Basic Airway Management

A Self-Directed Learning Module

Technical Skills Program

Queen’s University

Department of Emergency Medicine

Introduction

In the initial assessment and management of any critically ill patient the ABC's (Airway,
Breathing and Circulation) are the first priority. Hypoxia will begin to cause irreversible
brain injury within approximately 5 minutes and so airway management must precede
any other treatment. The ability to establish and maintain an open airway in a patient,
and the ability to ensure adequate ventilation and oxygenation of the patient, are
therefore essential skills for physicians. For the purposes of this module "basic airway
management" will refer to those basic interventions that maintain an open airway and
assist ventilation but do not include endotracheal intubation.

The goal of this module is for students to acquire the knowledge and skills necessary to
manage an apneic patient. There is a multitude of skills you will need to acquire, but at
all times the skills must be learned in the context of avoiding hypoxia in your patient.
This means establishing and maintaining an open airway and providing adequate
ventilation of the chest.

Students should complete this module and complete the embedded multiple-choice questions
prior to their scheduled suturing seminar. There will be a brief multiple-choice exam based
on this material at the beginning of the seminar.

Objectives

By the end of this session students will:

1. Understand the principles of ventilation and oxygenation.
2. Be able to demonstrate simple techniques, without the aid of equipment, for
opening a patient's airway.
3. Be able to demonstrate the correct technique for inserting an oropharyngeal and
nasopharnygeal airway.
4. Be able to demonstrate the correct technique for bag-mask ventilation.
Recognizing inadequate ventilation

It is of course important that physicians be able to recognize when a patient is not adequately
ventilating his/her chest. The reasons for inadequate chest ventilation include inadequate
respiratory effort, airway obstruction or a combination of these two. If the patient is not
breathing at all (apneic), then the physician must immediately perform a simple maneuver such
as a chin lift to open the airway and commence ventilation of the chest with a bag-mask device.

If the patient is making respiratory effort but is not adequately ventilating his/her chest because
of airway obstruction the physician must determine the cause and take immediate measures to
alleviate the obstruction. In an unconscious patient, the cause of the obstruction will often be
prolapse of the tongue into the posterior pharynx due to loss of tone in the submandibular
muscles. This problem can be quickly corrected using a simple maneuver such as a head tilt-chin
lift or jaw thrust and this may be all that is needed to open the airway and allow adequate chest
ventilation. If the physician encounters noisy or "gurgling" respirations at this point, the upper
airway should be suctioned for vomitus and excess secretions.

Simple airway maneuvers

Head Tilt-Chin Lift:

This maneuver should only be used if the physician is confident there is no risk of injury to the c-
spine. Standing on the patient's right hand side, the physicians left hand is used to apply pressure
to the forehead to extend the neck. The volar surfaces of the tips of the index and middle finger
are used to elevate the mandible which will lift the tongue from the posterior pharynx.

Jaw Thrust:

Where there is risk of c-spine injury, such as a patient who is unconscious as a result of a head
injury, the airway should be opened using a maneuver that does not require neck movement. The
jaw thrust is performed by having the physician stand at the head of the patient looking down at
the patient. The middle finger of the right hand is placed at the angle of the patient's jaw on the
right. The middle finger of the left hand is similarly placed at the angle of the jaw on the left. An
upward pressure is applied to elevate the mandible which will lift the tongue from the posterior
pharynx.

Airway adjuncts

Once an open airway has been established, the physician may choose to use either an
oropharyngeal or nasopharyngeal airway to make it easier to maintain an open airway. Both of
these devices prevent the tongue from occluding the airway and thereby provide an open conduit
for air to pass. It is important to note that these two airway devices, unlike a cuffed endotracheal,
tube will not protect the trachea from aspiration of secretions or stomach contents. If a patient is
unable to protect their own airway, they should have an endotracheal tube inserted as soon as
possible by someone who is has specific training and expertise in that skill.

Oropharyngeal airway

The oropharyngeal airway is essentially a curved hollow tube that is used to create an open
conduit through the mouth and posterior pharynx. A rough guide for choosing the correct size is
to hold the airway beside the patient's mandible, orienting it with the flange at the patient's mouth
and the tip at the angle of jaw. The tip should just reach the angle of the jaw. While inserting the
airway you want to avoid pushing the tongue into the posterior pharynx. This can be
accomplished by starting with the curve of the airway inverted, and then rotate the airway as the
tip reaches the posterior pharynx. Alternatively a tongue depressor can be used to move the
tongue out of the way as the airway is passed. Whichever technique is chosen the physician must
be certain that the airway is indeed in the right position. If there are problems ventilating the
patient after insertion of the airway then it should be removed and reinserted.

Nasopharyngeal airway

The nasopharyngeal airway is a soft rubber or plastic hollow tube that is passed through the nose
into the posterior pharynx. The tubes come in sizes based on the internal diameter(i.d.) of the
tube. The larger the internal diameter the longer the tube. An 8.0 – 9.0 i.d. is used for a large
adult, a 7.0 – 8.0 i.d. for a medium adult and a 6.0 – 7.0 i.d. for a small adult. These tubes can be
used when the use of an oropharyngeal airway is difficult, such as when a patient is clenching
their jaw. As well, the nasopharyngeal airway is generally better tolerated than the oropharyngeal
airway in a semiconscious patient. To insert, the nasopharyngeal airway is lubricated with water
soluble lubricant or anesthetic jelly along the floor of the nostril into posterior pharynx behind
the tongue.

Bag-mask ventilation

A patient who is not able to breathe adequately on their own will require support of their chest
ventilation through artificial means. In order to push oxygen rich air into the patient's chest, some
form of positive pressure ventilatory assistance is required. The simplest technique which can be
easily taught and mastered is mouth to mouth ventilation. One obvious downside to this
technique is that it requires contact with the patients saliva, and perhaps vomitus, and in this era
of universal precautions most people are disinclined to use it. A second downside is that the
physician is unable to provide supplemental oxygen while doing mouth to mouth. Students
should realize however, that using equipment such as a bag-mask device will not make it easier
to ventilate the patients chest. In fact the opposite is likely to be true. The technique of bag-mask
ventilation is difficult even in the best of hands and will require considerable practice before it
can be done effectively on a patient.

The first step in bag-mask ventilation is to select a mask that will cover the mouth and nose of
the patient and create a tight seal. The mask is then attached to the bag device, which should be
attached to high flow oxygen (15L/min.) such that the reservoir of the bag is fully inflated.

Generally, physicians will hold the bag device with their right hand and secure the mask to the
patient's face with their left hand. While securing the mask to the patient's face you want to
create a tight seal in addition to elevating the mandible to maintain an open airway. This is done
by hooking the fifth finger at the angle of the jaw, holding the mandibular body with the third
and fourth fingers and holding the mask between the index finger and thumb. The physician must
avoid the temptation to push down on the mask in order to create a tight seal as this will occlude
the patient's airway. The correct technique is to lift the mandible up with the third, fourth and
fifth fingers while holding the mask tight against the patient's face with the thumb and index
finger.

It is worth repeating that the technique of bag-mask ventilation is not easy under the best of
circumstances by even experienced operators. The physician who is performing bag-mask
ventilation must be carefully monitoring the success of his/her efforts at all times. The air should
flow easily into the patient, and the patient's chest should rise and fall with each cycle of
ventilation. If there is obstruction to air flow or the chest does not rise, the physician should
check that there is a tight seal to the face, that the mandible is being elevated to open the airway
and, if an artificial airway is being used, that it is in place.

Two person technique

The biggest challenge in bag-mask ventilation is maintaining an open airway and a tight seal
using one hand. If a second person is available, it is recommended that one person manages the
mask and the airway, while the second person squeezes the bag to ventilate the chest. The person
responsible for the mask stands at the head of the bed and places his thumbs on the top surface of
the mask. The remaining fingers are then used to grip the mandible on either side. The mask is
squeezed between the thumbs and the fingers to create a seal and at the same time the mandible
is elevated to open the airway. This technique is considerably easier, but again, the physicians
must be constantly checking that air is flowing easily into the patient and that the chest is rising
and falling.

Equipment tray

Gloves
The rescuer should at all times avoid direct contact with
the blood and other body fluids of the patient. If
available, gloves should be worn during all airway
management procedures.
Suction
In most resuscitation situations, the patient will either
vomit, or at the very least, have an excess of secretion in
their oropharynx. If available, a suction catheter should
be included as part of your basic airway equipment.

Lubricant
If a nasopharyngeal airway is used, it will require
lubrication of its outer surface prior to insertion.
Xylocaine(R) Jelly is used because it is a good lubricant
and it reduces irritaion through its local anesthetic effect.

Nasopharyngeal Airway
The nasopharyngeal airway is made of soft, pliable
plastic, and is inserted through the nares and into the
nasopharynx, thus providing a patent airway to facilitate
chest ventilation. It has the advantage of being better
tolerated in the conscious or semi-conscious patient than
the oropharyngeal airway. It is also easier to insert in a
patient who has his/her teeth clenched. It is important to
note that the NP airway does not protect the airway from
aspiration of vomitus.

Oropharyngeal Airway
The oropharyngeal airway is a rigid plastic device, which
is inserted through the mouth into the oropharynx. This
provides a patent airway to facilitate chest ventilation. It
is important to note that the OP airway does not protect
the airway from aspiration of vomitus.
 Bag-Valve Ventilator
The bag-valve ventilator is a device designed to ventilate
the chest. By attaching an oxygen supply, it can be used
to ventilate the chest with a high concentration of
oxygen. The bag-valve ventilator can be used with a
mask, as in basic airway management, or it can be
attached to an endotracheal tube as part of advanced
airway management.

Mask
Masks are used to provide a tight seal between the
patient's face and the bag-valve ventilator. Masks come
in various sizes. The correct size of the mask for a
particular patient should provide a tight seal around the
nose and mouth. The pointed end of the mask creates a
seal over the bridge of the patient's nose, while the round
end creates a seal between the lower lip and chin.

Step 1: Assess responsiveness

Use the "shake and shout" technique to assess responsiveness. The purpose of these verbal and
tactile stimuli is self-evident. Before performing more invasive maneuvers, you want to confirm
that the patient is in fact unresponsive.

Step 2: Call for help

In virtually all resuscitation situations, the first one on the scene will require assistance and hence
the importance of this step. As well, it is essential that a cardiac monitor and defibrillator be
brought immediately to the scene.

Step 3: Open the airway

In an unconscious patient, the most common cause of airway obstruction is the tongue. To
alleviate the obstruction and open the airway, a simple maneuver such as the Head-Tilt/Chin-Lift
Maneuver can be performed. Alternatively, a Jaw Thrust maneuver can be used if there is
concern that a C-spine injury may be present.
Step 4: Look, listen and feel for breathing

Check for movement of the chest and listen and feel for the feeling for air flow against your ear.

Step 5: Ventilate chest (x2)

In the absence of spontaneous respiration, the rescuer should immediately ventilate the chest
twice, as adequate chest ventilation is the single most important determinant of patient outcome.
The video shows the rescuer using a bag-valve ventilator. While squeezing the bag, watch for
chest expansion. The bag can be attached to an oxygen source so that a high inspired oxygen
concentration can be provided.

Step 6: Check pulse

This video shows the rescuer palpating for a carotid pulse. Note that he palpates in the groove
between the larynx and the anterior border of the sternocleidomastoid muscle. The rescuer
should palpate for 5-10 seconds. If the pulse is absent, the rescuer should immediately
commence chest compressions in concert with the chest ventilation. If a pulse is present, the
rescuer should resume ventilating the chest.

Step 7: Ventilate chest

Resume chest ventilation using the bag-valve-mask ventilator. Remember, adequate chest
ventilation is the single most important determinant of patient outcome in an apneic patient.
Regardless of whatever else is being done in the resuscitation, an open airway must be
maintained along with the continuous chest ventilation. The chest should be ventilated at a rate
of 10-12 per minute, or every 5-6 seconds.

Step 8: Insert airway

This video shows the rescuer inserting an oropharyngeal (OP) airway. An OP airway may make
it easier to maintain an open airway. When properly placed, it provides an open conduit for air to
pass between the tongues and the posterior pharynx. Alternatively, a nasopharyngeal (NP)
airway may be used. It is important to note that unlike the endotracheal tube used in advanced
airway management, neither an OP or a NP airway will protect the airway from aspiration.

Step 9: Ventilate chest

With the airway in place, the rescuer should resume chest ventilation, at a rate of 10-12 per
minute, or every 5-6 seconds. Regardless of the airway used, it should make it easier to ventilate
the patient. If it does not, reposition or remove the airway and resume ventilation.

Step 10: Two person technique

This video shows the two-person technique for bag-valve ventilation. the two-person technique
is much easier, and generally more effective, and so rescuers are encouraged to use it if a second
rescuer is available. A real resuscitation is no time to demonstrate prowess at rescuer technique.
If a second rescuer is available, use them!

Credits

Congratulations!

You have now completed the Basic Airway Management module.

Credits

 This web-based module was developed by Adam Szulewski based on content written by
Dr. Bob McGraw for the Queen's University Department of Emergency Medicine
Summer Seminar Series and Technical Skills Program.
 The module was created using exe : eLearning XHTML editor with support from Amy
Allcock and the Queen's University School of Medicine MedTech Unit.

License

This module is licensed under the Creative Commons Attribution Non-Commercial No

Derivatives license. The module may be redistributed and used provided that credit is given to
the author and it is used for non-commercial purposes only. The contents of this presentation
cannot be changed or used individually. For more information on the Creative Commons license
model and the specific terms of this license, please visit creativecommons.ca.