3. Anatomy of the Glottis
• Posterior tongue
• Epiglottis
• Vocal cords
– True
– False
• Esophagus
• Prehospital care providers
who perform endotracheal
intubation must know this anatomy
Courtesy of James P. Thomas, M.D., www.voicedoctor.net
4. Pediatric Airway Considerations
• Larger head and tongue
– Greater potential for airway obstruction
– Special attention to proper positioning
• Epiglottis
– Proportionally larger
– Floppier than adult
• Trachea
– Shorter and conical shape
– Greater potential for main
bronchus intubation
5. Airway Assessment (1 of 5)
• If the trauma patient is talking normally,
the airway is open
– Further assessment is still required
• Assessment of the airway requires the
provider to:
– Look
– Listen
– Feel
6. Airway Assessment (2 of 5)
• Look for findings that may indicate airway
obstruction or injury or may lead to
pulmonary aspiration
• Examples may include:
– Blood and secretions
– Fractured teeth
– Foreign bodies
7. Airway Assessment (3 of 5)
• Examples may include
(cont’d):
– Vomitus
– Hematomas/contusions
(e.g., tongue, neck)
– Gross subcutaneous
emphysema
Photograph provided courtesy of J.C. Pitteloud M.D., Switzerland
9. Airway Assessment (5 of 5)
• Feel for abnormal masses and signs of
airway injury
• Examples include:
– Hematomas
– Subcutaneous emphysema in the neck
• Additional consideration
– Measure oxygen saturation
10. Airway Obstruction (1 of 2)
• Causes of airway obstruction
– Tongue
• Most common cause
• Falls back, obstructing
the airway with
decreased mental
status
• Snoring — clinical
finding
11. Airway Obstruction (2 of 2)
• Causes of airway obstruction (cont’d)
– Foreign body
– Blood
– Vomit
– Teeth
12. Airway Trauma (1 of 2)
• Blunt injuries
– Examples of findings may include:
• Swelling and edema
• Fractured larynx
• Subcutaneous emphysema
• Hematoma
13. Airway Trauma (2 of 2)
• Penetrating injuries
– Examples of findings may include (cont’d):
• Bleeding into the airway
• Subcutaneous emphysema
• Hematoma
14. Inhalation Injuries of the Airway
• Examples of causes
– Dry
– Steam
– Chemical
• Signs and symptoms of airway burns
– Swelling/edema
– Stridor
15. Airway and Spine Stabilization
• Maintain cervical spine stabilization as
indicated by mechanism of injury
• Especially important when assessing and
performing airway maneuvers
16. Airway Management (1 of 3)
• The goal in managing the trauma patient’s
airway is to maintain a patent airway that
allows for adequate breathing, ventilation,
and oxygenation
• Management progresses from essential to
complex procedures and adjuncts
17. Airway Management (2 of 3)
• Prehospital care providers should be
knowledgeable and skilled in multiple
methods of ensuring a patent airway
• Providing a patent airway entails
anticipating difficulties and planning for
alternate methods of airway control
18. Airway Management (3 of 3)
• Essential skills and interventions are
applied first
• Complex skills and interventions are
performed only if needed
• The choice of technique to manage the
airway depends upon:
– Knowledge and skills of the provider
– Situation at the scene
– Severity of the patient
– Resources available
19. Methods and Categories of
Airway Management (1 of 2)
• Manual
– Trauma jaw thrust
– Chin lift
• Simple
– Oropharyngeal
airway (OPA)
– Nasopharyngeal
airway (NPA)
20. Methods and Categories of
Airway Management (2 of 2)
• Complex
– Supraglottic airways
– Endotracheal intubation
– Rapid sequence intubation (RSI)
– Percutaneous
airway
– Surgical airway
Courtesy of Ambu, Inc.
21. Trauma Jaw Thrust or Chin
Lift (1 of 2)
• Always the first airway maneuvers for the
trauma patient
• Performed while maintaining manual
cervical stabilization
22. Trauma Jaw Thrust or Chin
Lift (2 of 2)
• Both techniques lift the mandible,
elevating the tongue away from the
posterior pharynx, opening the airway
• Can be used for conscious or unconscious
patients
23. OPA and NPA (1 of 2)
• Both airway adjuncts mechanically elevate
the tongue off the poster pharynx to
maintain an open airway
• Both airways require measurement
(length) and sizing
(diameter) prior to
insertion.
24. OPA and NPA (2 of 2)
• Improperly sized or improperly inserted
airways can cause obstruction by pushing
the tongue against the posterior pharynx
• OPA insertion requires an absent gag
reflex
– Insertion technique is based on age of patient
• NPA insertion requires the use of a
water-soluble lubricant
25. Supraglottic Airways (1 of 2)
• Blind insertion technique
• Less complex technique than
endotracheal intubation
– Less initial training
– Easier to maintain proficiency
• Requires an
absent gag reflex
Courtesy of Ambu, Inc.
26. Supraglottic Airways (2 of 2)
• Supraglottic airways occlude the pharynx
to limit regurgitation but do not prevent
aspiration
• Some supraglottic airways are available in
pediatric sizes
• Examples of supraglottic airways include
the laryngeal mask airway (LMA),
Combitube, and King LT airway
27. Endotracheal Intubation (1 of 6)
• Complex technique
• Requires:
– Significant initial
training
– Multiple pieces of
equipment
– Substantial ongoing
training to maintain
proficiency
Courtesy of AMBU
29. Endotracheal Intubation (3 of 6)
• Assess need for intubation based on:
– Inability to maintain a patent airway
– Decreased LOC
– Upper airway burns
– Signs of impending airway obstruction
• Endotracheal intubation may also be
considered when alternate methods of
airway management are deemed
inadequate or inappropriate based on the
situation and severity of injuries
30. Endotracheal Intubation (4 of 6)
• Before attempting intubation:
– Anticipate potential difficulties
• Trauma-related
– Disrupted/displaced anatomy
• Pre-existing conditions
– Small mouth/mandible
– Short neck
– Obesity
31. Endotracheal Intubation (5 of 6)
• Before attempting intubation (cont’d):
– Prepare an alternate (backup) plan for airway
management in the event of unsuccessful
endotracheal tube placement
– Have all necessary equipment immediately at
hand
32. Endotracheal Intubation (6 of 6)
• Important considerations
– Essential airway skills are often sufficient to
provide a patent airway
– If intubation is required:
• Preoxygenate to maximize oxygen saturation
• Reoxygenate patient in between intubation
attempts
• Monitor oxygen saturation (e.g., pulse oximetry)
throughout the procedure
– Following intubation, verify proper tube
placement
33. Surgical Airways (1 of 3)
• Complex technique
• Requires:
– Significant initial training
– Multiple pieces of equipment
– Substantial ongoing training to
maintain proficiency
Courtesy of Peter T. Pons, MD, FACEP.
Courtesy of Peter T. Pons, MD, FACEP.
34. Surgical Airways (2 of 3)
• Potential for:
– Multiple complications
– Damage to nearby anatomic structures
35. Surgical Airways (3 of 3)
• May be considered for:
– Massive facial trauma that prevents
endotracheal intubation
– Upper airway obstruction unrelieved by other
techniques
– Failed intubation and alternative airway
methods are unavailable or unsuccessful
36. Confirmation of Tube
Placement (1 of 2)
• Should include at least one physiological
and one mechanical method
• Physiological
– Breath sounds
– Chest rise
– Change in skin color
– Pulse rate
• Continually monitored and reassessed
37. Confirmation of Tube
Placement (2 of 2)
• Mechanical
– End tidal CO2
• Colorimetric
• Capnometry
• Wave form
capnography
– Pulse oximetry
• Continually monitored
and reassessed Courtesy Masimo
41. Summary
• Goal is to secure and maintain a patent
airway
• Assess airway by looking, listening, and
feeling
• Maintain manual stabilization of the head and
spine as indicated
• Apply essential airway maneuvers first
• Utilize complex airway techniques only when
required
• Anticipate difficulties and plan and prepare
for alternate methods of airway control
Instructor Notes
Lesson 4 will provide participants with an overview on how to manage an airway in a trauma patient.
Remember, management of the airway is paramount in the successful resuscitation of the trauma patient.
Without a patent airway, all is lost.
However, the best airway for a particular patient may not be an advanced airway or endotracheal tube.
Instructor Notes
Expand on the following points:
Briefly review the anatomy of the upper airway and its relationship to airway management.
A patent airway is the first component in the delivery pathway of oxygen to the cells.
Oxygen is needed for cellular metabolism and energy production.
The tongue is the most common cause of airway obstruction.
The components of the upper airway include:
Nasal passage
Turbinates
Oral cavity
Epiglottis
Vocal cord
Esophagus
Instructor Notes
Expand on the following points:
The figures on screen illustrate the laryngoscopic view of the glottis.
Prehospital care providers who perform endotracheal intubation must know the anatomy of the glottis, including:
Posterior tongue
Epiglottis
Leaf-shaped structure
Acts as a gate or flapper valve
Directs air into the trachea and solids and liquids into the esophagus
Vocal cords
True
Folds of tissue that meet in the midline
False
Also called vestibular folds
Direct the airflow through the vocal cords
Esophagus
Instructor Notes
Expand on the following points:
Review the differences in the anatomy of the pediatric patient and potential areas of difficulty in maintaining a patent airway.
Pediatric airway considerations include:
A larger head and tongue as compared to an adult
There is a greater potential for airway obstruction in a pediatric patient.
Special attention to the proper positioning of the pediatric patient is required to maintain a patent airway.
The epiglottis is proportionally larger and floppier than in an adult.
The trachea is shorter and conical shape, which leads to a greater potential for main bronchus intubation.
Instructor Notes
Expand on the following points:
Even if the trauma patient is talking normally, still assess the airway.
While the talking patient is demonstrating that the airway is open now, further assessment is still required.
The assessment of the airway requires the prehospital care provider to:
Look, listen, and feel
This technique will be discussed in the following slides.
Instructor Notes
Expand on the following points:
During the airway assessment, look for findings that may indicate airway obstruction or injury or may lead to pulmonary aspiration.
Examples may include:
Blood and secretions
Fractured teeth
Foreign bodies
Instructor Notes
Expand on the following points:
During the airway assessment, look for findings that may indicate airway obstruction or injury or may lead to pulmonary aspiration.
Examples may include (continued):
Vomitus
Hematomas/contusions (e.g. tongue, neck)
Gross subcutaneous emphysema
The photo on this screen illustrates contusion over the trachea and gross subcutaneous emphysema (note the air-filled swollen eyelids) in a patient with a ruptured trachea.
It is courtesy of J. C. Pitteloud, MD, PHTLS Switzerland.
Instructor Notes
Expand on the following points:
Listen for abnormal sounds indicating airway compromise.
Examples include:
Snoring
Stridor (upon inhalation)
Gurgling (upon exhalation)
Hoarseness
Of all of the abnormal airway sounds, stridor is the most concerning because it indicates a high degree of airway obstruction and the need for immediate intervention.
Instructor Notes
Expand on the following points:
Feel for abnormal masses and signs of airway injury.
Examples include:
Hematomas
It is critical to note the presence of an expanding hematoma involving the neck.
May distort the normal anatomy and compromise the ability to manage the airway if necessary
Subcutaneous emphysema in the neck
The presence of subcutaneous emphysema indicates disruption of the pulmonary system.
The exact location of the air leak may not be apparent in the field.
Additional consideration during this phase:
Measure oxygen saturation.
Instructor Notes
Expand on the following points:
Causes of airway obstruction:
Tongue
The tongue obstructing the airway is the primary reason for death in the head-injured patient prior to EMS arrival.
With decreased mental status, the tongue falls back, obstructing the airway.
Snoring is a clinical finding indicating this obstruction.
Instructor Notes
Expand on the following points:
Additional causes of airway obstruction in the trauma patient are (continued):
A foreign body
Blood
Vomit
Teeth
Instructor Notes
Expand on the following points:
Examples of clinical findings of blunt trauma may include:
Swelling and edema
Fractured larynx
Subcutaneous emphysema
Hematoma
Note that this list is not inclusive of all possible findings.
Instructor Notes
Expand on the following points:
Examples of clinical findings of penetrating trauma may include (continued):
Bleeding into the airway
Subcutaneous emphysema
Hematoma
Note that this list is not inclusive of all possible findings.
Instructor Notes
Expand on the following points:
Inhalation injuries of the airway may be the result of smoke inhalation (dry), steam, or chemicals.
The signs and symptoms of airway burns include swelling/edema and stridor.
While the burn is of concern, the primary risk is the development of tissue edema obstructing the airway.
Early and aggressive management of the burned airway is recommended before swelling develops and further complicates airway management.
If the prehospital care provider cannot secure an airway, the patient needs to be immediately transported to a facility that can provide the needed airway.
This facility may not necessarily be a trauma or burn center since the patient can be transferred as appropriate after the airway has been managed.
The use of supraglottic airways in these cases may not secure the airway due to the increase in swelling of the upper airway.
Endotracheal intubation and rarely surgical airway management techniques are required.
Instructor Notes
Expand on the following points:
Maintain cervical spine stabilization as indicated by the mechanism of injury.
This is especially important when assessing and performing airway maneuvers in a trauma patient.
Instructor Notes
Expand on the following points:
The goal in managing the trauma patient’s airway is to maintain a patent airway that allows for adequate breathing, ventilation, and oxygenation.
The management of an airway progresses from essential maneuvers to complex procedures and adjuncts.
For example, progressing from the trauma jaw thrust to suctioning to ventilation with a bag-mask device to endotracheal intubation
Instructor Notes
Expand on the following points:
Prehospital care providers should be knowledgeable and skilled in multiple methods of ensuring a patent airway.
Providing a patent airway entails anticipating difficulties and planning for alternate methods of airway control.
Instructor Notes
Expand on the following points:
When managing the airway of a trauma patient:
Essential skills and interventions are applied first.
Essential skills include manual airway opening techniques and simple devices such as oropharyngeal airways and nasopharyngeal airways.
Complex skills and interventions are performed only if needed.
Complex skills and interventions are those that require significant initial training and skills maintenance.
Complex skills include devices and techniques such as endotracheal intubation, supraglottic airways, rapid sequence intubation (RSI), percutaneous airways, and surgical airways.
The choice of technique to manage the airway depends upon:
The knowledge and skills of the prehospital care provider
The situation at the scene
The severity of the patient
The resources available
Instructor Notes
Expand on the following points:
The methods and categories of airway management are:
Manual
Trauma jaw thrust
Chin lift
Simple
Oropharyngeal airway (OPA)
Nasopharyngeal airway (NPA)
The techniques listed will be covered in subsequent slides.
Instructor Notes
Expand on the following points:
The methods and categories of airway management are (continued):
Complex
Supraglottic airways
Endotracheal intubation
Rapid sequence intubation (RSI)
Percutaneous airway
Surgical airway
The techniques listed will be covered in subsequent slides.
Instructor Notes
Expand on the following points:
The trauma jaw thrust or chin lift is always the first airway maneuver for the trauma patient.
These techniques are performed while maintaining manual cervical stabilization.
They require NOTHING other than your hands to perform.
Instructor Notes
Expand on the following points:
Both techniques lift the mandible, elevating the tongue away from the posterior pharynx, and opening the airway.
They can be used for conscious or unconscious patients.
Remind participants that the tongue is attached directly to the mandible, thus explaining why both techniques are efficacious.
Instructor Notes
Expand on the following points:
Both types of airway adjuncts mechanically elevate the tongue off of the poster pharynx to maintain an open airway.
Both types of airways require measurement (length) and sizing (diameter) prior to insertion.
Review the measuring, sizing, and insertion techniques of both types of adjuncts with participants.
See the Specific Skills section at the end of the Airway and Ventilation chapter of PHTLS: Prehospital Trauma Life Support, Eighth Edition.
Oropharyngeal Airway
Nasopharyngeal Airway
Note that head injury is not an absolute contraindication to the use of an NPA.
Instructor Notes
Expand on the following points:
Improperly sized or improperly inserted airways can cause obstruction by pushing the tongue against the posterior pharynx.
OPA insertion requires an absent gag reflex.
The insertion technique is based on the age of patient.
OPA insertion in the pediatric patient requires the use of a tongue blade and de-rotation of the airway device in comparison to the technique utilized for adult patients.
NPA insertion requires the use of a water-soluble lubricant.
Instructor Notes
Expand on the following points:
Supraglottic airways require the blind insertion technique.
This is a less complex technique than endotracheal intubation.
It requires less initial training.
It is easier to maintain proficiency in this technique.
Supraglottic airways require an absent gag reflex.
See the Specific Skills section at the end of the Airway and Ventilation chapter to review specific supraglottic airway skills.
Instructor Notes
Expand on the following points:
Supraglottic airways occlude the pharynx to limit regurgitation, but do not prevent aspiration.
Some supraglottic airways are available in pediatric sizes.
Examples of supraglottic airways include the laryngeal mask airway (LMA), Combitube, and King LT airway
Not all manufacturers of supraglottic airways provide pediatric sizes.
Instructor Notes
Expand on the following points:
All prehospital care providers should know and understand the skill of endotracheal intubation, as they may be called to either assist or perform the procedure.
Endotracheal intubation is a complex technique that requires:
Significant initial training
Multiple pieces of equipment
Substantial ongoing training to maintain proficiency
Instructor Notes
Expand on the following points:
Several methods are available for performing endotracheal intubation.
Orotracheal intubation
Pharmacologically assisted intubation
Rapid-sequence intubation (RSI)
Nonpharmacologic
Nasotracheal intubation
Instructor Notes
Expand on the following points:
Assess for the need for endotracheal intubation based on:
The inability to maintain a patent airway
A decreased level of consciousness (LOC)
Upper airway burns
Signs of impending airway obstruction
Endotracheal intubation may also be considered when alternate methods of airway management are deemed inadequate or inappropriate based on the situation and severity of injuries.
Instructor Notes
Expand on the following points:
Anticipation and preparation are key to successful airway management.
Anticipated difficulties as well as the alternate plan will dictate what equipment should be out and readily available prior to any intubation attempt.
Before attempting intubation:
Anticipate potential difficulties:
Trauma-related
Disrupted/displaced anatomy
Pre-existing conditions
Small mouth/mandible
Short neck
Obesity
Instructor Notes
Expand on the following points:
Anticipation and preparation are key to successful airway management.
Before attempting intubation (continued):
Prepare an alternate (backup) plan for airway management in the event of unsuccessful endotracheal tube placement.
Have all necessary equipment immediately at hand.
Instructor Notes
Expand on the following points:
Important considerations when performing endotracheal intubation:
Essential airway skills are often sufficient to provide a patent airway.
If endotracheal intubation is required:
Preoxygenate to maximize oxygen saturation.
Reoxygenate patient in between intubation attempts.
Monitor oxygen saturation (e.g., pulse oximetry) throughout the procedure.
Following intubation, verify proper endotracheal tube placement.
Instructor Notes
Expand on the following points:
A surgical airway utilizes a complex technique and requires:
Significant initial training
Multiple pieces of equipment
Substantial ongoing training to maintain proficiency
Instructor Notes
Expand on the following points:
With surgical airways, there is a potential for:
Multiple complications
Damage to nearby anatomic structures
Surgical airways in most cases are not the first choice for obtaining a patent airway.
Instructor Notes
Expand on the following points:
Surgical airways may be considered for:
Massive facial trauma that prevents endotracheal intubation
Upper airway obstruction unrelieved by other techniques
Failed intubation and alternative airway methods are unavailable or unsuccessful
However, massive facial injury does not always prevent the use of endotracheal intubation.
Just because your protocols say you may perform a surgical airway does not mean that you should.
Instructor Notes
Expand on the following points:
Confirmation of tube placement should include at least one physiological and one mechanical method:
Physiological
Breath sounds
Chest rise
Change in skin color
Pulse rate
The patient’s airway should be continually monitored and reassessed.
Instructor Notes
Expand on the following points:
Confirmation of tube placement should include at least one physiological and one mechanical method (continued):
Mechanical
End tidal CO2
Colorimetric
Capnometry
Wave form capnography
Pulse oximetry
Wave form capnography is the preferred method for monitoring tube placement in complex airways.
The patient’s airway should be continually monitored and reassessed.
Instructor Notes
Expand on the following points:
Use of this airway management algorithm presents a logical approach to a difficult or failed airway.
Review the first section of the airway management algorithm with the participants.
Not all devices or procedures may be allowed or available within an individual EMS system.
Instructor Notes
Expand on the following points:
Use of this airway management algorithm presents a logical approach to a difficult or failed airway.
Review the second section of the airway management algorithm with the participants.
Not all devices or procedures may be allowed or available within an individual EMS system.
Instructor Notes
Expand on the following points:
Use of this airway management algorithm presents a logical approach to a difficult or failed airway.
Review the third section of the airway management algorithm with the participants.
Not all devices or procedures may be allowed or available within an individual EMS system.
Instructor Notes
Expand on the following points:
The goal is to secure and maintain a patent airway.
Assess the airway by looking, listening, and feeling.
Maintain manual stabilization of the head and spine as indicated.
Apply essential airway maneuvers first.
Utilize complex airway techniques only when required.
Anticipate difficulties and plan and prepare for alternate methods of airway control.
Instructor Notes
Allow time for a question and answer session to answer any questions about the topics presented in the lesson.
