The document outlines key concepts and techniques for airway management in trauma care, emphasizing its critical importance to prevent fatalities. It covers anatomical details of the airway, basic airway techniques, and essential protocols for managing compromised airways. The use of bag-valve mask ventilation is highlighted as a crucial skill for first responders, with recommendations for various adjuncts and monitoring systems to ensure effective patient care.

1. Designing a Clinical Trial
Dr.Ramakrishna HK
MS, DNB, FMAS
Lakshmi Nursing Home
Bhadravathi
E mail: swarama@hotmail.com

2. BASIC AIRWAY
MANAGEMENT
Rafal Banek CRNA

3. Learning Objectives
● Anatomy of the airway and respiratory
system
● Fundamentals of Airway Management
● Familiarity with airway adjuncts

4. IF YOU CAN’T BREATH,
NOTHING ELSE MATTERS !!!
● Airway management is one of the most
critical aspect of trauma care.
● Airway compromise may quickly result in
fatality yet, it may be easy to treat
● Unrecognized airway compromise may lead
to patient deterioration and death within
minutes.
● No trauma interventions should be
undertaken before addressing the airway
status……….ANY EXCEPTIONS TO THIS
?

5. AIRWAY ANATOMY
TWO MAJOR
COMPONENTS
1.Upper airway
 Humidification, filtration and warming of
the inhaled air
 Filtration of bacteria (Tonsils/Adenoids)
 Phonation
2.Lower airway
 Exchange of O2, CO2 with blood
 Phonation

6. UPPER AIRWAY
1. Nasal cavity
 Warms, filters,
humidifies air
2. Nasopharynx
 From the internal
nostrils to lower edge of
soft palate
3. Oral cavity,
4. Oropharynx
 Soft palate to epiglottis
5. Laryngopharynx
(hypopharynx)
 From epiglottis to
cricoid cartilage
Nasal Cavity
Oral
Cavit
y
Oral cavity

7. LOWER AIRWAY
1. Trachea
2. Bronchi
 Two mainstem
 Secondary, tertiary
3. Bronchioles
4. Alveolar ducts
5. Alveolar sacs
4. Alveoli
 “Balloon-like” clusters
 Actual sites of gas
exchange
Carina

8. Basic Airway Techniques
• Everyone involved in trauma care should be
familiar with and proficient in their use
• These should be executed before advanced
airway management is undertaken
1. Head tilt/chin lift
2. Jaw thrust (known or suspected c-spine injury)
3. Nasopharyngeal airway
4. Oropharyngeal airway
5. Bag valve mask assist or PPV

9. Key points to remember
during initial airway evaluation
 Airway is patent if the victim is able to speak
 Muscular tone of the head and neck muscles keeps the
airway open in awake conscious patient
 As LOC decreases, the airway muscle tone decreases
leading to partial or complete obstruction
 The tongue is the most common cause of airway
obstruction in an unconscious adult.
 Unconscious victim’s respirations may be sufficient to
maintain life but death may result from airway
obstruction
 Patients with head, face, neck, chest and inhalational
injury have higher likelihood of airway compromise

10. Conscious victim

11. Airway obstruction in
unconscious victim
Obstruction

12. Types of airway
obstruction
Partial
Snoring
Stridor
Abnormal phonation
Paradoxical motion of
the abdominal and
Complete
Absent air movement
Aphonia
Rapidly ensuing
hypoxia
Paradoxical motion may

13. Airway Evaluation
• If patient is conscious and speaking
normally-provide supplemental 02, assess
BS, continue close monitoring
• If patient is unconscious
 Head tilt/chin lift or forward thrust the
mandible if known or suspected c-spine
trauma
 If facial trauma present, may need to
inspect the mouth for blood, bone
fragments and other foreign objects-
remove or suction if necessary

14. Head tilt/chin lift
Jaw thrust
• One hand on forehead
• Second grasping the
bony portion of
mandible
• Avoid pressing on the
soft tissue !!!
• Tilt the head and lift the
chin at the same time.
• This lifts the tongue
and creates a pocket
for oxygen to travel.
• Assess for air
movement

15. Jaw thrust
• Safest maneuver if c-
spine injury is
suspected
• Avoids c-spine
extension
• Stand behind the
patient
• Heels of the hands on
the temporal areas
• Locate angle of the
mandible

16. Nasopharyngeal Airway
(NPA)
• Better tolerated in semi-
conscious patient with
intact airway reflexes
• Properly sized from NPA
extends from the nostril
to the angle of the
mandible
• Do not use with facial
trauma or suspected
skull fracture
• Epistaxis not uncommon
from NPA use
(coagulopathic patients???)

17. NPA insertion
• Lubricate-KY or
Lidocaine jelly
• Perpendicular to the
face
• Twisting motion
• Avoid forcing in the
device
• Once placed, reassess
the airway patency

18. Oropharyngeal airway
(OPA)
• Do not use in semiconscious
patient with intact airway reflexes
(vomiting, aspiration,
laryngospasm !!!)
•Properly sized from OPA extends
from the mouth to the angle of the
mandible

19. OPA insertion
•Begin inserting from the
inverted position
•When advancing, gently
rotate the device 180
degrees
•Tongue blade may be
used to aid the passage of
the OPA
•Reassess airway patency

20. Oxygenation and ventilation must be reassessed
after airway patency has been re-established
Indicators of inadequate ventilation and
oxygenation
Central cyanosis
Rapid shallow respirations
Accessory muscle use
Retractions
Abdominal paradoxical respirations
SpO2<90%

21. Bag-Valve mask (BVM) ventilation
(“bagging”)
• Critically important airway skill
• Always the first response to inadequate
oxygenation and ventilation
• The first “bail-out” maneuver to a failed
intubation attempt
• Attenuates the urgency to intubate

22. Golden Rules of “Bagging”
• Almost anybody can be oxygenated
and ventilated with a bag and a mask
• Manual ventilation skill with proper
equipment is a fundamental premise of
basic and advanced airway
management
• The art of bagging should be mastered
before the learning advanced airway
skills

23. BVM Ventilation
• Requires practice to master
• One hand to
– maintain face seal
– position head
– maintain patency
• Sniffing position if c-spine
clear
• Thumb + index to maintain
face seal
• Middle finger under
mandibular symphysis
• Ring/little finger under angle
of mandible
• Other hand ventilates
ALL fingers rest on the bony
portion of the mandible

24. “Bagging” with C-spine
precautions
• Two person maneuver
• Primary maintains the
seal and neutral head
postition
• Assistant provides jaw
thrust
• NPA or OPA may be
helpful

25. Predictors of difficult “bagging”
•Upper airway obstruction
•Lack of dentures
•Beard
•Midfacial trauma
•Facial burns, dressings, scarring
•Poor lung mechanics-resistance or
compliance

26. Algorithm for difficulty
“Bagging”
• Reassess for blood, fractured teeth
and foreign bodies –suction or
remove if applicable
• Triple maneuver if c-spine clear
– Head tilt, jaw thrust, mouth
opening
• Nasal or/and oropharyngeal airways
• Two-person, four-hand technique

27. Two-person, four-hand
technique
OPA and 2 NPA’s in place
Two hands on the mask and face for
optimal seal/position
Two hands on the bag to ventilate

28. Excessive gastric distention from
“bagging”
• Possible consequences
Gastric contnents regurgitation and aspiration
Restricted diaphragmatic movement
In rare cases gastric rupture
• Minimizing the risks
Minimize the duration of “bagging”
Avoid excessive tidal volumes
Minimize the positive pressure (<20 cm H2O) if possible
Consider cricoid pressure
Decompress the stomach with NGT or OGT after the
airway is secured

29. What if “bagging” is difficult
or impossible????
• Rescue devices
Laryngeal Mask Airway (LMA)
Combitube

30. LMA
• Can be inserted blindly by
unskilled personnel
• Creates seal around the
laryngeal inlet, enabling
ventilation from immediately
above the cords,
• Bypasses proximal upper
airway obstruction- mostly
tongue
• >90% rescue success rate in
impossible or difficult face
mask ventilation situations

31. LMA placement
1. Lubricate posterior part of
the cuff
2. Place the tip behind pt’s
upper teeth
3. Place the finger in pt’s
mouth, while advancing
push your finger against the
palate and forward against
the cuff
4. Continue advancing till
resistant is felt
5. Inflate the cuff

32. Combitube
• Inserted blindly
• Easy to use by the
unskilled rescuers
• Esophageal
placement is most
likely (90% of the
insertions)
• Easy to use by the
unskilled rescuers
• Provides better
esophageal seal

33. Combitube insertion
• Head tilt (clear C-spine?)
with lower jaw lift
• Advance gently with other
hand trying to follow
curvature of the tongue,
until transverse lines are
adjacent to the teeth
• If this is emergency
airway, inflate both lumens
•

34. Combitube insertion
• Inflate proximal cuff (#1) first (80-10mL) then distal
(5-15mL)
• Attempt ventilation via #1, assess for CO2, BS,
chest movement
• If no CO2 return and no breathsounds are present
>90% placements <10% placements
#1
#2

35. Combitube troubleshooting
• If ventilations are ineffective, through
either lumen, the tube is to deep in
esophagus
• Withdraw at 1cm increments
• Reassess BS, CO2, chest movement as
you withdraw

36. Exhaled CO2
(ETCO2)monitoring
• Golden standard to ascertain patent airway and correct
placement of advance airway device
• 2 types of monitors
 Capnograph – bedside monitoring
 “Easy cap”-Responds quickly to exhaled CO2 with a
simple color change, breath-to-breath response, highly
portable,
What color
if CO2 is
present?
• Golden standard to ascertain patent airway and correct
placement of advance airway device
• 2 types of monitors
 Capnograph – bedside monitoring
 “Easy cap”-Responds quickly to exhaled CO2 with a simple
color change, breath-to-breath response, highly portable,

37. Key points
• Airway compromise can be quickly fatal but
in most cases is easy to correct
• Tongue is the most frequent cause of airway
obstruction
• In the absence of severe extremity
hemorrhage, airway is evaluated and treated
first, regardless of severity of other injuries
• Bag-valve mask ventilation is the most critical
airway management skill set, the first
responders must learn
• ETCO2 monitoring is the golden standard for
ascertaining the airway patency

38. References
1. Kovacs G, Law JA. Airway
Management in Emergencies.
McGraw Hill Medical; 2008:33-51

39. ??????????????

40. Why?
• To answer a clinical problem
• To gain new knowledge about a new or
existing treatment
• To support a claim
To get govt. regulatory approval
To market a drug, device or technique

41. “ I don’t teach my children.
I create condition for them to
learn”.
-Albert Einstein

42. Thank You