Airway Management.ppt

Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
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Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Airway management

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Emergency Care, 13e
Introduction
• Airway management is the practice of e
valuating, planning, and using a wide a
rray of medical procedures and devices
for the purpose of maintaining or restor
ing a safe, effective pathway for oxyge
nation and ventilation

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Emergency Care, 13e
Topics
• Airway Physiology
• Airway Pathophysiology
• Opening the Airway
• Airway Adjuncts
• Suctioning
• Keeping an Airway Open: Definitive Car
e
• Special Considerations

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Emergency Care, 13e
Airway Physiology

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Emergency Care, 13e
Airway Physiology
• Upper airway
 Begins at mouth and nose
• Air is warmed and humidified in nasal tur
binates.
 Pharynx
• Oropharynx, nasopharynx, and laryngoph
arynx
 Ends at glottic opening

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Emergency Care, 13e
Airway Physiology
The upper airway.

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• Larynx
 Complex structu
re formed by m
any independen
t cartilaginous s
tructures
 Marks where th
e upper airway
ends and the lo
wer airway begi
ns
Larynx

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Airway Physiology
• Lower airway
 Begins below the larynx
 Composed of:
• Trachea
• Bronchial passages
• Alveoli

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Airway Physiology
The lower airway. (A) The bronchial tree.

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Airway Physiology
• Alveoli
 Tiny sacs in grapelike bunches at the en
d of the airway
 Surrounded by pulmonary capillaries
 Oxygen and carbon dioxide diffuse throu
gh pulmonary capillary membranes.

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Emergency Care, 13e
Airway Physiology
The lower airway. (B) The alveolar sacs (clusters of individual alveoli).

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Airway Pathophysiology

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• Variety of obstructions interfere with air
flow
 Foreign bodies
• Food, small toys
 Liquids
• Blood, vomit
• Obstruction may also result from poor
muscle tone caused by altered mental s
tatus.
continued on next slide

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Emergency Care, 13e
• Obstructions can be acute or chronic.
• Providers must initially evaluate airway
and monitor patency over time.

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• Airway obstructions
 Acute
• Foreign bodies
• Vomit
• Blood
 Occurring over time
• Edema from burns, trauma, or infection
• Decreasing mental status

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• Airway obstructions
 Bronchoconstriction
• Disorder of lower airway
• Smooth muscle constricts internal diamet
er of airway.

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Critical golden minutes
• Eventually all cells will die if deprived o
f oxygen.

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Patient Assessment
• Addressed in primary assessment
• Two questions must be answered.
 Is airway open?
 Will airway stay open?

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Is the Airway Open?
• In most patients, can be determined by
simply saying hello
• "Sniffing position" seen when swelling o
bstructs airflow through upper airway

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Is the Airway Open?
• Findings indicating breathing problems
 Inability to speak
 Unusual raspy quality to voice
 Stridor
 Snoring
 Gurgling

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Will the Airway Stay Open?
• Airway assessment is not just a momen
t in time.
• Must give constant consideration

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Signs of an Inadequate Airway
• No signs of breathing or air movement
• Evidence of foreign bodies in airway
• No air felt or heard
• Inability or difficulty speaking
• Unusual hoarse or raspy voice
• Absent, minimal, or uneven chest move
ment

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Emergency Care, 13e
Signs of an Inadequate Airway
• Abdominal breathing
• Diminished or absent breath sounds
• Abnormal noises such as wheezing, cro
wing, stridor, snoring, gurgling, or gasp
ing during breathing
• In children and infants, nasal flaring
• In children, retractions above the clavic
les

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Emergency Care, 13e
Responding to an Adult with an
Obstructed Airway Video
Click on the screenshot to view a video on the subject of obstructed airway in an
adult.
Back to Directory

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Emergency Care, 13e
Opening the Airway

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Emergency Care, 13e
Patient Care
• The airway
 When primary assessment indicates ina
dequate airway, a life-threatening condi
tion exists.
 Take prompt action to open and the mai
ntain airway

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Emergency Care, 13e
Opening the Airway
• If airway is not open, use position to op
en it.
• Indications of head, neck, spinal injury
 Mechanism of injury known to cause suc
h injuries
 Any injury at or above the level of the s
houlders
 Family or bystanders give information le
ading you to suspect it.

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Opening the Airway
• Head-tilt, chin-lift maneuver and jaw-th
rust maneuver move airway structures i
nto position allowing air movement.

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Head-Tilt, Chin-Lift Maneuver
Head-tilt, chin-lift maneuver, side view. Right image shows EMT’s fingertips under
the bony area at the center of the patient’s lower jaw.

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Emergency Care, 13e
Head-Tilt, Chin-Lift Maneuver
1. Place one hand on patient's forehead a
nd fingertips of other hand at the cent
er of patient's lower jaw.
2. Tilt head.
3. Lift chin.
4. Do not allow mouth to close.

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Jaw-Thrust Maneuver
Jaw-thrust maneuver, side view. Inset shows EMT’s finger position at angle of the
jaw just below the ears.

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Jaw-Thrust Maneuver
1. Keep patient's head, neck, and spine a
ligned, moving patient as a unit into th
e supine position.
2. Kneel at the top of patient's head.
3. Place one hand on each side of patient'
s lower jaw, at angles of jaw below ear
s.
4. Stabilize patient's head with your forea
rms.

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Emergency Care, 13e
Performing Jaw-Thrust Maneuver
5. Using index fingers, push angles of pat
ient's lower jaw forward.
6. You may need to retract patient's lowe
r lip with your thumb to keep the mout
h open.
7. Do not tilt or rotate patient's head.

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Emergency Care, 13e
Airway Management
• After airway has been opened, position
must be maintained to keep airway ope
n.
• Airway must be cleared of secretions an
d other obstructions.

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Emergency Care, 13e
Airway Adjuncts

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Emergency Care, 13e
Airway Adjuncts
• Airway position and maneuvers are sho
rt-term solutions.
• Airway adjunct provides longer term air
channel.
• Two most common airway adjuncts
 Oropharyngeal airway (OPA)
 Nasopharyngeal airway (NPA)

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Rules for Using Airway Adjuncts
• Use OPA only on patients not exhibiting
gag reflex.
• Open patient's airway manually before
using adjunct device.
• When inserting airway, take care not to
push patient's tongue into pharynx.

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• Have suction ready prior to inserting an
y airway.
• Do not continue inserting airway if patie
nt gags.
• Maintain head position after adjunct ins
ertion and monitor airway.

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• Continue to be ready to provide suction
if fluid or blood obstructs the airway.
• If patient regains consciousness or dev
elops a gag reflect, remove the airway i
mmediately.
• Use infection control practices while ma
intaining airway.

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Oropharyngeal Airway
• Device used to move tongue forward as
it curves back to pharynx
• Sizes
 Infant to large adult

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Oropharyngeal airways.

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Emergency Care, 13e
Sizing Oropharyngeal Airways
Ensure the oropharyngeal airway is the correct size by checking to make sure it
either extends from the center of the mouth to the angle of the jaw or…

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Sizing Oropharyngeal Airways
Measure from the corner of the patient's mouth to the tip of the earlobe.

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Emergency Care, 13e
• Inserting OPA
1. Place patient on his back, and use appr
opriate method to open the airway
2. Open mouth with crossed-finger techni
que
3. Position airway with tip pointing toward
roof of mouth

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Emergency Care, 13e
Inserting OPA
Use the crossed-fingers technique to open the patient's mouth.

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Emergency Care, 13e
• Inserting OPA
4. Insert device along roof of mouth
5. Gently rotate airway 180 degrees so tip
is pointing down into patient's pharynx
6. Position patient
7. Check that flange of airway is against p
atient's lips
8. Monitor patient closely

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Inserting OPA
Insert the airway with the tip pointing to the roof of the patient's mouth.

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Emergency Care, 13e
• Inserting OPA
 Use tongue depressor or rigid suction tip
and insert OPA directly

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Emergency Care, 13e
Nasopharyngeal Airway
• Soft, flexible tube inserted through nost
ril and into hypopharynx
• Moves tongue and soft tissue forward t
o provide a channel for air

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• Can be used in patients with intact gag
reflex or clenched jaw
• Contraindicated if clear (cerebrospinal)
fluid coming from nose or ears

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• Come in various sizes
• Must be measured
• Typical adult sizes
 34, 32, 30, and 28 French

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Inserting NPA
• Inserting NPA
1. Measure for correct size
2. Lubricate outside of tube with water-ba
sed lubricant before insertion

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Emergency Care, 13e
Inserting NPA
Measure the nasopharyngeal airway from the patient's nostril to the tip of the earlobe
or to the angle of the jaw.

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Emergency Care, 13e
Inserting NPA
Apply a water-based lubricant before insertion.

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Emergency Care, 13e
Inserting NPA
• Inserting NPA
3. Push tip of nose upward; keep head in
neutral position
4. Insert into nostril; advance until flange
rests firmly against nostril

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Emergency Care, 13e
Inserting NPA
Gently push the tip of the nose upward, and insert the airway with the beveled side
toward the base of the nostril or toward the septum (wall that separates the nostrils).
Insert the airway, advancing it until the flange rests against the nostril.

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Emergency Care, 13e
Suctioning

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Emergency Care, 13e
Suctioning
• Obvious liquids (blood, secretions, vomi
tus) must be removed from airway to p
revent aspiration into lungs.
• Use vacuum device to remove liquids fr
om airway.

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Emergency Care, 13e
Suction Devices
• Mounted suction systems
 Installed near head of stretcher
 Furnish air intake of at least 30 liters pe
r minute
 Generate vacuum of no less than 300 m
mHg when collecting tube clamped

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Suction Devices
• Portable suction units
 Same requirements as mounted
 Oxygen- or air-powered or powered by
batteries/electricity
 Manual

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Suction Devices
• Tubing, tips, and catheters
 Tubing
 Suction tips
 Suction catheters
 Collection container
 Container of clean or sterile water

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Suction Systems
A mounted suction unit installed in the ambulance’s patient compartment.

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Suction Devices
 Rigid pharyngeal suction tip
• Also called Yankauer tip
• Larger bore than flexible catheters

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Rigid Pharyngeal Tip
Place the convex side of the rigid tip against the roof of the mouth. Insert just to the
base of the tongue.

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Emergency Care, 13e
Suction Devices
 Rigid pharyngeal suction tip
• Suction only as far as you can see.
• Do not lose sight of distal end.
• Careful insertion helps prevent gag reflex
or vagal stimulation.

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Emergency Care, 13e
Suction Devices
 Flexible suction catheters
• Designed to be used when a rigid tip can
not be used
• Can be passed through a tube such as th
e nasopharyngeal or endotracheal tube
• Can be used for suctioning the nasophary
nx

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Emergency Care, 13e
Suction Devices
• Not typically large enough to suction vom
itus or thick secretions
• May kink
• In event of copious, thick secretions cons
ider removing tip or catheter and using la
rge bore, rigid suction tubing.

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Emergency Care, 13e
Suction Devices
• Measured in similar way as OPA
• Length of catheter that should be inserte
d into patient's mouth equals distance be
tween corner of patient's mouth and earl
obe.

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Emergency Care, 13e
Measuring Flexible Suction
Catheter
If you are using a flexible catheter, measure it from the patient's earlobe to the
corner of the mouth or from the center of the mouth to the angle of the jaw.

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Emergency Care, 13e
• Suction no longer than ten seconds at a
time.
 Prolonged suctioning can cause hypoxia
and bradycardia.
 If patient vomits for longer than ten sec
onds, continue suction.

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Definitive Care
• Keeping the airway open may exceed c
apabilities of a basic EMT.
• Medications and/or surgical procedures
may be necessary to resolve airway obs
truction.

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Emergency Care, 13e
Definitive Care
• Rapidly evaluate and treat airway probl
ems.
• Quickly recognize when more definitive
care is necessary.
 May be Advanced Life Support intercept
 May be closest hospital

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• Facial injuries
 Frequently result in severe swelling or bl
eeding that may block or partially block
airway
 Bleeding may require frequent suctionin
g or more definitive airway.

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Emergency Care, 13e
• Obstructions
 Many suction units are not adequate for
removing solid objects.
 Objects may have to be removed with
manual techniques
• Abdominal thrusts
• Chest thrusts
• Finger sweeps

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Emergency Care, 13e
• Dental appliances
 Leave in place during airway procedures
when possible.
 Partial dentures may become dislodged
during an emergency.
 Be prepared to remove if airway endang
ered.

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Emergency Care, 13e
Pediatric Note
• Variety of anatomical differences to con
sider when managing the airway
• Anatomic considerations
 Smaller mouth and nose
 Larger tongue
 Narrow, flexible trachea

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Emergency Care, 13e
Pediatric Note
• Management considerations
 Open airway gently
 Do not hyperextend neck
 Consider adjuncts when other measures
fail
 Use rigid tip with adjunct, but do not to
uch back of airway

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Emergency Care, 13e
Chapter Review
• The airway is the passageway by which
air enters the body during respiration, o
r breathing.
• A patient cannot survive without an ope
n airway.
• Airway adjuncts—the oropharyngeal an
d nasopharyngeal airways—can help ke
ep the airway open.

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Emergency Care, 13e
Chapter Review
• It may be necessary to suction the airw
ay or to use manual techniques to remo
ve fluids and solids from the airway bef
ore, during, or after artificial ventilation
.

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Emergency Care, 13e
Remember
• Always use proper personal protective e
quipment when managing an airway.
• Airway assessment must be an ongoing
process. Airway status can change over
time.
• Airway management should start simpl
y and become more complicated only if
necessary.

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Emergency Care, 13e
Questions to Consider
• Name the main structures of the airway
.
• Explain why care for the airway is the fi
rst priority of emergency care.
• Describe the signs of an inadequate air
way.

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Emergency Care, 13e
Questions to Consider
• Explain when the head-tilt, chin-lift ma
neuver should be used and when the ja
w-thrust maneuver should be used to o
pen the airway—and why.
• Explain how airway adjuncts and suctio
ning help in airway management.

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Emergency Care, 13e
Critical Thinking
• On arrival at the emergency scene, you
find an adult female patient with gurgli
ng sounds in the throat and inadequate
breathing slowing to almost nothing. Ho
w do you proceed to protect the airway
?

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Emergency Care, 13e
Critical Thinking
• When assessing an unconscious patient
, you note snoring respirations. Should
you be concerned with this and if so, w
hat steps can you take to correct this si
tuation?

Airway Management.ppt

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