Airway management

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

In cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid, airway management is the process of ensuring that:

1. There is an open pathway between a patient’s lungs and the outside world, and
2. The lungs are safe from aspiration.

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.

Manual Methods

Head Tilt/ Chin Lift

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.

Jaw Thrust

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.

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 position 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 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 that an ET tube.

In the case of a choking patient, laryngoscopy or even bronchoscopy may be performed in order to visualize and remove the blockage.

An oropharyngeal airway or nasopharyngeal airway can 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.

Related Chapter

• Intubation
• Endotracheal Tube
• Laryngeal Mask Airway
• Oropharyngeal Airway
• Nasopharyngeal Airway
• Ventilation
• Cricothyrotomy

References

Emergency Medical Responder (Second Canadian Version). Brady. 2006. pp. 92–97. ISBN 0-13-127824-X.