Basic Airway Management

Basic Airway Management

• Inadequate oxygenated blood delivery to the brain and vital organs is the leading cause of death in critically ill patients.
• Airway and ventilation management is the initial priority in treating critically ill patients.

Airway Assessment

• The most crucial initial assessment is to engage the patient in conversation and stimulate a verbal response.
• A clear, appropriate verbal response indicates:
  • A patent airway
  • Adequate ventilation
  • Proper brain perfusion
• Assessment should include evaluating not only a patent airway but also a protected airway.
• Patients with altered mental status are particularly vulnerable to airway compromise and typically necessitate airway management.

Recognition of Airway Obstruction

• For unconscious patients or when airway patency is questionable, a look-listen-feel approach is recommended.

Look for:

• Vomit or secretions
• Facial bone fractures
• Facial burns
• Neck injuries or hematomas
• Abnormal chest and abdominal movement
• Increased work of breathing (accessory muscle use)

Listen for:

• Snoring
• Gurgling
• Stridor
• Hoarseness of voice

Feel for:

• Airflow at the mouth and nose with your cheeks
• Avoid close contact with patients if airborne infections are a concern.

Basic Techniques for Opening Airway

• Head tilt-chin lift — This manoeuvre involves tilting the head back and lifting the chin to open the airway. Diagrams are included in the slides.
• Jaw thrust manoeuvre — The jaw is moved forward to lift the tongue off the back of the throat, opening the airway. Diagrams are included in the slides.
• Avoid head tilting in polytraumatized patients.
  • In trauma situations, utilize chin lift only, or jaw thrust only, without head tilting.

Basic Adjuncts for Opening Airway

• Oropharyngeal airway — This is a curved tube that is inserted into the mouth to keep the tongue from blocking the airway.
  • Contraindicated in conscious patients with an active gag reflex to avoid vomiting and aspiration.
  • Patients who tolerate oropharyngeal airways often require endotracheal intubation.
• Nasopharyngeal airway — A flexible tube inserted through the nose to open the airway.
  • Better tolerated by conscious patients.
  • Contraindicated in patients with suspected skull base fractures (potential cribriform plate fracture).

Supraglottic Airway Devices

• Laryngeal mask airway (LMA) — A device that fits over the larynx and creates a seal to facilitate ventilation.
• i-gel supraglottic airway — A device used for airway management.
• Supraglottic airway devices are often easier to insert than endotracheal tubes and are considered life-saving alternatives for cases of difficult or failed endotracheal intubation or when proper intubation skills are unavailable.

Definitive Airway

• Definition: A tube inserted into the trachea with an inflated cuff placed below the vocal cords.
• Types:
  • Orotracheal tube
  • Nasotracheal tube
  • Surgical cricothyroidotomy
  • Tracheostomy

Endotracheal Tube

• Considered the definitive airway device. It passes through the vocal cords, directly into the trachea.
• Most tubes include an inflatable cuff to form a seal between the tube and the trachea, enhancing protection against aspiration.
• Only trained personnel with the necessary competency and skill should perform endotracheal intubation.
• Complications:
  • Failure to intubate
  • Esophageal intubation
  • Right main bronchus intubation
  • Dental trauma
  • Laryngeal injury
  • Tracheal injury

Management of Ventilation

• Definition: The movement of air between the environment and lungs during inspiration and expiration.
• Important Factor: Ensuring a patent airway is critical for oxygen delivery, but adequate ventilation is essential for patient benefit.
• Potential Causes of Inadequate Ventilation:
  • Airway obstruction
  • Central nervous system depression
  • Chest trauma, particularly with rib fractures
  • Cervical spinal cord injury
  • Underlying chronic pulmonary diseases
• Objective Signs of Inadequate Ventilation:
  • Altered mental status or lethargy
  • Shallow rapid breathing
  • Use of accessory muscles
  • Diminished chest expansion (detected through inspection and palpation)
  • Diminished breath sounds (detected by auscultation)
  • Low oxygen saturation
• Improving Ventilation Recognition:
  • Regularly monitor respiratory rate and work of breathing
  • Obtain arterial or venous blood gas samples
  • Utilize capnography (if available)
• Management Techniques:
  • Intubation of trachea and connection to mechanical ventilation is the most effective method.
  • Prior to intubation, utilize the Bag-Valve-Mask (BVM) technique for ventilatory support.
    • Single-person BVM technique methods
    • Two-person BVM technique methods