Airway

Management
 Learning Objectives :

• Describe essential techniques involved in basic airway management .

• Discuss airway maneuvers.

• Identify different airway adjuncts in basic airway management.

Causes of inadequate ventilation

• Respiratory Effort
• Airway Obstruction
Causes Of Inadequate Ventilation
Respiratory effort :Poor
• can result from intrinsic (eg, intracranial hemorrhage) or
extrinsic (eg, opioid overdose) factors.
• Poor respiratory effort causing inadequate ventilation can be
difficult to discern:
o it is often silent
o detection depends on close observation of chest wall
movement.
Causes Of Inadequate Ventilation
Respiratory effort :Poor
Observe:
• the rate
• Pattern
• depth of breathing
• use of accessory muscles
• abnormal sounds
• signs of injury
Causes Of Inadequate Ventilation

Respiratory effort :Poor

 Causes Of Inadequate Ventilation

Airway obstruction —
Soft tissue airway obstruction in the
unconscious patient can occur by several
mechanisms.
• prolapse of the tongue into the posterior
pharynx and loss of muscular tone in the
soft palate.
• Obstruction by foreign bodies, injured tissue,
blood, and secretions.
Causes Of Inadequate Ventilation
Airway obstruction —
• obstructed upper airway
o snoring or gurgling noises may be heard when the upper
airway becomes partially obstructed by soft tissue or liquid
(eg, blood, emesis).

o Complete airway obstruction is silent but may manifest

transiently as retractions of the accessory muscles of
respiration (suprasternal, supraclavicular, intercostal,
subcostal) or as cyanosis
Airway Adjuncts

• Oropharyngeal Airway

• Nasopharyngeal Airway
 Airway Adjuncts

• Oropharyngeal
Airway (OPA )

• Used to maintain or open an individual’s airway by preventing the tongue

from covering the epiglottis, a small flap in the throat.

• Typically used in unresponsive individuals.

• Measured from the corner of the mouth to the earlobe.

• Contraindicated with gag reflex .

Airway Adjuncts

• NPAs are measured from the nostril to

the earlobe

• Due to the risk for epistaxis or

nasopharyngeal injury, NPAs are
contraindicated in patients who are
anticoagulated; have basilar skull
fractures, nasal deformities or nasal
infections; and pediatric patients.
Bag-Valve Mask (BVM ) Ventilation

• most important skill in basic airway

management
• BVM ventilation requires a good
mask seal and a patent airway.
 Bag Valve mask Ventilation
While providing BVM ventilation:

• extend the patient's head slightly using the head-tilt chin-lift

maneuver.

• The mask should cover the nose and mouth without

extending over the chin.

• The mask is held in place with the one-handed E-C

technique.

• Using the non dominant hand, create a C shape with the

thumb and index finger (left image) over the top of the
mask and apply gentle downward pressure.
Image courtesy of Medscape
• Hook the remaining fingers around the mandible taking
care not to apply pressure to the soft tissues of the neck,
and lift it upward toward the mask creating the E.
Bag-Valve Mask (BVM ) Ventilation

The two-handed technique is preferred if a

second person is available to provide
ventilations.

Image courtesy of Medscape.

Entubation
 Intubation

• Endotracheal intubation is a critical, often lifesaving

procedure for severely ill or injured patients who
cannot maintain adequate oxygenation, perform
effective ventilation, or maintain a protected airway.
 Intubation

• Often used when a patient is at risk for serious

deterioration or is considered unstable and needs a
procedure or transfer that requires leaving the
resuscitation room environment.
 Intubation

• Preparation is key to the success of endotracheal

intubation..

• Endotracheal tubes (ETT) (shown) come in a

number of sizes, usually designated in millimeters
of internal diameter.
 Laryngoscope

• The laryngoscope is a rigid instrument

used to facilitate intubation of the
trachea.

• The two main components are a

cylindrical handle (left) and the blade.
BVM (Bag Valve Mask Ventilation )
 BVM (Bag Valve Mask Ventilation )
• When preoxygenating using manual ventilations with
the BVM (shown), remember to squeeze the bag once
every 5 seconds delivering volumes just enough to
cause the chest to rise.

• Gastric inflation can occur when the bag is squeezed

too forcefully or too quickly.
 BVM (Bag Valve Mask Ventilation )
• The ventilatory rate should not exceed 10-12 breaths per
minute.
• Use a tidal volume of approximately 8-10 mL/kg or just
large enough to cause chest rise. During cardiopulmonary
resuscitation, smaller tidal volumes (5-6 mL/kg) are
adequate because of reduced cardiac output of such
patients.
• Contraindications to bag-valve mask include severe facial
trauma and airway obstruction. A surgical airway may be
indicated in these patients.
Difficult Airway Assessment

• must be performed before attempting intubation,

especially when using neuromuscular-blocking age

• The mnemonic "LEMON" is a helpful tool.

"L" = Look for signs of obesity, micrognathia,

evidence of previous head and neck surgery or irradia
facial hair, poor dentition, dentures, large teeth, a narro
face, a high and arched palate, a short or thick neck, a
facial or neck trauma.

"E" = Evaluate the 3-3-2 rule. Normal mouth

opening is 3 of the patient's fingerbreadths. Hyomenta
distance (left image) when measured should be at leas
fingerbreadths, whereas the thyrohyoid distance (right
image) should be at least 2 fingerbreadths
Difficult Airway Assessment

• must be performed before attempting intubation,

especially when using neuromuscular-blocking age

• The mnemonic "LEMON" is a helpful tool.

"L" = Look for signs of obesity, micrognathia,

evidence of previous head and neck surgery or irradia
facial hair, poor dentition, dentures, large teeth, a narro
face, a high and arched palate, a short or thick neck, a
facial or neck trauma.

"E" = Evaluate the 3-3-2 rule. Normal mouth

opening is 3 of the patient's fingerbreadths. Hyomenta
distance (left image) when measured should be at leas
fingerbreadths, whereas the thyrohyoid distance (right
image) should be at least 2 fingerbreadths
"M" in the "LEMON" mnemonic is for Mallampati
classification

Class I: soft palate, uvula, and pillars visible = no difficulty;

Class II: soft palate, uvula visible = no difficulty;

Class III: soft palate and base of uvula visible = moderate

difficulty

Class IV: only the hard palate is visible = severe difficulty

 LMA

• used as a rescue airway device to ventilate patients

when traditional endotracheal intubation is not feasible.
 Video Laryngoscopy
• Direct laryngoscopy and improves glottic exposure in
most patients with poor direct glottic visualization..

• Indications for video laryngoscopy include:

o morbid obesity
o poor direct laryngoscopic view from trauma or
anatomic variation
o inability to view the vocal cords, small mouth
opening (< 3 cm),
o limited neck extension
o suspected cervical spine injury.
 When is airway management required?

• simple choking to complicated airway obstruction

• Airway obstruction most commonly occurs as a result of
the tongue or foreign bodies blocking the airway.
• It can also be the result of injury to the airway, increased
presence of blood and secretions (e.g., saliva and mucus),
or inflammation of the airway.
When is airway management required?

• Specific clinical signs that may indicate the need for

airway management include respiratory failure, reduced
level of consciousness, rapid change in mental status,
active choking, or penetrating trauma. Depending on the
particular circumstance, various different types of airway
management may be performed.
 Most important facts to know about airway
management.

• Airway management is an essential technique for clinicians

taking care of individuals in critical situations and
emergency medicine.
• Airway management involves a series of maneuvers and
medical procedures used to maintain or restore airway
functionality.
• Airway management may be required in situations of
airway obstruction, respiratory distress, or when the
individual is under sedation.
 Most important facts to know about airway
management.

• Depending on the clinical presentation of an individual,

basic or advanced forms of airway management may be
used.
• Basic airway management techniques are non-invasive,
whereas advanced airway management techniques are
invasive and require specialized medical equipment, such
as OPAs, NPAs and ETAs.
• Bag valve mask ventilation serves as another approach to
prevent inadequate ventilation, which can result from
impaired breathing or airway obstruction.
 References:
• https://www.osmosis.org/answers/airway-management
• https://reference.medscape.com/features/slideshow/airway-
management#page=28
• Airway management :
• https://youtu.be/M50u-DvNB9E