Lesson 4Airway

Airway Anatomy

• Upper airway– Nasal passage– Turbinates– Oral cavity– Epiglottis– Vocal cord– Esophagus

Anatomy of the Glottis

• Posterior tongue• Epiglottis• Vocal cords

– True– False

• Esophagus• Prehospital care providers

who perform endotracheal intubation must know this anatomy

Courtesy of James P. Thomas, M.D., www.voicedoctor.net

Pediatric Airway Considerations

• Larger head and tongue– Greater potential for airway obstruction– Special attention to proper positioning

• Epiglottis– Proportionally larger– Floppier than adult

• Trachea– Shorter and conical shape– Greater potential for main

bronchus intubation

Airway Assessment (1 of 5)

• If the trauma patient is talking normally, the airway is open– Further assessment is still required

• Assessment of the airway requires the provider to:– Look– Listen– Feel

Airway Assessment (2 of 5)

• Look for findings that may indicate airway obstruction or injury or may lead to pulmonary aspiration

• Examples may include:– Blood and secretions– Fractured teeth– Foreign bodies

Airway Assessment (3 of 5)

• Examples may include (cont’d):– Vomitus– Hematomas/contusions

(e.g., tongue, neck)– Gross subcutaneous

emphysema

Photograph provided courtesy of J.C. Pitteloud M.D., Switzerland

Airway Assessment (4 of 5)

• Listen for abnormal sounds indicating airway compromise

• Examples include: – Snoring– Stridor (inspiratory) – Gurgling (expiratory)– Hoarseness

Airway Assessment (5 of 5)

• Feel for abnormal masses and signs of airway injury

• Examples include:– Hematomas– Subcutaneous emphysema in the neck

• Additional consideration– Measure oxygen saturation

Airway Obstruction (1 of 2)

• Causes of airway obstruction– Tongue

• Most common cause• Falls back, obstructing

the airway with decreased mental status

• Snoring — clinical finding

Airway Obstruction (2 of 2)

• Causes of airway obstruction (cont’d)– Foreign body– Blood– Vomit– Teeth

Airway Trauma (1 of 2)

• Blunt injuries – Examples of findings may include:

• Swelling and edema • Fractured larynx• Subcutaneous emphysema• Hematoma

Airway Trauma (2 of 2)

• Penetrating injuries– Examples of findings may include (cont’d):

• Bleeding into the airway• Subcutaneous emphysema• Hematoma

Inhalation Injuries of the Airway

• Examples of causes– Dry– Steam– Chemical

• Signs and symptoms of airway burns– Swelling/edema– Stridor

Airway and Spine Stabilization

• Maintain cervical spine stabilization as indicated by mechanism of injury

• Especially important when assessing and performing airway maneuvers

Airway Management (1 of 3)

• The goal in managing the trauma patient’s airway is to maintain a patent airway that allows for adequate breathing, ventilation, and oxygenation

• Management progresses from essential to complex procedures and adjuncts

Airway Management (2 of 3)

• Prehospital care providers should be knowledgeable and skilled in multiple methods of ensuring a patent airway

• Providing a patent airway entails anticipating difficulties and planning for alternate methods of airway control

Airway Management (3 of 3)

• Essential skills and interventions are applied first

• Complex skills and interventions are performed only if needed

• The choice of technique to manage the airway depends upon:– Knowledge and skills of the provider– Situation at the scene– Severity of the patient– Resources available

Methods and Categories ofAirway Management (1 of 2)

• Manual– Trauma jaw thrust– Chin lift

• Simple– Oropharyngeal

airway (OPA)– Nasopharyngeal

airway (NPA)

Methods and Categories ofAirway Management (2 of 2)

• Complex– Supraglottic airways– Endotracheal intubation– Rapid sequence intubation (RSI)– Percutaneous

airway– Surgical airway

Courtesy of Ambu, Inc.

Trauma Jaw Thrust or ChinLift (1 of 2)

• Always the first airway maneuvers for the trauma patient

• Performed while maintaining manual cervical stabilization

Trauma Jaw Thrust or ChinLift (2 of 2)

• Both techniques lift the mandible, elevating the tongue away from the posterior pharynx, opening the airway

• Can be used for conscious or unconscious patients

OPA and NPA (1 of 2)

• Both airway adjuncts mechanically elevate the tongue off the poster pharynx to maintain an open airway

• Both airways require measurement (length) and sizing (diameter) prior to insertion.

OPA and NPA (2 of 2)

• Improperly sized or improperly inserted airways can cause obstruction by pushing the tongue against the posterior pharynx

• OPA insertion requires an absent gag reflex– Insertion technique is based on age of patient

• NPA insertion requires the use of a water-soluble lubricant

Supraglottic Airways (1 of 2)

• Blind insertion technique• Less complex technique than

endotracheal intubation– Less initial training – Easier to maintain proficiency

• Requires an absent gag reflex

Courtesy of Ambu, Inc.

Supraglottic Airways (2 of 2)

• Supraglottic airways occlude the pharynx to limit regurgitation but do not prevent aspiration

• Some supraglottic airways are available in pediatric sizes

• Examples of supraglottic airways include the laryngeal mask airway (LMA), Combitube, and King LT airway

Endotracheal Intubation (1 of 6)

• Complex technique • Requires:

– Significant initial training

– Multiple pieces of equipment

– Substantial ongoing training to maintain proficiency

Courtesy of AMBU

Endotracheal Intubation (2 of 6)

• Placement options– Oral

• Pharmacologically assisted intubation • Rapid-sequence intubation (RSI)• Nonpharmacologic

– Nasal

Endotracheal Intubation (3 of 6)

• Assess need for intubation based on:– Inability to maintain a patent airway– Decreased LOC– Upper airway burns– Signs of impending airway obstruction

• Endotracheal intubation may also be considered when alternate methods of airway management are deemed inadequate or inappropriate based on the situation and severity of injuries

Endotracheal Intubation (4 of 6)

• Before attempting intubation:– Anticipate potential difficulties

• Trauma-related– Disrupted/displaced anatomy

• Pre-existing conditions– Small mouth/mandible – Short neck– Obesity

Endotracheal Intubation (5 of 6)

• Before attempting intubation (cont’d):– Prepare an alternate (backup) plan for airway

management in the event of unsuccessful endotracheal tube placement

– Have all necessary equipment immediately at hand

Endotracheal Intubation (6 of 6)

• Important considerations– Essential airway skills are often sufficient to

provide a patent airway– If intubation is required:

• Preoxygenate to maximize oxygen saturation• Reoxygenate patient in between intubation

attempts• Monitor oxygen saturation (e.g., pulse oximetry)

throughout the procedure– Following intubation, verify proper tube

placement

Surgical Airways (1 of 3)

• Complex technique • Requires:

– Significant initial training– Multiple pieces of equipment – Substantial ongoing training to

maintain proficiency

Courtesy of Peter T. Pons, MD, FACEP.

Courtesy of Peter T. Pons, MD, FACEP.

Surgical Airways (2 of 3)

• Potential for:– Multiple complications– Damage to nearby anatomic structures

Surgical Airways (3 of 3)

• May be considered for:– Massive facial trauma that prevents

endotracheal intubation– Upper airway obstruction unrelieved by other

techniques – Failed intubation and alternative airway

methods are unavailable or unsuccessful

Confirmation of TubePlacement (1 of 2)

• Should include at least one physiological and one mechanical method

• Physiological– Breath sounds– Chest rise– Change in skin color– Pulse rate

• Continually monitored and reassessed

Confirmation of TubePlacement (2 of 2)

• Mechanical– End tidal CO2

• Colorimetric• Capnometry• Wave form

capnography– Pulse oximetry

• Continually monitored and reassessed Courtesy Masimo

Airway Protocol (1 of 3)

Airway Protocol (2 of 3)

Airway Protocol (3 of 3)

Summary

• Goal is to secure and maintain a patent airway• Assess airway by looking, listening, and feeling• Maintain manual stabilization of the head and

spine as indicated• Apply essential airway maneuvers first• Utilize complex airway techniques only when

required• Anticipate difficulties and plan and prepare for

alternate methods of airway control

Questions?