airway]], this route may not be doable, for instance in supine unconscious persons, the backward movement of the [[tongue]] and lower [[jaw]] may cause [[airway obstruction]] and performing [[orotracheal intubation]] may not be the optimal way of managing airway.
* The [[pharynx]] is a membrane-lined cavity behind the [[mouth]] and nose, extends from the base of the [[skull]] to the [[cricoid cartilage]] at the level of sixth [[cervical vertebrae]] which is an entrance to the [[esophagus]]. Anteriorly it opens into the [[nasal cavity]], the [[mouth]], and the [[larynx]], which divide it into the naso-, oro-, and [[laryngopharynx]], respectively. The [[pharynx]] is involved with the act of [[swallowing]].  
*The [[pharynx]] is a membrane-lined cavity behind the [[mouth]] and [[nose]], extends from the base of the [[skull]] to the [[cricoid cartilage]] at the level of sixth [[cervical vertebrae]] which is an entrance to the [[esophagus]]. [[Anterior]]<nowiki/>ly it opens into the [[nasal cavity]], the [[mouth]], and the [[larynx]], which divide it into the naso-, oro-, and [[laryngopharynx]], respectively. The [[pharynx]] is involved with the act of [[swallowing]].
* The [[larynx]] consists of [[Cartilages of the larynx|cartilages]] and fibro-elastic membranes covered by a sheet of [[muscles]] and [[mucous membrane]]. It functions as an open valve in [[respiration]], helps in [[phonation]], and protects against [[aspiration]] during [[swallowing]]. The [[larynx]] extends from its entrance which is formed by the [[Aryepiglottic fold|aryepiglottic folds]], to the lower border of the [[cricoid cartilage]] till the tip of the [[epiglottis]], and bulges posteriorly into the [[laryngopharynx]].
*The [[larynx]] consists of [[Cartilages of the larynx|cartilages]] and fibro-elastic membranes covered by a sheet of [[muscles]] and [[mucous membrane]]. It functions as an open valve in [[respiration]], helps in [[phonation]], and [[swallowing]]. The [[larynx]] extends from its entrance which is formed by the [[Aryepiglottic fold|aryepiglottic folds]], to the lower border of the [[cricoid cartilage]] till the tip of the [[epiglottis]], and bulges [[posterior]]<nowiki/>ly into the [[laryngopharynx]].
* The trachea extends from the lower edge of the [[cricoid cartilage]] to the [[carina]] where it divides into the [[mainstem bronchus]]. It is formed by U-shaped [[cartilaginous]] rings anteriorly and is closed posteriorly by the [[trachealis muscle]]. A properly placed [[endotracheal tube]] should have its tip at about midtracheal level.
*The trachea is formed by U-shaped [[cartilaginous]] rings in anterior and [[trachealis muscle]] in [[posterior]], it extends from the lower edge of the [[cricoid cartilage]] to the [[carina]] where it divides into the [[mainstem bronchus]]. In order to place [[endotracheal tube]] in proper way, tip of the tube should be at mid [[Tracheal bronchus|tracheal]] level.




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The basic approach in airway management in the [[emergency]] setting includes:<ref name="RosenbergPhero2014">{{cite journal|last1=Rosenberg|first1=M. B|last2=Phero|first2=J. C|last3=Becker|first3=D. E|title=Essentials of Airway Management, Oxygenation, and Ventilation: Part 2: Advanced Airway Devices: Supraglottic Airways|journal=Anesthesia Progress|volume=61|issue=3|year=2014|pages=113–118|issn=0003-3006|doi=10.2344/0003-3006-61.3.113}}</ref>
The basic approach in airway management in the [[emergency]] setting includes:<ref name="RosenbergPhero2014">{{cite journal|last1=Rosenberg|first1=M. B|last2=Phero|first2=J. C|last3=Becker|first3=D. E|title=Essentials of Airway Management, Oxygenation, and Ventilation: Part 2: Advanced Airway Devices: Supraglottic Airways|journal=Anesthesia Progress|volume=61|issue=3|year=2014|pages=113–118|issn=0003-3006|doi=10.2344/0003-3006-61.3.113}}</ref>


:* Protection from [[aspiration]] and [[pneumonia]] related to that.
:*Protection from [[aspiration]] and [[pneumonia]] related to that.
:* Providing adequate [[oxygenation]] and [[ventilation]].        
:*Providing adequate [[ventilation]] and [[oxygenation]].
 
Following are steps that must be considered prior to conducting airway management, these include:
Following are steps that must be considered prior to conducting airway management, these include:
:*'''History:''' An [[airway]] [[history]] should be conducted whenever it is possible before airway management in all patients to detect medical, [[surgical]], and [[anesthetic]] factors that may indicate the presence of a difficult [[airway]]. A detailed review of previous [[anesthetic]] records, if available, may provide useful information about airway management.


:*'''Physical Examination:''' An airway [[physical examination]] should be conducted before the initiation of airway management. The goal of [[physical examination]] is to detect physical characteristics that may indicate the presence of a difficult airway because an unsuccessful [[upper airway]] mangaement is associated with increase in mortality and morbidity.  
:*'''History:''' An [[airway]] [[history]] should be conducted whenever it is possible before airway management in all [[patients]] to detect medical, [[surgical]], and [[anesthetic]] factors that may indicate the presence of a difficult [[airway]]. A detailed review of previous [[anesthetic]] records, if available, may provide useful information about airway management.
 
:*'''Physical Examination:''' An airway [[physical examination]] should be conducted before the initiation of airway management. The goal of [[physical examination]] is to detect physical characteristics that may indicate the presence of a difficult airway because an unsuccessful [[upper airway|airway]] management is associated with increase in [[mortality]] and [[morbidity]].
 
:*'''Additional Evaluation:''' Additional evaluation may be indicated in some [[patients]] to characterize the likelihood or nature of the anticipated difficult airway. Certain diagnostic tests (e.g., [[radiography]], [[computed tomography]] scans, [[fluoroscopy]]) can identify a variety of acquired or congenital features in patients with difficult airways
 
==Techniques for airway management==
The decision about whether an airway intervention is required or not is crucial for patient's [[Survival rate|survival]] and depends on first responders skills and quick assessment and decision. These crucial steps requires techniques which are used universally in order to manage [[patient]]'s airway. Following are initial evaluation methods which had been developed to assist patient's [[ventilation]] and keep the [[airway]] patent, these techniques include:<ref name="RoychoudhuryJose2016">{{cite journal|last1=Roychoudhury|first1=Ajoy|last2=Jose|first2=Anson|last3=Nagori|first3=ShakilAhmed|last4=Agarwal|first4=Bhaskar|last5=Bhutia|first5=Ongkila|title=Management of maxillofacial trauma in emergency: An update of challenges and controversies|journal=Journal of Emergencies, Trauma, and Shock|volume=9|issue=2|year=2016|pages=73|issn=0974-2700|doi=10.4103/0974-2700.179456}}</ref><ref name="pmid18946431">{{cite journal |vauthors=Agrò FE, Cataldo R, Mattei A |title=New devices and techniques for airway management |journal=Minerva Anestesiol |volume=75 |issue=3 |pages=141–9 |date=March 2009 |pmid=18946431 |doi= |url=}}</ref><ref name="pmid29560073">{{cite journal |vauthors=Gleason JM, Christian BR, Barton ED |title=Nasal Cannula Apneic Oxygenation Prevents Desaturation During Endotracheal Intubation: An Integrative Literature Review |journal=West J Emerg Med |volume=19 |issue=2 |pages=403–411 |date=March 2018 |pmid=29560073 |pmc=5851518 |doi=10.5811/westjem.2017.12.34699 |url=}}</ref><ref name="LawBroemling2013">{{cite journal|last1=Law|first1=J. Adam|last2=Broemling|first2=Natasha|last3=Cooper|first3=Richard M.|last4=Drolet|first4=Pierre|last5=Duggan|first5=Laura V.|last6=Griesdale|first6=Donald E.|last7=Hung|first7=Orlando R.|last8=Jones|first8=Philip M.|last9=Kovacs|first9=George|last10=Massey|first10=Simon|last11=Morris|first11=Ian R.|last12=Mullen|first12=Timothy|last13=Murphy|first13=Michael F.|last14=Preston|first14=Roanne|last15=Naik|first15=Viren N.|last16=Scott|first16=Jeanette|last17=Stacey|first17=Shean|last18=Turkstra|first18=Timothy P.|last19=Wong|first19=David T.|title=The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient|journal=Canadian Journal of Anesthesia/Journal canadien d'anesthésie|volume=60|issue=11|year=2013|pages=1089–1118|issn=0832-610X|doi=10.1007/s12630-013-0019-3}}</ref><ref name="OkuboGibo2017">{{cite journal|last1=Okubo|first1=Masashi|last2=Gibo|first2=Koichiro|last3=Hagiwara|first3=Yusuke|last4=Nakayama|first4=Yukiko|last5=Hasegawa|first5=Kohei|title=The effectiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study|journal=International Journal of Emergency Medicine|volume=10|issue=1|year=2017|issn=1865-1372|doi=10.1186/s12245-017-0129-8}}</ref>
 
*'''Spontaneous breathing:'''  When a provider is confronted with an awake [[patient]] having a patent airway. Spontaneous ventilation can be assisted through the placement of a nasal or oral airway. [[Oxygenation]] can be improved by giving [[oxygen]] via nasal [[cannula]], simple [[face mask]], or nonrebreather face mask. Unfortunately, the maximally achieved [[FiO2]] is often overestimated by care providers and [[hypoventilation]] resulting in [[hypercapnia]] cannot be normalized with increase in [[oxygen]] supply.
*'''Mouth-to-Mouth ventilation:''' Mouth-to-mouth or mouth-to-nose ventilation is a useful management technique, however, because of the risk of [[infection]] transmission it is recommended by American heart association that health care providers do "Hands-only" [[CPR]]. Proper face masks should be utilized if they are available.
*'''Bag-mask ventilation:''' It is a standard initial approach to airway management in the prehospital and [[hospital]] settings.
 
:*Proper preoxygenation prior to [[intubation]] and [[anesthetic]] induction provides patients with improved [[oxygenation]] and increases the time to [[hypoxemia]].
:*Bag-mask [[ventilation]] is a basic essential technique when [[endotracheal tube]] [[intubation]] is difficult, it assists for rapid [[ventilation]] and [[oxygenation]] in patients.
:*Bag-mask [[ventilation]] can be achieved by a single practitioner alone or side by side with a second care provider in an [[Operating room|emergency room or an operating room]]
:*Bag mask [[ventilation]] can also be utilized as a pressure support during spontaneous [[respiration]] in patients with decre<nowiki/>ased [[tidal volume]]<nowiki/>s and insufficient [[ventilation]], very similar to the use of [[CPAP]] or [[BiPAP]] to assist [[patients]] who are spontaneously [[breathing]] but are not adequately ventilating or oxygenating.
 
*'''Oropharyngeal and nasopharyngeal airways:'''
 
:*This is used as an adjunct device for spontaneous or [[assisted ventilation]].
:*[[Oropharyngeal]] and [[nasopharyngeal airway]]<nowiki/>s are frequently utilized by prehospital care providers to improve [[oxygenation]] and [[ventilation]].
:*These devices are frequently used until a more definitive [[airway]] is obtained, and there are several circumstances that prohibit their placement (severe head or [[facial]] injuries).
 
*'''Supraglottic airway devices:''' [[Supraglottic laryngeal cancer|Supraglottic]] airway (SGA) device placement is very useful to keep the [[airway]]<nowiki/>s open, it has advantages in comparison with [[endotracheal tube]] intubation, or other methods, these advantages include:<ref name="pmid27537593">{{cite journal |vauthors=Park SK, Ko G, Choi GJ, Ahn EJ, Kang H |title=Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis |journal=Medicine (Baltimore) |volume=95 |issue=33 |pages=e4598 |date=August 2016 |pmid=27537593 |doi=10.1097/MD.0000000000004598 |url=}}</ref>


:*'''Additional Evaluation'''. Additional evaluation may be indicated in some patients to characterize the likelihood or nature of the anticipated airway difficulty. Certain diagnostic tests (e.g., [[radiography]], [[computed tomography]] scans, [[fluoroscopy]]) can identify a variety of acquired or congenital features in patients with difficult airways
:*They act as a niche between [[bag and mask ventilation]] and endotracheal [[intubation]].
:*Requires less training than [[ETI]].
:*It is less invasive than [[ETI]].
:*It can offer better [[ventilation]] during transport than bag-mask [[ventilation]] alone.
:**[[Supraglottitis|Supraglottic]] airway devices can be used as an alternative tool in cases of failed [[intubation]].


==Techniques for airway management ==
*'''[[Endotracheal intubation]]:''' It is the gold standard for definitive airway management in the prehospital setting, and also hospital setting. It allows for positive pressure [[ventilation]], [[positive end-expiratory pressure]] (PEEP), positive pressure recruitment maneuvers, and protection from [[aspiration]].
The decision about whether an airway intervention is required or not is crucial for patients survival and depends on first responders skills and qucik assessment and decision. These crucial steps requires techniques which is used universally in order to manage patient's airway, followings are initial evaluation and methods which had been developed to assist patient's ventilation and keep the airway patent, these techniques include:<ref name="RoychoudhuryJose2016">{{cite journal|last1=Roychoudhury|first1=Ajoy|last2=Jose|first2=Anson|last3=Nagori|first3=ShakilAhmed|last4=Agarwal|first4=Bhaskar|last5=Bhutia|first5=Ongkila|title=Management of maxillofacial trauma in emergency: An update of challenges and controversies|journal=Journal of Emergencies, Trauma, and Shock|volume=9|issue=2|year=2016|pages=73|issn=0974-2700|doi=10.4103/0974-2700.179456}}</ref><ref name="pmid18946431">{{cite journal |vauthors=Agrò FE, Cataldo R, Mattei A |title=New devices and techniques for airway management |journal=Minerva Anestesiol |volume=75 |issue=3 |pages=141–9 |date=March 2009 |pmid=18946431 |doi= |url=}}</ref><ref name="pmid29560073">{{cite journal |vauthors=Gleason JM, Christian BR, Barton ED |title=Nasal Cannula Apneic Oxygenation Prevents Desaturation During Endotracheal Intubation: An Integrative Literature Review |journal=West J Emerg Med |volume=19 |issue=2 |pages=403–411 |date=March 2018 |pmid=29560073 |pmc=5851518 |doi=10.5811/westjem.2017.12.34699 |url=}}</ref><ref name="LawBroemling2013">{{cite journal|last1=Law|first1=J. Adam|last2=Broemling|first2=Natasha|last3=Cooper|first3=Richard M.|last4=Drolet|first4=Pierre|last5=Duggan|first5=Laura V.|last6=Griesdale|first6=Donald E.|last7=Hung|first7=Orlando R.|last8=Jones|first8=Philip M.|last9=Kovacs|first9=George|last10=Massey|first10=Simon|last11=Morris|first11=Ian R.|last12=Mullen|first12=Timothy|last13=Murphy|first13=Michael F.|last14=Preston|first14=Roanne|last15=Naik|first15=Viren N.|last16=Scott|first16=Jeanette|last17=Stacey|first17=Shean|last18=Turkstra|first18=Timothy P.|last19=Wong|first19=David T.|title=The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient|journal=Canadian Journal of Anesthesia/Journal canadien d'anesthésie|volume=60|issue=11|year=2013|pages=1089–1118|issn=0832-610X|doi=10.1007/s12630-013-0019-3}}</ref><ref name="OkuboGibo2017">{{cite journal|last1=Okubo|first1=Masashi|last2=Gibo|first2=Koichiro|last3=Hagiwara|first3=Yusuke|last4=Nakayama|first4=Yukiko|last5=Hasegawa|first5=Kohei|title=The effectiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study|journal=International Journal of Emergency Medicine|volume=10|issue=1|year=2017|issn=1865-1372|doi=10.1186/s12245-017-0129-8}}</ref>


* '''Spontaneous breathing:'''  When a provider is confronted with an awake patient having a patent airway. Spontaneous ventilation can be assisted through the placement of a nasal or oral airway. [[Oxygenation]] can be improved by giving [[oxygen]] via nasal [[cannula]], simple [[face mask]], or nonrebreather face mask. Unfortunately, the maximally achieved [[FiO2]] is often overestimated by care providers and hypoventilation resulting in hypercapnia cannot be normalized with increase [[oxygen]] supply.
:*'''Mallampati classification for assessment of upper airway anatomical Balance:''' It is named after the Indian-born American [[anesthesiologist]] Seshagiri Mallampati, is used to predict the ease of [[endotracheal intubation]].The test assess the distance from the [[tongue]] base to the roof of the [[mouth]] visually. It is an indirect way of assessing how the airway and predicting the difficult intubation.
*'''Mouth-to-Mouth ventilation:''' Mouth-to-mouth or mouth-to-nose ventilation is a useful management technique, however, because of the risk of infection transmission it is recommended by American heart association that health care providers do "Hands-only" [[CPR]]. Proper face masks should be utilized if they are available.
*'''Bag-mask ventilation:''' It is a standard initial approach to airway management in the prehospital and hospital settings.
:*Proper preoxygenation prior to [[intubation]] provides patients with improved [[oxygenation]] and increases the time to [[hypoxemia]].
:* BMV is basic essential technique when [[endotracheal tube]] [[intubation]] is difficult, it assists for rapid [[oxygenation]] and [[ventilation]] in patients.
:*BMV can be applied by a sole practitioner or in conjunction with a second care provider in an [[operating room]].
:*BMV can also be done as a pressure support method for patients with depressed [[tidal volume]]<nowiki/>s and inadequate [[ventilation]].
:*This is similar to the use of [[CPAP]] or [[BiPAP]] to assist patients who are spontaneously breathing but are not adequately oxygenating or ventilating.
*'''Oropharyngeal and nasopharyngeal airways:'''
:*This is used as an adjunct device for spontaneous or [[assisted ventilation]].
:*[[Oropharyngeal]] and [[nasopharyngeal airway]]<nowiki/>s are frequently utilized by prehospital care providers to improve [[oxygenation]] and [[ventilation]].
:*These devices are frequently used until a more definitive airway is obtained, and there are several circumstances that prohibit their placement (severe head or facial injuries).
*'''Supraglottic airway devices:''' [[Supraglottic laryngeal cancer|Supraglottic]] airway (SGA) device placement is very useful to keep the [[airway]]<nowiki/>s open, it has advantages in comparison with [[endotracheal tube]] intubation, or other methods, these advantages are include:<ref name="pmid27537593">{{cite journal |vauthors=Park SK, Ko G, Choi GJ, Ahn EJ, Kang H |title=Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis |journal=Medicine (Baltimore) |volume=95 |issue=33 |pages=e4598 |date=August 2016 |pmid=27537593 |doi=10.1097/MD.0000000000004598 |url=}}</ref>
:*Requires less training than ETI.
:*It is less invasive than ETI.
:*It can offer better ventilation during transport than bag-mask ventilation alone.
:**Supraglottic airway devices can be used as an alternative tool in cases of failed intubation.
*'''[[Endotracheal intubation]]:''' It is the gold standard for definitive airway management in the prehospital setting, it allows for positive pressure [[ventilation]], positive end-expiratory pressure (PEEP), positive pressure recruitment maneuvers, and protection from aspiration.
:*'''Mallampati classification for assessment of upper airway anatomical Balance:''' It's named after the Indian-born American anaesthesiologist Seshagiri Mallampati, is used to predict the ease of endotracheal intubation.The test assess the distance from the tongue base to the roof of the mouth visually. It is an indirect way of assessing how difficult intubation will be.
:*'''Modified Mallampati Scoring:'''
:*'''Modified Mallampati Scoring:'''
:**Class I: [[Soft palate]], [[uvula]], [[fauces]], [[Pillars of the fauces|pillars]] visible.
:**Class I: [[Soft palate]], [[uvula]], [[fauces]], [[Pillars of the fauces|pillars]] visible.
:**Class II: [[Soft palate]], a major part of the [[uvula]], fauces visible.
:**Class II: [[Soft palate]], a major part of the [[uvula]], [[fauces]] visible.
:**Class III: [[Soft palate]], the base of [[uvula]] visible.
:**Class III: [[Soft palate]], the base of [[uvula]] visible.
:**Class IV: Only hard palate visible.
:**Class IV: Only [[hard palate]] visible.
*'''Rapid sequence intubation versus no-medication intubation''':
 
:*Use of [[pharmacological]] muscle relaxant eases the [[intubation]] process by relaxing muscles in the pharynx. [[Rapid sequence induction|Rapid sequence intubation]] ([[RSI]]) techniques incorporate [[pharmacologic]] muscle relaxation and are utilized by anesthesiologists and emergency medicine physicians. However, the disadvantage of these techniques is the elimination of a patient's ability to breathe spontaneously if the intubation fails. There is a debate that optimal intubating conditions should be achieved first before trying to attempt [[intubation]] in the prehospital setting. Time is an important factor and critical in prehospital airway management of [[patients]], due to [[trauma]], [[cardiac arrest]], [[hypoxemia]], or aspiration risk. Administration of the [[Neuromuscular blocking agents|neuromuscular blocking agent]] is associated with a reduction in time from rapid sequence intubation administration to the end of intubation attempt.  
:*'''[[Cormack-Lehane grading ]]on [[Direct laryngoscopy]]:''' This grading is used to predict the difficulty in [[intubation]] based on the structures visualised on [[laryngoscopy]]. The grade 2 was subdivided into 2a and 2b in the modified [[Cormack-Lehane classification]].
:*'''Modified [[Cormack-Lehane classification]]:'''
:**Class 1:Full view of [[glottis ]]is visible.
:**Class 2a:Partial view of [[glottis]] is visible.
:**Class 2b:Only posterior extremity of [[glottis]] or only [[arytenoid cartilages]] are seen.
:**Class 3:Only [[epiglottis]] ,but not [[glottis]] is seen.
:**Class 4:Neither of the [[glottis]] or [[epiglottis]] are seen.
<br />
 
*'''Rapid sequence intubation''':
 
:*[[Rapid sequence intubation]] ([[RSI|RSI)]] is a technique used for endotracheal [[intubation]] when the patient is at high risk of [[aspiration]]. For RSI to be performed, it requires two persons, first patient's lungs are preoxygenated with bag and mask . One person applies constant pressure on the [[cricoid cartilage]], occluding the [[esophagus]]. Sedative-hypnotic or an [[induction agent]] and a [[muscle relaxant]] is administered and patient's [[trachea]] is intubated, and [[cricoid pressure ]]is released after the cuff is inflated. Traditionally, [[thiopentone sodium]] and [[succinylcholine]] were used for [[RSI]], and it had an advantage that patient's airway will be relaxed and paralysed, facilitating the [[intubation] and if any unanticipated difficulty occurs, these drugs were short acting and the effect weans off quickly. There is a debate that optimal intubating conditions should be achieved first before trying to attempt [[intubation]] in the prehospital setting. Time is an important factor and critical in prehospital [[airway]] management of [[patients]], due to [[trauma]], [[cardiac arrest]], [[hypoxemia]], or [[aspiration]] risk. Administration of the [[Neuromuscular blocking agents|neuromuscular blocking agent]] is associated with a reduction in time from rapid sequence [[intubation]] administration to the end of [[intubation]] attempt.


[[File:Glidescope 02.jpg|400px|thumb|left|Photograph of an anesthesiologist using the Glidescope video laryngoscope to intubate the trachea of a morbidly obese elderly person with challenging airway anatomy[https://en.wikipedia.org/wiki/Airway_managementI (DiverDave (talk)) created this work entirely by myself. (Original uploaded on en.wikipedia)]]]<br style="clear:left" />
[[File:Glidescope 02.jpg|400px|thumb|left|Photograph of an anesthesiologist using the Glidescope video laryngoscope to intubate the trachea of a morbidly obese elderly person with challenging airway anatomy[https://en.wikipedia.org/wiki/Airway_managementI (DiverDave (talk)) created this work entirely by myself. (Original uploaded on en.wikipedia)]]]<br style="clear:left" />


==Management of the Airway in Patients with Trauma==
==Management of the Airway in Patients with Trauma==
*[[Airway management]] includes maintaining a patent [[airway ]]by [[bag and mask ventilation]], using [[oroapharyngeal]] or[[ nasopharyngeal]]airways, endotracheal [[intubation]] and also management of the airway during [[extubation]] and after [[extubation]].
===[[Difficult airway]]===
*[[Difficult airway]] includes problems encountered during [[bag and mask ventilation]], like holding of [[face mask]] applying [[positive pressure ventilation]], problems with [[laryngoscopy]] and [[intubation]].
===Suspected Spinal Cord Injury===
===Suspected Spinal Cord Injury===
* In patients with suspected [[trauma]], extreme caution must be taken in aligning the [[head]] and [[neck]]. The [[cervical spine]] must be maintained in a neutral mid-line position, the exception to this is physical resistance.<ref name="ThiboutotNicole2009">{{cite journal|last1=Thiboutot|first1=François|last2=Nicole|first2=Pierre C.|last3=Trépanier|first3=Claude A.|last4=Turgeon|first4=Alexis F.|last5=Lessard|first5=Martin R.|title=Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial|journal=Canadian Journal of Anesthesia/Journal Canadien d'anesthésie|volume=56|issue=6|year=2009|pages=412–418|issn=0832-610X|doi=10.1007/s12630-009-9089-7}}</ref><ref>{{cite journal|doi=10.1016/j.jclinane.2005.04.003 [Indexed for MEDLINE]}}</ref><ref name="KrishnamoorthyDagal2014">{{cite journal|last1=Krishnamoorthy|first1=Vijay|last2=Dagal|first2=Arman|last3=Austin|first3=Naola|title=Airway management in cervical spine injury|journal=International Journal of Critical Illness and Injury Science|volume=4|issue=1|year=2014|pages=50|issn=2229-5151|doi=10.4103/2229-5151.128013}}</ref><ref name="GhafoorMartin2005">{{cite journal|last1=Ghafoor|first1=Abid U.|last2=Martin|first2=Timothy W.|last3=Gopalakrishnan|first3=Senthil|last4=Viswamitra|first4=Sanjaya|title=Caring for the patients with cervical spine injuries: what have we learned?|journal=Journal of Clinical Anesthesia|volume=17|issue=8|year=2005|pages=640–649|issn=09528180|doi=10.1016/j.jclinane.2005.04.003}}</ref><ref name="SriganeshBusse2018">{{cite journal|last1=Sriganesh|first1=Kamath|last2=Busse|first2=JasonW|last3=Shanthanna|first3=Harsha|last4=Ramesh|first4=VenkatapuraJ|title=Airway management in the presence of cervical spine instability: A cross-sectional survey of the members of the Indian Society of Neuroanaesthesiology and Critical Care|journal=Indian Journal of Anaesthesia|volume=62|issue=2|year=2018|pages=115|issn=0019-5049|doi=10.4103/ija.IJA_671_17}}</ref>
 
*In [[patients]] with suspected [[trauma]], extreme caution must be taken in aligning the [[head]] and [[neck]]. The [[cervical spine]] must be maintained in a neutral mid-line position, the exception to this is physical resistance.<ref name="ThiboutotNicole2009">{{cite journal|last1=Thiboutot|first1=François|last2=Nicole|first2=Pierre C.|last3=Trépanier|first3=Claude A.|last4=Turgeon|first4=Alexis F.|last5=Lessard|first5=Martin R.|title=Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial|journal=Canadian Journal of Anesthesia/Journal Canadien d'anesthésie|volume=56|issue=6|year=2009|pages=412–418|issn=0832-610X|doi=10.1007/s12630-009-9089-7}}</ref><ref>{{cite journal|doi=10.1016/j.jclinane.2005.04.003 [Indexed for MEDLINE]}}</ref><ref name="KrishnamoorthyDagal2014">{{cite journal|last1=Krishnamoorthy|first1=Vijay|last2=Dagal|first2=Arman|last3=Austin|first3=Naola|title=Airway management in cervical spine injury|journal=International Journal of Critical Illness and Injury Science|volume=4|issue=1|year=2014|pages=50|issn=2229-5151|doi=10.4103/2229-5151.128013}}</ref><ref name="GhafoorMartin2005">{{cite journal|last1=Ghafoor|first1=Abid U.|last2=Martin|first2=Timothy W.|last3=Gopalakrishnan|first3=Senthil|last4=Viswamitra|first4=Sanjaya|title=Caring for the patients with cervical spine injuries: what have we learned?|journal=Journal of Clinical Anesthesia|volume=17|issue=8|year=2005|pages=640–649|issn=09528180|doi=10.1016/j.jclinane.2005.04.003}}</ref><ref name="SriganeshBusse2018">{{cite journal|last1=Sriganesh|first1=Kamath|last2=Busse|first2=JasonW|last3=Shanthanna|first3=Harsha|last4=Ramesh|first4=VenkatapuraJ|title=Airway management in the presence of cervical spine instability: A cross-sectional survey of the members of the Indian Society of Neuroanaesthesiology and Critical Care|journal=Indian Journal of Anaesthesia|volume=62|issue=2|year=2018|pages=115|issn=0019-5049|doi=10.4103/ija.IJA_671_17}}</ref>




* '''Neck Maneuvers During Airway Management:'''
*'''Neck Maneuvers During Airway Management:'''
**Immobilizing patient's neck by using sandbag-collar-tape on hardboard in a pre-hospital care setting.
**Immobilizing patient's [[neck]] by using sandbag-collar-tape on hardboard in a pre-hospital care setting.
**Applying pressure on cricoid with [[anterior]] half of hard [[cervical collar]] removed and another hand behind the [[posterior]] [[cervical collar]].
**Applying pressure on cricoid with [[anterior]] half of hard [[cervical collar]] removed and another hand behind the [[posterior]] [[cervical collar]].
**Manual in-line stabilization is the technique of choice in any suspected [[cervical spine]] injury, during endotracheal intubation. In this technique, head grasped firmly at the [[mastoid process]] and the occiput.
**Manual in-line stabilization is the technique of choice in any suspected [[cervical spine]] injury, during endotracheal intubation. In this technique, head grasped firmly at the [[mastoid process]] and the occiput.


* Traction should be avoided as it may distract the cervical spine and cause more neurological damage, even after manual in-line stabilization.  
*Traction should be avoided as it may distract the [[cervical spine]] and cause more [[neurological]] damage, even after manual in-line stabilization.


* Jaw thrust is the only basic [[airway]] opening maneuver appropriate for any patient with a suspected cervical spine injury. This method is used when head-tilt/chin-lift can be potentially dangerous to use on a patient who may have a cervical spine injury. In jaw-thrust maneuver, first care provider lifts the [[hyoid bone]] and [[tongue]] away from the posterior pharyngeal wall by pulling the mandible forward, displacing the tongue anteriorly.  
*Jaw thrust is the only basic [[airway]] opening maneuver appropriate for any [[patient]] with a suspected [[cervical spine injury]]. This method is used when head-tilt/chin-lift can be potentially dangerous to use on a patient who may have a [[cervical spine injury]]. In jaw-thrust maneuver, first care provider lifts the [[hyoid bone]] and [[tongue]] away from the [[posterior]] [[pharyngeal]] wall by pulling the [[mandible]] forward, displacing the [[tongue]] anteriorly.
* Suction and use of [[forceps]] under direct vision using a laryngoscope with the [[head]] and [[neck]] maintained in the neutral position.  
*[[Suction]] and use of [[forceps]] under direct vision using a [[laryngoscope]] with the [[head]] and [[neck]] maintained in the neutral position.
* In order to minimize the risk of hypoxic damage from [[airway obstruction]] in an [[unconscious]] patient, proper positioning is done by placing patients in the [[lateral]] side with log rolling technique.
*In order to minimize the risk of [[hypoxic]] damage from [[airway obstruction]] in an [[unconscious]] patient, proper positioning is done by placing patients in the [[lateral]] side with log rolling technique.


===Approach to airway management of a patient with Maxillo-Facial Injury===
===Approach to airway management of a patient with Maxillo-Facial Injury===
Airway management of patients with [[maxillofacial]] trauma is challenging and vital because it's directly affecting the patient's survival. Endotracheal intubation is the gold standard procedure to secure the airway in trauma patients, however, in these patients passage of endotracheal tube may not be possible because the oral cavity, [[pharynx]], and [[larynx]] may be filled with [[blood]], secretions, soft tissue, and bone fragments. Another reason for this is that the risk of aspiration and regurgitation is high in these patients.<ref name="BarakBahouth2015">{{cite journal|last1=Barak|first1=Michal|last2=Bahouth|first2=Hany|last3=Leiser|first3=Yoav|last4=Abu El-Naaj|first4=Imad|title=Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach|journal=BioMed Research International|volume=2015|year=2015|pages=1–9|issn=2314-6133|doi=10.1155/2015/724032}}</ref><ref name="pmid21655009">{{cite journal |vauthors=Raval CB, Rashiduddin M |title=Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases |journal=Saudi J Anaesth |volume=5 |issue=1 |pages=9–14 |date=January 2011 |pmid=21655009 |pmc=3101764 |doi=10.4103/1658-354X.76476 |url=}}</ref><ref name="pmid7588664">{{cite journal |vauthors=Brimacombe J, Tucker P, Simons S |title=The laryngeal mask airway for awake diagnostic bronchoscopy. A retrospective study of 200 consecutive patients |journal=Eur J Anaesthesiol |volume=12 |issue=4 |pages=357–61 |date=July 1995 |pmid=7588664 |doi= |url=}}</ref><ref name="HsiaoPacheco-Fowler2008">{{cite journal|last1=Hsiao|first1=James|last2=Pacheco-Fowler|first2=Victor|title=Cricothyroidotomy|journal=New England Journal of Medicine|volume=358|issue=22|year=2008|pages=e25|issn=0028-4793|doi=10.1056/NEJMvcm0706755}}</ref>
[[Airway]] management of patients with [[maxillofacial]] trauma is challenging and vital because it's directly affecting the patient's survival. [[Endotracheal intubation]] is the [[Gold standard (test)|gold standard]] procedure to secure the [[airway]] in [[trauma]] [[patients]], however, in these [[patients]] passage of [[endotracheal tube]] may not be possible because the oral cavity, [[pharynx]], and [[larynx]] may be filled with [[blood]], secretions, [[soft tissue]], and [[bone]] fragments. Another reason for this is that the risk of [[aspiration]] and [[regurgitation]] is high in these patients.<ref name="BarakBahouth2015">{{cite journal|last1=Barak|first1=Michal|last2=Bahouth|first2=Hany|last3=Leiser|first3=Yoav|last4=Abu El-Naaj|first4=Imad|title=Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach|journal=BioMed Research International|volume=2015|year=2015|pages=1–9|issn=2314-6133|doi=10.1155/2015/724032}}</ref><ref name="pmid21655009">{{cite journal |vauthors=Raval CB, Rashiduddin M |title=Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases |journal=Saudi J Anaesth |volume=5 |issue=1 |pages=9–14 |date=January 2011 |pmid=21655009 |pmc=3101764 |doi=10.4103/1658-354X.76476 |url=}}</ref><ref name="pmid7588664">{{cite journal |vauthors=Brimacombe J, Tucker P, Simons S |title=The laryngeal mask airway for awake diagnostic bronchoscopy. A retrospective study of 200 consecutive patients |journal=Eur J Anaesthesiol |volume=12 |issue=4 |pages=357–61 |date=July 1995 |pmid=7588664 |doi= |url=}}</ref><ref name="HsiaoPacheco-Fowler2008">{{cite journal|last1=Hsiao|first1=James|last2=Pacheco-Fowler|first2=Victor|title=Cricothyroidotomy|journal=New England Journal of Medicine|volume=358|issue=22|year=2008|pages=e25|issn=0028-4793|doi=10.1056/NEJMvcm0706755}}</ref>
*In such circumstances, there are numerous [[airway]] devices are available to rescue patients with maxillofacial injuries, some of these devices include:<ref name="BarakBahouth2015">{{cite journal|last1=Barak|first1=Michal|last2=Bahouth|first2=Hany|last3=Leiser|first3=Yoav|last4=Abu El-Naaj|first4=Imad|title=Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach|journal=BioMed Research International|volume=2015|year=2015|pages=1–9|issn=2314-6133|doi=10.1155/2015/724032}}</ref><ref name="MeyerPatel2014">{{cite journal|last1=Meyer|first1=TanyaK|last2=Patel|first2=SapnaA|title=Surgical Airway|journal=International Journal of Critical Illness and Injury Science|volume=4|issue=1|year=2014|pages=71|issn=2229-5151|doi=10.4103/2229-5151.128016}}</ref>
 
**flexible fiberoptic bronchoscope (FOB), enable an indirect view of vocal cords.  
*In such circumstances, there are numerous [[airway]] devices are available to rescue patients with [[maxillofacial]] injuries, some of these devices include:<ref name="BarakBahouth2015">{{cite journal|last1=Barak|first1=Michal|last2=Bahouth|first2=Hany|last3=Leiser|first3=Yoav|last4=Abu El-Naaj|first4=Imad|title=Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach|journal=BioMed Research International|volume=2015|year=2015|pages=1–9|issn=2314-6133|doi=10.1155/2015/724032}}</ref><ref name="MeyerPatel2014">{{cite journal|last1=Meyer|first1=TanyaK|last2=Patel|first2=SapnaA|title=Surgical Airway|journal=International Journal of Critical Illness and Injury Science|volume=4|issue=1|year=2014|pages=71|issn=2229-5151|doi=10.4103/2229-5151.128016}}</ref>
**laryngeal mask airway (LMA) or the double lumen esophageal-tracheal combitube, do not require a view of the vocal cords. Another option for securing the [[airway]] in these patients is to pass the endotracheal tube after placing an LMA for them.  
**Flexible [[fiberoptic]] [[bronchoscopy]] (FOB), enable an indirect view of [[vocal cords]].
*Final option for establishing the airway in patients with maxillofacial injury is surgery by [[cricothyroidotomy]].  
**[[Laryngeal mask airway]] (LMA) may be inserted blindly since it does not require a view of the [[vocal cords]]. Another option for securing the [[airway]] in these patients is to pass the endotracheal tube after placing an LMA for them.
**[[Cricothyroidotomy]] also known as [[cricothyrotomy]] is a procedure done by trained health care providers, they make a small [[incision]] through the skin and cricoid membrane which lies between the thyroid and cricoid cartilages, followed by inserting a [[tracheostomy tube]] to open alternative way of [[ventilation]] and [[oxygenation]] in the [[emergency]] situation which uses of endotracheal intubation is almost impossible or difficult and time-consuming.  
*Final option for establishing the airway in [[patients]] with [[maxillofacial]] injury is [[surgery]] by [[cricothyroidotomy]].  
**[[Cricothyroidotomy]] also known as [[cricothyrotomy]] is a procedure done by trained [[health care providers]], they make a small [[incision]] through the skin and [[cricoid]] membrane which lies between the [[thyroid]] and [[cricoid]] [[cartilage]]<nowiki/>s, followed by inserting a [[tracheostomy tube]] to open alternative way of [[ventilation]] and [[oxygenation]] in the [[emergency]] situation which uses of [[endotracheal intubation]] is almost impossible or difficult and time-consuming.
**'''Indication for cricothyroidotomy include:'''
**'''Indication for cricothyroidotomy include:'''
***Inability to secure [[airway]] through an [[endotracheal tube]]
***Inability to secure [[airway]] through an [[endotracheal tube]]
***Major trauma to [[facial]] [[muscles]], pharynx, larynx.
***Major [[trauma]] to [[facial]] [[muscles]], [[pharynx]], [[larynx]].
***Congenital deformities and upper airway stenosis
***[[Congenital deformities]] and [[upper airway]] [[stenosis]].


*'''Contraindications for cricothyroidotomy:'''
*'''Contraindications for cricothyroidotomy:'''
Line 97: Line 122:
**Inability to identify surface landmarks due to [[obesity]], [[cervical]] trauma.
**Inability to identify surface landmarks due to [[obesity]], [[cervical]] trauma.
**When [[Orotracheal intubation|orotracheal]] and [[Nasotracheal intubation|nasotracheal]] [[intubation]] are viable options
**When [[Orotracheal intubation|orotracheal]] and [[Nasotracheal intubation|nasotracheal]] [[intubation]] are viable options
**[[Airway obstruction]] distal to [[subglottic airway]], e.g. [[tracheal stenosis]]  
**[[Airway obstruction]] distal to [[subglottic airway]], e.g. [[tracheal stenosis]]
**[[Laryngeal cancer]]: Other than for an extreme airway [[emergency]], cricothyroidotomy must be avoided to not to seed the soft tissue of the neck with cancer cells
**[[Laryngeal cancer]]: Other than for an extreme airway [[emergency]], [[cricothyroidotomy]] must be avoided to not to seed the [[soft tissue]] of the [[neck]] with [[cancer]] cells
**Coagulopathy (other than emergency situation)
**[[Coagulopathy]] (other than [[emergency]] situation)


*'''Complications of cricothyroidotomy:'''
*'''Complications of cricothyroidotomy:'''
**[[Esophageal]] perforation if the blade penetrates too deeply.
**[[Esophageal]] perforation if the blade penetrates too deeply.
**[[Subcutaneous emphysema]]
**[[Subcutaneous emphysema]]
**Rupture of vital [[vessels]] such as a [[carotid artery]], excessive bleeding, and hemorrhage.  
**Rupture of vital [[vessels]] such as a [[carotid artery]], excessive [[bleeding]], and [[hemorrhage]].


*'''Indications of definitive airway management in patients with maxillofacial injury:'''
*'''Indications of definitive airway management in patients with maxillofacial injury:'''
Line 117: Line 142:
==Complications of airway management==
==Complications of airway management==


Airway management complications are common, these complications usually occur in intensive care units and emergency departments, summary of airway management related complactions include:<ref name="CookMacDougall-Davis2012">{{cite journal|last1=Cook|first1=T.M.|last2=MacDougall-Davis|first2=S.R.|title=Complications and failure of airway management|journal=British Journal of Anaesthesia|volume=109|year=2012|pages=i68–i85|issn=00070912|doi=10.1093/bja/aes393}}</ref>
Airway management complications are common, these complications usually occur in [[intensive care units]] and [[emergency department]]<nowiki/>s, summary of airway management related complactions include:<ref name="CookMacDougall-Davis2012">{{cite journal|last1=Cook|first1=T.M.|last2=MacDougall-Davis|first2=S.R.|title=Complications and failure of airway management|journal=British Journal of Anaesthesia|volume=109|year=2012|pages=i68–i85|issn=00070912|doi=10.1093/bja/aes393}}</ref>
* Patient harm/death associated with suboptimal care
 
* Hypoxia is the most common cause of airway-related deaths
*[[Patient]] harm/death associated with suboptimal care
* Obesity
*[[Hypoxia]] is the most common cause of [[airway]]-related deaths
* Pulmonary aspiration remains the leading cause of airway-related anesthetic deaths
*[[Obesity]]
* Failure in airway management techniques
*[[Pulmonary]] [[aspiration]] remains the leading cause of airway-related [[anesthetic]] deaths
*Failure in airway management techniques




Line 128: Line 154:


==Related Chapters==
==Related Chapters==
*[[intubation|Intubation]]
*[[intubation|Intubation]]
*[[endotracheal tube|Endotracheal Tube]]
*[[endotracheal tube|Endotracheal Tube]]

Latest revision as of 01:33, 27 May 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Nima Nasiri, M.D.[2]

Overview

Airway management is the process of ensuring that there is an open pathway between a patient’s lungs and the outside world, and the lungs are safe from aspiration. Airway loss is a major cause of preventable prehospital death in trauma patients. Airway management complications are common, especially in trauma patients because of associated pathology, lack of complete evaluation before intubation, unanticipated difficulty during ventilation and intubation. Additionally, trauma patients are at increased risk of airway obstruction, aspiration, hypoxia and hypotension, and other unstable vital The providers must have skillset related to working with a variety of tools and techniques used in airway management and knowledge of the important anatomical, physiological, and pathological features related to the airway. They also should know the differences between the adult versus pediatric and neonatal airways as these anatomical and physiological differences are critical, impactful on patients lives and knowing these leads to effective control and management of the airway. Some of the indications for managing the airway in patients include respiratory failure, altered sensorium(Glasgow Coma Scale less than or equal to 8), rapid deterioration of mental status, airway injury or compromise, injuries causing a high risk for aspiration-which includes all penetrating injuries to the abdomen or chest wall. Inadequate airway management may lead to cardiovascular arrest and compromise life-saving interventions in a trauma patient. Several airway control devices and techniques are available to assist healthcare providers in order to maintain the airway by ventilation and oxygenation. These include bag valve mask (BVM) ventilation, direct laryngoscopy with endotracheal intubation (ETI) and adjunct supraglottic airway devices such as the laryngeal mask airway.

Functional anatomy of the upper airway

For a successful approach to airway management, health care providers must have knowledge of important anatomical, physiological, and pathological features related to the airway as well as knowledge of the various equipment and methods that can be utilized for this purpose. Also, the difference between airway management in adults, pediatrics, and neonates is very critical.[1]


upper airway systemstaff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.


Recommendations for evaluation of airway

The basic approach in airway management in the emergency setting includes:[2]

Following are steps that must be considered prior to conducting airway management, these include:

  • History: An airway history should be conducted whenever it is possible before airway management in all patients to detect medical, surgical, and anesthetic factors that may indicate the presence of a difficult airway. A detailed review of previous anesthetic records, if available, may provide useful information about airway management.
  • Physical Examination: An airway physical examination should be conducted before the initiation of airway management. The goal of physical examination is to detect physical characteristics that may indicate the presence of a difficult airway because an unsuccessful airway management is associated with increase in mortality and morbidity.
  • Additional Evaluation: Additional evaluation may be indicated in some patients to characterize the likelihood or nature of the anticipated difficult airway. Certain diagnostic tests (e.g., radiography, computed tomography scans, fluoroscopy) can identify a variety of acquired or congenital features in patients with difficult airways

Techniques for airway management

The decision about whether an airway intervention is required or not is crucial for patient's survival and depends on first responders skills and quick assessment and decision. These crucial steps requires techniques which are used universally in order to manage patient's airway. Following are initial evaluation methods which had been developed to assist patient's ventilation and keep the airway patent, these techniques include:[3][4][5][6][7]

  • Spontaneous breathing: When a provider is confronted with an awake patient having a patent airway. Spontaneous ventilation can be assisted through the placement of a nasal or oral airway. Oxygenation can be improved by giving oxygen via nasal cannula, simple face mask, or nonrebreather face mask. Unfortunately, the maximally achieved FiO2 is often overestimated by care providers and hypoventilation resulting in hypercapnia cannot be normalized with increase in oxygen supply.
  • Mouth-to-Mouth ventilation: Mouth-to-mouth or mouth-to-nose ventilation is a useful management technique, however, because of the risk of infection transmission it is recommended by American heart association that health care providers do "Hands-only" CPR. Proper face masks should be utilized if they are available.
  • Bag-mask ventilation: It is a standard initial approach to airway management in the prehospital and hospital settings.
  • Oropharyngeal and nasopharyngeal airways:
  • Supraglottic airway devices: Supraglottic airway (SGA) device placement is very useful to keep the airways open, it has advantages in comparison with endotracheal tube intubation, or other methods, these advantages include:[8]


  • Rapid sequence intubation:
Photograph of an anesthesiologist using the Glidescope video laryngoscope to intubate the trachea of a morbidly obese elderly person with challenging airway anatomy(DiverDave (talk)) created this work entirely by myself. (Original uploaded on en.wikipedia)


Management of the Airway in Patients with Trauma

Difficult airway

Suspected Spinal Cord Injury


  • Neck Maneuvers During Airway Management:
    • Immobilizing patient's neck by using sandbag-collar-tape on hardboard in a pre-hospital care setting.
    • Applying pressure on cricoid with anterior half of hard cervical collar removed and another hand behind the posterior cervical collar.
    • Manual in-line stabilization is the technique of choice in any suspected cervical spine injury, during endotracheal intubation. In this technique, head grasped firmly at the mastoid process and the occiput.
  • Traction should be avoided as it may distract the cervical spine and cause more neurological damage, even after manual in-line stabilization.

Approach to airway management of a patient with Maxillo-Facial Injury

Airway management of patients with maxillofacial trauma is challenging and vital because it's directly affecting the patient's survival. Endotracheal intubation is the gold standard procedure to secure the airway in trauma patients, however, in these patients passage of endotracheal tube may not be possible because the oral cavity, pharynx, and larynx may be filled with blood, secretions, soft tissue, and bone fragments. Another reason for this is that the risk of aspiration and regurgitation is high in these patients.[14][15][16][17]

Complications of airway management

Airway management complications are common, these complications usually occur in intensive care units and emergency departments, summary of airway management related complactions include:[19]


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Related Chapters

References

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  2. Rosenberg, M. B; Phero, J. C; Becker, D. E (2014). "Essentials of Airway Management, Oxygenation, and Ventilation: Part 2: Advanced Airway Devices: Supraglottic Airways". Anesthesia Progress. 61 (3): 113–118. doi:10.2344/0003-3006-61.3.113. ISSN 0003-3006.
  3. Roychoudhury, Ajoy; Jose, Anson; Nagori, ShakilAhmed; Agarwal, Bhaskar; Bhutia, Ongkila (2016). "Management of maxillofacial trauma in emergency: An update of challenges and controversies". Journal of Emergencies, Trauma, and Shock. 9 (2): 73. doi:10.4103/0974-2700.179456. ISSN 0974-2700.
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  10. . doi:10.1016/j.jclinane.2005.04.003 [Indexed for MEDLINE] Check |doi= value (help). Missing or empty |title= (help)
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  14. 14.0 14.1 Barak, Michal; Bahouth, Hany; Leiser, Yoav; Abu El-Naaj, Imad (2015). "Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach". BioMed Research International. 2015: 1–9. doi:10.1155/2015/724032. ISSN 2314-6133.
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  19. Cook, T.M.; MacDougall-Davis, S.R. (2012). "Complications and failure of airway management". British Journal of Anaesthesia. 109: i68–i85. doi:10.1093/bja/aes393. ISSN 0007-0912.


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