BASIC AIRWAY MANAGEMENT

2/15/2014

Clinical Skills Resource Centre, University of Liverpool, UK

AIRWAY OBSTRUCTION
Obstruction of the airways is a medical emergency. It may be partial or complete, and may occur at any level of the respiratory tract. If untreated, airway obstruction leads to a lowered blood oxygen levels and risks hypoxic damage to the brain, kidneys and heart, or even death.

2/15/2014 Clinical Skills Resource Centre, University of Liverpool, UK

CAUSES OF AIRWAY OBSTRUCTION

Decreased muscle tone Vomit Blood Regurgitation of stomach contents Trauma Foreign Bodies Oedema

Inflammation Anaphylaxis Excessive bronchial secretions Mucosal Oedema Bronchospasm Pulmonary Oedema Aspiration of gastric contents
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Clinical Skills Resource Centre, University of Liverpool, UK

RECOGNITION OF OBSTRUCTION 1

Inspiratory Stridor Upper airway problem Expiratory Wheeze Lower airway problem

Complete obstruction paradoxical movement (see-saw respirations)

Central cyanosis is a late sign of airway obstruction
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

RECOGNITION OF AIRWAYS OBSTRUCTION 2 Look - for chest and abdominal movement Listen - for air-flow at mouth and nose and absence of breath sounds Feel - for airflow against cheek

2/15/2014

Clinical Skills Resource Centre, University of Liverpool, UK

RECOGNITION OF AIRWAYS OBSTRUCTION 3

In complete upper airway obstruction, there are no breath sounds at the mouth or nose. In partial obstruction, air entry is diminished and often noisy. Certain noises assist in localising the level of the obstruction: Gurgling suggests the presence of liquid in the mouth or upper airways Snoring occurs when the pharynx is partially obstructed by the tongue
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

RECOGNITION OF AIRWAYS OBSTRUCTION 4

Crowing occurs during laryngeal spasm Inspiratory stridor is caused by obstruction above or at the level of the larynx Expiratory wheeze results from airway narrowing or irregularities of the air passages during expiration (e.g. asthma)

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Clinical Skills Resource Centre, University of Liverpool, UK

MANAGEMENT OF AIRWAY OBSTRUCTION

In the majority of cases, the use of simple methods is all that is required to open the airway, such as suction to remove secretions, use of head tilt chin lift manoeuvre or the insertion of an oropharyngeal or nasopharyngeal airway.

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Clinical Skills Resource Centre, University of Liverpool, UK

SUCTION

The patients airway must be kept clear of foreign materials, blood, vomitus, and other secretions. Materials that are allowed to remain in the airway may be forced into the trachea and eventually into the lungs. This causes complications ranging from severe pneumonia to complete airway obstruction. Suctioning is the method of using a vacuum device to remove such materials. A patient needs to be suctioned immediately whenever a gurgling sound is heard whether before, during or after artificial ventilation.
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

SUCTION

Each suction unit consists of a suction source, a collection container for materials you suction and a suction catheter. The most popular type of suction catheter is the rigid pharyngeal tip known as a Yankauer. This rigid device allows you to suction the mouth and pharynx with excellent control over the distal end of the device.
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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HOW TO USE SUCTION

Always use appropriate infection control practices while suctioning. Suction as much as you can before opening the airway further Suction should not be used for longer than 15 seconds at a time. Place the tip of the catheter where you want to begin suctioning and suction on the way out only. SUCTION ONLY WHERE YOU CAN SEE
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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WALL MOUNTED SUCTION UNIT

YANKAEUR SUCKER

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Clinical Skills Resource Centre, University of Liverpool, UK

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Oxygen non re-breathing mask

This device is used when a patient needs additional oxygen and is breathing independently, it can also be used with simple airway adjuncts inserted

All acute medical / trauma emergencies, e.g Asthma Myocardial infarction (Heart attack) Pre / post operative Trauma Respiratory distress

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Clinical Skills Resource Centre, University of Liverpool, UK

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Oxygen non re-breathing mask

It is designed to function with an oxygen flow rate in excess of 10 L/min which will if used correctly deliver 80 90% oxygen. It works by having a simple valve that permits the flow of oxygen, but during exhalation closes to prevent dilution of oxygen in the reservoir bag.

However, not all exhaled air is removed. Therefore, there is an element of rebreathing
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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Preparing the mask

Turn the oxygen supply to at least a 10L flow rate. Block the mask and allow the reservoir bag to fill. Immediately apply the mask to the patients face. To monitor effectiveness,

Observe the rise & fall of the patients chest. Observe the contraction & expansion of the reservoir bag. Effective method at distance. The mask fogging on exhalation & clearing on inhalation.

2/15/2014

Clinical Skills Resource Centre, University of Liverpool, UK

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Preparing the mask 1

Turn the oxygen supply to at least a 10L flow rate. Grasp the body of the mask allowing the reservoir bag to fill. Then apply it to the patients face

2/15/2014

Clinical Skills Resource Centre, University of Liverpool, UK

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Preparing the mask 2

Immediately apply the mask to the patients face. To monitor effectiveness,

Observe the rise & fall of the patients chest. Observe the contraction & expansion of the reservoir bag. Effective method at distance. The mask fogging on exhalation & clearing on inhalation.
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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Head Tilt - Chin Lift

Assessment of the airway

Head tilt stretches anterior neck muscles, lifts tongue away from posterior pharyngeal wall and epiglottis away from laryngeal inlet Chin lift stretches structures more and pulls mandible and tongue forward If neck injury suspected, do not tilt the head unless jaw thrust fails (jaw
thrust is considered and advanced manoeuvre and will not be covered in 1st year)

Death from hypoxic airway obstruction is much more common than quadriplegia resulting from emergency airway manipulation
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Clinical Skills Resource Centre, University of Liverpool, UK

Simple airway adjuncts

Simple airway adjuncts may assist maintenance of an airway in either the spontaneously breathing or ventilated patient May be useful if prolonged resuscitation is undertaken without formal endotracheal intubation They can be used in addition to head tilt-chin lift or jaw thrust The two commonest are the oropharyngeal (Guedal) and the nasopharyngeal airways
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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Nasopharyngeal airway

Only airway device tolerated by the conscious patient. May be lifesaving in people with clenched jaws, trismus or jaw injuries Should NOT be used where there is evidence of fracture of the base of the skull Size to use = diameter of the nostril, length is predetermined corresponding to the width selected in adults. To prevent inhalation, or passing of the nasopharyngeal airway too far into the nasal cavity, a safety pin if provided must be inserted through the flange This airway adjunct will protect the airway from obstruction of by the soft palate, but may not from obstruction by the tongue
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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Nasopharyngeal airway

Most new models have a wide flange and no longer require the insertion of pin lubricate well with water based jelly to ease insertion Check nostril patency Insert airway bevel end first, pass vertically along floor of the nose using slight rotation If obstruction felt, try other nostril Tip should lie in the pharynx Once in place look, listen, feel
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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NASOPHARYNGEAL AIRWAY

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Clinical Skills Resource Centre, University of Liverpool, UK

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Oropharyngeal airways

Curved plastic tubes Size = incisors to angle of the jaw Incisors should be level with some part of the bite block ( coloured section) Should only be used in the unconscious patient as stimulation of the gag-reflex may result in vomiting and stimulation of the laryngeal-reflex may result in laryngospasm Open mouth and ensure no foreign material
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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Oropharyngeal airways

Introduce into oral cavity inverted

Rotate through 180 as passes below palate

Any coughing or retching should prompt removal of the airway

After insertion check airway with look, listen, feel

(insertion technique is different in children)

2/15/2014 Clinical Skills Resource Centre, University of Liverpool, UK

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OROPHARYNGEAL AIRWAY

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Clinical Skills Resource Centre, University of Liverpool, UK

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Is the Patient breathing ?

YES. Give additional oxygen via a re-breathing mask Set Oxygen flow rate at 10 -15 litres / minute This should deliver approx 85% oxygen NO. (but has a pulse) If the patient stops breathing you need to ventilate Methods of ventilation include :

Mouth to mouth (as in BLS) Pocket mask Self inflating Bag Valve Mask (BVM)

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Clinical Skills Resource Centre, University of Liverpool, UK

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Using a Pocket-mask

A pocket face mask allows easier ventilation with jaw thrust and can be used with head tilt chin lift Non-return valve prevents rescuer from re-breathing victims expired air Removes need for mouth to mouth ventilation, but administers only 16% O2 concentration Adding high flow (10-15 litres/min) oxygen can improve oxygenation markedly (45-50% concentration)
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2/15/2014

Clinical Skills Resource Centre, University of Liverpool, UK

Technique of using pocket-mask

Apply mask to face using thumbs of both hands Lift jaw using pressure applied to angles of the jaw by fingers Blow through inspiratory valve Watch chest rise and fall Any leaks can be reduced or abolished by adjusting position of mask, contact pressure, position of digits or altering jaw thrust Apply oxygen via input nipple at 10-15 litres/min if available
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2/15/2014

Clinical Skills Resource Centre, University of Liverpool, UK

Self Inflating Bag-valve-mask

Mask applied to face Contact and jaw lift are maintained with two hands The bag is squeezed by a second person, to deliver approx 500mls of air per breath Watch chest rise and fall Delivers 21% oxygen Attaching oxygen at a high flow (> 10 Litres/min) can raise concentration to 50-55% Ideally there should be a filter in situ. Preferably it should be once use only B.V.M.
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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SELF INFLATING BAG-VALVE-MASK

TWO PERSON TECHNIQUE TWO PERSON TECHNIQUE

ONE PERSON TECHNIQUE

2/15/2014 Clinical Skills Resource Centre, University of Liverpool, UK

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Bag-valve-mask-reservoir

The addition of a reservoir to the bag-valve-mask arrangement raises oxygen concentration to approx.. 90% with a high-flow rate of 10 -15 litres
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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Delivery of oxygen
Method
Mouth to mouth Mouth to mask Mouth to mask with O2 attached (10-15l/min) Mask and bag Mask and bag mask with O2 attached (10-15l/min) Mask and bag mask with reservoir and O2 attached (10-15l/min)
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O2 concentration
16% 16% 45-50% 21% 50-55% 90%

Clinical Skills Resource Centre, University of Liverpool, UK

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Self inflating bag valve mask.

In cardiac or respiratory arrest it maybe desirable to use this device. It has the advantage of delivering a higher concentration of oxygen to the patient plus allowing connectivity to more advanced airway devices. The disadvantage is that it is not easy to use and it is recommended that it is used as a two person technique. However, if there is no alternative or the individual is skilled it may be used by one person. If necessary the person tasked to squeeze the bag may also do the 30 chest compressions between squeezes.
Clinical Skills Resource Centre, University of Liverpool, UK

2/15/2014

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