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?