1. Airway management is the highest priority for unconscious patients. The airway can become obstructed due to loss of muscle tone and positioning, requiring techniques like head-tilt chin-lift and jaw thrust to open the airway. 2. Various airway devices exist to help maintain an open airway, from oropharyngeal and nasopharyngeal airways for basic obstruction to advanced devices like laryngeal mask airways and endotracheal tubes. Bag-valve-mask ventilation is also important to provide oxygen until a more secure airway is in place. 3. Proper patient positioning in the recovery position helps prevent airway obstruction and allows drainage of secretions. Ongoing assessment of

1. Management Of
Airway In
Unconscious Patients
DR ZIKRULLAH

2. Criteria for the Diagnosis of Coma
1. Eyes do not open spontaneously or to
stimulation
2. Patient does not follow commands
3. Patient does not utter recognizable words
4. Patient does not demonstrate intentional
movements
5. Patient cannot sustain visual pursuit
movements when eyes are manually held
open

3. The Glasgow Coma Scale
(GCS)
• The Glasgow Coma Scale (GCS) is a widely
recognized scale used to measure the severity
of brain injury.
• The GCS may not capture important clinical
changes and should not be viewed as a
substitute for careful neurologic assessment.

4. The Glasgow Coma Score can be used
as follows:-
1. To define coma (GCS <8).
2. To stratify the severity of head injury
(mild 13–15, moderate 9–12, severe
<8)
3. To identify candidates for intubation
4. As a prognostic marker

5. Approach to the Comatose
Patient
• Finding a cause or making a diagnosis in
unconscious patient is of secondary
importance. In nearly all circumstances
airway management is the highest priority
for clinical care.

6. Approach to the Comatose Patient
Initial Treatment
• Airway
• Breathing
• Circulation
• Treat rapidly progressive metabolic
disorders e.g. hypoglycemia
• Evaluate for intracranial hypertension
and imminent herniation and treat
appropriately

7. Airway anatomy

8. Specific anatomical considerations
• Displacement of the tongue posteriorly
against the soft palate and the pharynx is the
leading cause of airway blockage in the
unconscious patient
• Manipulation of the mandible with a
modified jaw thrust, which includes head
tilt, is the best general method to open an
airway

9. • The epiglottis acts
like a trap door
covering the glottis.
• This is another
common site for
airway obstruction.

10. • The membrane
between cricoid
cartilage and the
thyroid cartilage is the
location for
cricothyrotomy.

11. Management of airway
• Airway management is the most important
skill for an anaesthesiologist to master
because failure to secure an adequate
airway can quickly lead to death or
disability.
11

12. Airway management is the process of
ensuring that:
• there is an open pathway between the
patient’s lungs and the outside environment
• the lungs are safe from aspiration
12

13. • The unconscious patient lying on their back
may have an obstructed airway.
• The first step in basic life support is to keep
the airway clear.
13

14. Look to see if the chest is rising and
falling with respiration.
Partial or complete obstruction :
• diaphragm works harder
• paradoxical movement
• indrawing of the spaces between the ribs
and above the collar bones during
inspiration
14

15. • Listen with you ear at the patient’s mouth
or with a stethoscope
• A partially obstructed airway may have
noises on inspiration or expiration. A
completely obstructed airway may be silent.
• Feel for breaths at the mouth and nose with
your hands 15

16. Mechanism of airway obstruction in
unconscious patients
• Prolapse of the tongue into the posterior pharynx
• Loss of muscular tone in the soft palate
• Obstruction by foreign bodies, injured tissue,
blood, and secretions
• Loss of cough reflex ,blood or regurgitated
stomach contents are often aspirated into the
lungs.
• Edema of upper airway
16

17. Open the Airway by simple manoeuvres :
• Head-tilt chin-lift
• Jaw thrust
17

18. • Head-tilt chin-lift
• Head tilt- One hand is placed over victim's forehead
and firm, backward pressure is applied with palm to
tilt the head back
• Chin lift-Fingers of other hand are placed under bony
portion of the lower jaw near the chin to bring the
chin forward
18

19. head-tilt chin-lift
19

20. • Jaw thrust
• Technique to open the airway by placing the
fingers behind the angle of the jaw and
bringing the jaw forward and tilting the
head backward
20

21. Jaw thrust
21

22. Suctioning:
• used to clear an airway obstructed by oral
secretions, blood, other liquids, or food
particles
• required when a gurgling sound is heard
during breathing, or when fluid is seen in the
airway
• catheter should be inserted upto the base of the
tongue. 22

23. • Do not try to clear the airway without looking.
• Sweeping a finger “blindly” in the airway may
push the obstruction further in.
23

24. ARTIFICIAL AIRWAYS
• Airway adjuncts are devices used for assisting
upper airway control in patients who cannot
control their own airways.
• The main function of adjuncts is to prevent
obstruction of the upper airway by the tongue.
24

25. • Oropharyngeal Airways
• A curved piece of plastic inserted over the
tongue that creates an air passage between the
mouth and the posterior pharyngeal wall.
• Select the proper size by measuring the
distance from angle of mouth to the tragus of
the ear.
• should only be used in patients who are
unresponsive and do not have an intact gag
reflex. 25

27. Select the proper size by measuring the distance from angle of mouth to the
tragus of the ear.
27

28. • Technique of insertion
• The airway is inserted with its concave side
facing the upper lip.
• When the junction of the bite portion and the
curved section is near the incisors, the airway
is rotated 180° and slipped behind the tongue
into the final position.
28

29. Technique of insertion
29

30. • Alternate Technique of insertion
• An alternate method of insertion is by using a
tongue blade.
• A tongue blade is used to push forward and
depress the tongue.
• The airway is inserted with the concave side
towards the tongue.
• As it is advanced, it is rotated to slide around
the tongue. 30

31. Insertion of oral airway.
31

32. • Nasopharyngeal airway
• smooth non-cuffed tube with a flange to prevent pushing it
completely into the nose.
• avoids damage to the teeth and can be inserted if the
mouth cannot be opened
• can cause bleeding from nose which may cause further
obstruction.
• well tolerated by awake or sedated patients with an intact
gag reflex. 32

33. 33
Nasopharyngeal airway

34. Technique of insertion
• The correct size nasopharyngeal airway will reach from
the tip of the nose to the tragus of the ear.
• must be lubricated before insertion.
• Gently insert along the floor of the nostril, perpendicular
to the face (never upwards towards the cribriform plate).
34

35. •
35

36. 36

37. • Contraindications
• the roof of the patients mouth is fractured or the brain
matter is exposed
• clear fluid coming from the ear or nose ( skull
fracture )
• Coagulation disorder , nasal pathology and/or sepsis
37

38. Positioning of the patient
• The recovery position or coma position – it
refers to the variations on a lateral recumbent
position into which an unconscious but
breathing patient can be placed as part of first
aid treatment.
38

39. • gives gravity assistance to the clearance of
physical obstruction of the airway by the
tongue, and also gives a clear route by which
fluid can drain from the airway.
• The International Liaison Committee on
Resuscitation (ILCOR) does not recommend
one specific recovery position, but advises on
six key principles to be followed.
39

40. 1. The patient should be in a true lateral position
with the head dependant to allow free
drainage of fluid.
2. The position should be stable.
3. Any pressure on the chest that impairs
breathing should be avoided.
40

41. 4. It should be possible to turn the patient onto the
side and return back easily and safely, having
particular regard to the possibility of cervical
spine injury.
5. Good observation and access to the airway
should be possible.
6. The position itself should not give rise to any
injury to the patient. 41

42. To put the patient in the recovery
position grab the patient’s leg and
shoulder and roll him towards you.
42

43. Continue to roll the victim
until he is on his side. 43

44. Adjust the top leg so that both the hip and knee are
bent at right angles
Gently tilt the head back to keep the airway open.
44

45. • Bag-Valve-Mask
• A bag valve mask (also known as a BVM or Ambu
bag) is a hand-held device used to provide positive
pressure ventilation to a patient who is not breathing or
who is breathing inadequately.
• an essential emergency skill.
• allows for oxygenation and ventilation of patients until
a more definitive airway can be established.
45

46. The Bag-Valve-Mask
46

47. • Requires a good seal and a patent airway.
• Choosing the appropriate size helps to create a
good seal and, therefore, aids effective
ventilation.
• Most devices also have a reservoir which can
fill with oxygen while the patient is exhaling.
47

49. Tips for good BVM use
• Oxygen flow rates should be 12-15 LPM so that the
reservoir bag never fully deflates.
• Always think of bringing the face up to the mask, not
the mask down into the face.
• A common mistake is trying to get a mask seal by
pushing down onto the face. This leads to neck
flexion and further airway obstruction.
49

50. • One of the biggest problems associated with
BVM use is delivering volumes of air under
high pressure, which in the unintubated patient
leads to air going down into the stomach.
• deliver just enough tidal volume to cause the
patient’s chest rise.
50

51. • Deliver the volume over at least two seconds,
this will minimize the chances of opening the
esophagus and sending air down into the
stomach.
• The use of cricoid pressure during ventilation
with a BVM can occlude the esophagus and
significantly reduce the amount of air that
enters the stomach.
51

52. • Technique of BVM ventilation
• Open the airway or Use an airway adjunct.
• Place the mask on the patient’s face before
attaching the bag.
• Cover the nose and the mouth with the mask
without extending it over the chin.
52

53. • Use the non-dominant hand.
• Create a C-shape with the thumb and index
finger over the top of the mask and apply
gentle downward pressure.
• Hook the remaining fingers around the
mandible and lift it upward toward the mask,
creating the E. 53

54. One-hand E-C technique
54

55. • If a second person is available to provide
ventilation by compressing the bag, a two-
hand technique can be used.
• Create two opposing semicircles with the
thumb and index finger of each hand to form a
ring around the mask connector, and hold the
mask on the patient’s face. Then, lift up the
mandible with the remaining digits.
55

56. `
Two-hand technique
56

57. • Alternatively, place both thumbs opposing the
mask connector, using the thenar eminences to
hold the mask on the patient’s face, while
lifting up the mandible with the fingers.
57

58. Alternate two-hand technique.
58

59. • No matter which technique is being used,
avoid applying pressure on the soft
tissues of the neck or on the eyes.
• The two-hand technique is preferred to
the one-hand technique and should be
used whenever possible.
59

60. Assess the adequacy of ventilation.
• Observe for chest rise, improving color, and
oxygen saturation.
• Monitor for air leak.
60

61. • Nasal Prongs
• The nasal cannula delivers a low concentration
of oxygen and should only be used in patients
who are not in acute respiratory distress.
• The maximum flow rate for nasal cannulas is
5-6 L/min. They deliver about 35% inspired
oxygen concentration.
61

62. • High Flow Masks
• The non-rebreather mask delivers oxygen
concentrations in the range of 60-95%.
• used for patients in acute respiratory distress.
• An oxygen reservoir bag and a number of one way
valves allow for high oxygen delivery. Flow rates
should be at least 10 LPM.
62

63. Non-Rebreather Mask
63

64. • Laryngeal Mask Airway
• an airway adjunct that is composed of cuffed mask on
the end of a tube.
• introduced into the pharynx and advanced until the
mask portion is in the distal hypopharynx and
meeting resistance.
• The cuff is then inflated, which provides a seal
against the larynx.
64

65. Laryngeal Mask Airway Family
• Classic LMA
• LMA Unique
• LMA Flexible
• LMA Fastrach
• LMA C Trach
• LMA AirQ
• LMA ProSeal
• LMA Supreme

66. Laryngeal Mask Airway ( classic )
66

67. Proseal LMA
• The Proseal has a larger wedge shaped
mask that creates a better seal, allowing the
proseal to be used for positive pressure
ventilation.
• The Proseal also has a drainage tube, which
will direct regurgitated contents away from
the laryngeal inlet.

68. LMA Proseal

69. LMA Supreme
• Disposable
• Double lumen tube
• Hybrid of PLMA and ILMA
• The airway tube has a gentle curve and an
oblong shape

70. LMA Supreme

71. LMA Fastrach
• Although the LMA-Fastrach has been designed
to facilitate tracheal intubation , it can also be
used as a primary airway device.
• It can be used with the patient in the lateral
position

73. 73

74. The Combitube
• Double lumen tube most often inserted blindly.
• A curved shape that favours insertion into the
oesophagus.
74

75. 75
The Combitube

76. Indications
• Unsuccessful endotracheal intubation
• Patients who do not exhibit an intact gag
reflex.
• Cardiac or respiratory arrest.
• Visualization of the vocal cords is not
possible
• Limited access to airway
• Neck movement contraindicated

77. Contraindications
• Crush injury to hypopharynx or throat
• Intact gag reflexes
• Known esophageal pathology
• Ingestion of caustic substances
• Under 4 feet tall
• CONSIDER: Latex Allergy

78. • Advantages of the combitube
• Direct visualization of the trachea is not needed
• Relatively simple to insert
• Ventilation is possible with either tracheal or
esophageal intubation
• Reduced risk of aspiration compared to BVM 78

79. • More reliable ventilation than with BVM
• Gastric inflation of air less likely than BVM
• Requires less skill than endotracheal intubation
• Less invasive than tracheal intubation
79

80. • Disadvantages of the combitube airway include:
• Potential to ventilate wrong port if proper post-
insertion assessment is not done
• Possible complication of oesophageal trauma
80

81. • Tracheal Intubation
• Intubation of the trachea has long been the
primary method of securing a patient’s airway
in advanced life support situations.
• Tracheal intubation requires a well organized
systematic approach by a skilled person.
81

82. • Indications for intubation:
• Cardiac arrest
• Inability to maintain adequate ventilation
• Inability to protect the airway against
aspiration 82

83. • Inability to ventilate an unconscious patient
with less invasive methods
• A Glasgow Coma Score of 8 or less
• Anticipation of a deteriorating course that will
eventually lead to the inability to maintain
airway patency or protection.
83

84. • RSI is the preferred method of
endotracheal intubation in the emergency
department .
• This is important in patients who have not
fasted and are at much greater risk for
vomiting and aspiration.
• The goal of RSI is to intubate the trachea
without intermittent bag-valve-mask
(BVM) ventilation.
84

85. sellicks manoeuvre
• This manoeuvre is used to decrease the
likelihood of regurgitation and aspiration.
• It is performed by applying pressure on the
cricoid cartilage with the thumb and index
finger just lateral to the midline.
85

86. • RSI is not indicated in a patient who is
unconscious and apneic.
• This situation is considered a "crash"
airway, and immediate endotracheal
intubation without pretreatment,
induction, or paralysis is indicated.
86

87. Extubation
• The patient should be fully awake, reversed
and receive 100% oxygen before removing the
tube.
• If in doubt, insert a bougie or a guide wire
though the endotracheal tube and extubate the
patient.
• The endotracheal tube may be re-inserted over
the bougie if the patient needs re-intubation.

88. Thank You !