AIRWAY MANAGEMENT

( Basic )

Anang Achmadi
Department of Anesthesiology & Intensive Care
Santosa Hospital Bandung Central
 Airway Management

• Air reaches the

lungs only through
the trachea.
– In a compromised
airway, clearing the
airway and
maintaining patency
are vital.
 Positioning the Patient
• Move unresponsive patients found in a prone position to
a supine position.
– Log roll and assess for breathing.

• If the patient is breathing adequately and is not injured,

move to recovery position.
 Manual Airway Maneuvers
• If an unresponsive
patient has a pulse
but is not breathing,
you must open the
airway.
– Maneuver patient’s
head to propel the
tongue forward and
open the airway.
Head Tilt-Chin Lift Maneuver
• Advantages
• Indications: – No equipment
– Unresponsive – Noninvasive

– No spinal injury • Disadvantages

– Unable to protect airway – Hazardous to spinal injury

• Contraindications: – No protection from

aspiration
– Responsive

– Possible spinal injury • Refer to

Skill Drill 15-1.
 Jaw-Thrust Maneuver

• Indications
– Unresponsive • Advantages
– Possible spine injury – Used with spine injury or
– Unable to protect airway cervical collar

• Contraindications – No special equipment

required
– Resistance to opening
the mouth
 Jaw-Thrust Maneuver

• Disadvantages
– Thumb must remain in
– Cannot maintain if patient
place
becomes responsive or
combative – Requires second rescuer

– Difficult to maintain for an – No protection against

extended time aspiration

– Difficult to use with bag- • Refer to

mask ventilation Skill Drill 15-2.
 Tongue-Jaw Lift Maneuver
• Used more commonly to open airway for:
– Suctioning
or
– Inserting an oropharyngeal airway

• Cannot be used to ventilate a patient

– Does not allow for an adequate mask seal

• Refer to Skill Drill 15-3.

 Suctioning

• Removes material from the mouth or

throat quickly and efficiently
– Ventilating with secretions in the mouth will
result in upper airway obstruction or aspiration.

• Next priority after opening airway manually

 Suctioning Equipment
• Fixed or portable
– Hand-operated
suctioning units with
disposable
canisters
– Mechanical or
vacuum-powered
suction units
 Suctioning Equipment

• The following should be readily accessible:

– Wide-bore, thick-walled, nonkinking tubing

– Soft and rigid suction catheters

– Nonbreakable, disposable collection bottle

– Supply of water for rinsing the catheters

 Suctioning Equipment
• Yankauer catheter
– Use with adults (pharynx),
infants, children
• Whistle-tip catheter
– Can be placed in ET tube
– Use for nose, back of
mouth, when a rigid
catheter cannot be used
 Suctioning Techniques

• Suctioning removes oxygen.

– Preoxygenate before suctioning.

– Maximum suctioning time

• Adult: 15 seconds

• Child: 10 seconds

• Infant: 5 seconds
 Suctioning Techniques
• Do not stimulate back of throat.
• After suctioning, continue ventilation and
oxygenation.
• Soft-tip catheters
– Must lubricate when suctioning the nasopharynx
– Best when passed through an ET tube
– Suction during extraction of catheter
 Suctioning Techniques

• Before inserting, measure for proper size.

– Corner of the mouth to the earlobe

• Never insert a catheter past the base of

the tongue.

• Refer to Skill Drill 15-4.

 Airway Adjuncts

• May be needed to help maintain patency

in an unresponsive patient after manually
opening and suctioning
– Not a substitute for proper head positioning
 Oropharyngeal (Oral) Airway
• Curved, hard plastic device
• Fits over back of the tongue
• Should be inserted in unresponsive
patients who have no gag reflex
Oropharyngeal (Oral) Airway
• Advantages
– Noninvasive and easily
• Indications placed
– Unresponsive patients – Prevents blockage by the
who have no gag reflex tongue

• Contraindications • Disadvantages
– No prevention of aspiration
– Responsive patients
• Refer to
– Patients with a gag reflex
Skill Drill 15-5
and 15-6.
Nasopharyngeal (Nasal) Airway
• Soft, rubber tube
• Insert through nose
• Better tolerated
– Do not use with
trauma to the nose or
skull fracture.

• Lubricate the airway

and insert gently.
Nasopharyngeal (Nasal) Airway
• Indications
– Unresponsive
– Altered mental status
with an intact gag reflex
• Contraindications
– Patient intolerance
– Facial fracture or skull
fracture
• Advantages
– Suctioned through
– Patent airway
– Tolerated by responsive
patients
– Can be placed “blindly”
– No requirement for the
mouth to be open
 Nasopharyngeal Airway

• Disadvantages
– Improper technique may result in severe
bleeding.

– Does not protect from aspiration

• Refer to Skill Drill 15-7.

Causes of Airway Obstruction

• Foreign body • Trauma

• Tongue • Aspiration
• Laryngeal edema • Infection or severe
• Laryngeal spasm allergic reaction
Causes of Airway Obstruction

• Tongue
– With altered LOC, tongue can fall backwards,
closing off the airway
• Partial obstruction: snoring respirations

• Complete obstruction: no respirations

– Simple to correct with manual maneuver

 Causes of Airway Obstruction
• Foreign body
– Typical victim: middle-aged or older, dentures, alcohol
– Signs may include:
• Choking
• Gagging
• Stridor
• Dyspnea
• Aphonia or dysphonia
Laryngeal Spasm and Edema
• Laryngeal spasm
• Laryngeal edema
– Spasmodic closure of
– Glottic opening narrows
vocal cords
or totally closes
– Completely occludes
– Causes include:
airway
• Epiglottitis
– Causes include:
• Anaphylaxis
• Intubation trauma
• Inhalation injury
• Extubation
 Laryngeal Spasm and Edema
• May be relieved by
– Aggressive ventilation
– Forceful upward jaw pull

• May be relieved by muscle relaxants

• May recur; transport patient to hospital for
evaluation
 Laryngeal Injury

• Fracture of the larynx increases airway

resistance by decreasing airway size.

• Penetrating and crush injuries to the

larynx can compromise the airway.
 Aspiration
• Increases mortality
– Can obstruct the airway
– Destroys bronchiolar tissue
– Introduces pathogens into the lungs
– Decreases patient’s ability to ventilate

• Have suction readily available

 Recognition of an
Airway Obstruction
• Mild obstruction
– Patient is responsive, able to exchange air

– Usually has noisy respirations and coughing

– Should be left alone

– Closely monitor the patient’s condition.

– Be prepared to intervene.
 Recognition of an
Airway Obstruction
• Severe obstruction
– Inability to breathe, talk, or cough

– May grasp at throat, turn cyanotic, make frantic movements

– Cough is weak, ineffective, or absent

– Weak inspiratory stridor and cyanosis

Courtesy of Rhonda Beck

 Emergency Medical Care for Foreign Body
Airway Obstruction

• Begin treatment immediately if choking is

confirmed by a responsive patient.
– If large pieces of foreign body are found, sweep them
out of the mouth with your finger.
– Insert your finger along the inside of the cheek and
into the throat.
– Try to hook the foreign body to dislodge it.
– Suction as needed.
 Emergency Medical Care for Foreign Body
Airway Obstruction

• Abdominal thrust (Heimlich) maneuver

– Creates an artificial cough, expelling the
object

– Perform until the object is expelled or the

patient becomes unresponsive.
 Emergency Medical Care for Foreign Body
Airway Obstruction

• If patient becomes unresponsive, position

supine, begin chest compressions
– 30 chest compressions
– 15 with two rescuers or infant/child

• Open airway, remove any visible object

• Attempt rescue breath, look for chest rise
 Emergency Medical Care for Foreign Body
Airway Obstruction

• If techniques do not work, proceed with direct

laryngoscopy.
– If you see the foreign body, remove it with Magill forceps.

– Refer to Skill Drill 15-8.

 Supplemental
Oxygen Therapy

• Administer to any patient with potential

hypoxia
– Enhances compensatory mechanisms during
shock and distressed states
 Oxygen Sources
• Oxygen cylinders
– Stores pure oxygen

– Check label and

test date.

– Various sizes

– Oxygen delivery is
measured in L/min.
 Oxygen Sources
• Oxygen cylinders
(cont’d)
– Replace cylinder when
pressure falls to 200 psi
or lower.
– Using the pressure and
flow rate, you can
calculate how long the
supply will last.
 SUCTIONING

OPEN SUCTION CLOSED SUCTION

 Patient Preparation

Ø Explain the procedure to the patient (If

patient is concious).
Ø The patient should receive hyper
oxygenation by the delivery of 100%
oxygen for >30 seconds prior to the
suctioning (Either with Bain’s circuit or
by increasing the FiO2 by mechanical
ventilator).
Ø Position the patient in supine position.
Ø Auscultate the breath sounds.
 PROCEDURE
Ø Perform hand hygiene, wash
hands. It reduces transmission
of microorganisms.

Ø Turn on suction apparatus and

set vacuum regulator to
appropriate negative pressure.
For adult a pressure of 100-120
mmHg, 80-100mmhg for
children & 60-80mmhg for
infants.