AIRWAY

MANAGEMENT
Airway management is one of the fundamental skill which healthcare
providers have to be well versed in. It is the passage by which air enter
and leave the lungs. Studies indicate that majority of deaths in emergency
situation occur due to poor airway management. The critical element in
emergency management is preventing cardiac arrest and brain death. It is
vigilant observation and prompt intervention of a skilled healthcare
professional that can save the life of an individual.
 Airway Obstruction
• Obstruction of the airways is a medical emergency.

• It may be partial or complete, and may occur at any level of the

respiratory tract.

• If untreated, airway obstruction leads to a lower blood oxygen

tension and risks hypoxic damage to the brain, kidneys and heart or
even death.
 Cause of Airway Obstruction

01 02 03 04
Decreased Vomit Blood Edema
muscle tone

05 06 07
Trauma Foreign bodies Regurgitation of
stomach contents
 Cause of Airway Obstruction

08 09 10
Inflammation Anaphylaxis Excessive bronchial
secretion

11 12 13
Mucosal Edema Bronchospasm Aspiration
 Management of Airway Obstruction
The most common cause of upper airway obstruction in unconscious / unresponsive patient is loss of
tone in the throat muscles. In this case, the tongue falls back and occludes the airway at the level of
pharynx. Basic airway opening technique will effectively relieve airway obstruction caused either by
the tongue or from relaxation of muscle in the upper airway. The basic airway opening technique is
head tilt with anterior displacement of the mandible, ie head tilt-chin lift.

In the trauma patient with suspected neck injury, use a jaw thrust without head extension. Because
maintaining an open airway and providing ventilation is a priority, use a head tilt- chin lift maneuver
if the jaw thrust does not open the airway.

In majority of the cases, the use of simple methods such as suctioning to remove secretions, used of
head-tilt, chin-lift maneuver or insertion of an oropharyngeal or nasopharyngeal airway
BASIC AIRWAY SKILLS
• Head tilt-chin lift
• Jaw thrust without head extension
(suspected cervical spine trauma)
• Mouth-to-mouth ventilation
• Mouth-to-nose ventilation
• Mouth-to-barrier device (using a pocket mask) ventilation
• Bag-mask ventilation
Goals of Airway Management
● To obtain and maintain patent airway.
● To correct deficient gas exchange.
● To protect the airway.
● To prevent the predicted clinical
deterioration.
 Indications
● Decreased cardiac output
● Head trauma
● Drug overdose
● Anesthesia
● Metabolic disagreement
● Hypo / Hyperthermia
● Congenital abnormalities
● Infection
Healthcare Provider Roles in Airway Management
• Ensure that all patient presenting to the ED have adequate and patent airway
• All nursing assessments should start with the ABC of CPR.
• Without a patent airway, any further patient assessment is futile, and irreversible brain
• damage will occur within minutes.
• Use manual methods to open the airway.
• Use basic airway adjuncts to intervene if the airway is compromised, e.g. suction, oral
airway.
• Assist in the maintenance of the airway using advanced airway adjuncts
• Deliver O2, when required using appropriate methods.
• Continually assess airway patency using clinical observation and relevant monitoring.
• Explain procedures clearly to the patient and the family.
 Airway Management
A. SUCTION
- Suctioning is an essential component of maintaining a patient’s airway.

• The patient’s airway must be kept clear of foreign materials, blood, vomitus and
other secretions. Materials that are allowed to remain in the airway may be forced
into the trachea and eventually into the lungs.
• This causes complications ranging from severe pneumonia to complete airway
obstruction.
• SUCTIONING is the method of using a vacuum device to remove such materials.
• A patient need to be suctioned immediately whenever a gurgling sound is heard-
whether before, during or after artificial ventilation.
• Suction devices consist of both portable and wall-mountedunits.
• Portable suction devices are easy to transport but may not provide
adequate suction power.
• A suction force of 80 – 120 mmHg is generally necessary
• Wall-mounted suction units should be capable of
providing airflow of greater than 40L/min at the end of
the delivery tube and a vacuum of more than–300mmHg
when the tube is clamed at full suction
• Adjust the amount of suction force for use in children
and intubated patients.
• Both soft flexible and rigid suctioning catheter are available. Soft flexible catheters
may be used in the mouth and nose. Soft flexible catheters are available in sterile
wrappers and can also be used for ET tube deep suctioning. Rigid catheters
(Yankauer) are used to suction the oropharynx. These are better for suctioning thick
secretions and particulate matter.
B. OXYGEN SUPPLEMENTATION VIA NON RE-BREATHER MASK

B. 1 Indications
All acute medical / trauma like:
1. Asthma
2. Medical infarction (Heart attack)
3. Pre / post-operative
4. Trauma
5. Respiratory Distress

It is designed to function with an oxygen flow rate in excess of 10L/min which will if
used correctly deliver 80 – 90% oxygen. It works by having a simple valve that permits
the flow of oxygen, but during exhalation closes to prevent dilution of oxygen in the
reservoir bag.
B. OXYGEN SUPPLEMENTATION VIA NON RE-BREATHER MASK

B. 2 Preparing the mask

1. Turn the oxygen supply to at least a 10L flow rate.

2. Block the mask and allow the reservoir bag to fill.

3. Immediately apply the mask to the patients face.

4. Monitor for effectiveness.

C. AIRWAY MANEUVERS

Airway management includes a set of maneuvers and medical procedures performed to

prevent and relieve airway obstruction. This ensures an open pathway for gas exchange
between a patient’s lungs and the atmosphere In patients who have a decreased level of
consciousness, the tongue can fall backward and obstruct the hypopharynx. Maneuvers
used to establish an airway can produce or aggravate cervical spine injury, so in line
immobilization of the cervical spine is essential during these procedures.
C. 1 Chin-Lift Maneuver

In the chin-lift maneuver, the fingers of one hand

are placed under the mandible, which is then gently
lifted upward to bring the chin anterior. The thumb
of the same hand lightly depresses the lower lip
to open the mouth. The thumb may be placed
behind the lower incisors and, simultaneously,
the chin is gently lifted. The chin-lift maneuver
should not hyperextend the neck. This maneuver
is useful for trauma victims because it can prevent converting a cervical fracture without cord
injury into one with cord injury.
C.2. Jaw-Thrust Maneuver

The jaw-thrust maneuver is performed by

grasping the angles of the lower jaw, one
hand on each side, and displacing the
Mandible forward. When this method
is used with the face mask of a bag-mask
device, a good seal and adequate
ventilation can be achieved. Care
must be taken to prevent neck extension.
D. AIRWAY ADJUNCT DEVICES

D.1 Oropharyngeal Airway

Oral airway is inserted into the mouth behind the tongue. It is used in patients who
are at risk for developing airway obstruction from the tongue or from relaxed upper
airways muscles. The preferred technique is used a tongue blade to depress the
tongue and then insert the airway posteriorly, taking care not to push the tongue
backward, which would block rather than clear the airway.
This J- shaped device fits over the tongue to hold it and the soft
hypopharyngeal structures away from the posterior wall of the pharynx.
This device must be used to unconscious patients because it can induce
gagging, vomiting, and aspiration. Patients who tolerate on oropharyngeal
airway are highly likely to require intubation. The key assessment is to
check whether the patient has an intact cough and gag reflex. If so, do not
use an OPA.
An alternative technique is to insert an oral airway, upside down, so its concavity is
directly upward until the soft palate is encountered. At this point, with the device rotated
180 degrees, the concavity is directed inferiorly, and the device is slipped into placed
over the tongue. This alternative method should not be used in children, because the
rotation of the device can damage the mouth and pharynx.

D.1.1 Uses
• Helps to maintain an open airway in unconscious patient.
• Prevent patient from biting and occluding an oral endotracheal tube.
• Protect the tongue from biting.
• Facilitate oropharyngeal suctioning.
• Provides a pathway for inserting devices into the esophagus or pharynx.
D.2. Nasopharyngeal Airway

Nasopharyngeal airways are inserted in one nostril and passed gently into the
posterior oropharynx. It is used as an alternative to an OPA in patient who need a basic
airway management adjunct. The NPA is a soft rubber or plastic uncuffed tube that
provides a conduit for airflow between the nares and the pharynx. They should be well
lubricated and inserted into the nostril that appears to be unobstructed. If obstruction is
encountered during introduction in the airway, stopped and try to other nostril.
This is used with patients who are conscious or
semi- conscious. The NPA is indicated when
insertion of an OPA is technically difficult or
dangerous. Example include patients with gag
reflex, trismus, massive trauma around the mouth,
or wiring of the jaws. The NPA may also be used in
patients who are neurologically impaired with poor
pharyngeal tone or coordination leading to upper
airway obstruction.
D.2.2. Uses
• Used during and after pharyngeal surgery.

• To apply continuous positive airway pressure (CPAP)

• To facilitate suctioning and as a guide for nasogastric tube.

• To dilate the nasal passages in preparation for nasotracheal intubation.

• Used in dental surgery.

• Can be fitted with a tracheal tube connector and used with an anesthesia breathing system.

D.2.3. Advantages over Oropharyngeal Airway.

• Better tolerated than an oral airway

• Preferable if the patient’s teeth are loose or there is trauma or pathology of the oral cavity.

• Used when the mouth cannot be opened for introducing an airway.

IX. INDICATIONS FOR DEFINITIVE AIRWAY

IX.1. Failure to maintain a patent airway and protect against aspiration - Inadequate
gag reflex and inability to handle secretions.
- Decreased mental status ( GCS < 8 ) not due to a rapid reversible cause ( eg,
hypoglycemia, opioid overdose )
- Severe maxillofacial trauma

IX.2. Failure to adequately oxygenate or ventilate

- Hypoxemia unresponsive to supplemental oxygen, as measured by pulse
oximeter with good waveform.
- Hypercapnea, as measured by ABG or end tidal CO2 with decreased mental
status.

IX.3. Anticipated clinical deterioration

- Status epilepticus, multiple trauma
X. CHECKLIST FOR EQUIPMENT REQUIRED FOR MANAGING AIRWAY
X. ASSESSMENT
AIRWAY ACTIONS

Is the airway patent? Look for chest rise, if absent start giving breath with
bag mask

Is an advanced airway indicated? Absence of chest rise indicate need of airway device,
start with

Is the airway properly placed? Assess the placement by bilateral auscultation

Is tube secured and placement reconfirmed Reconfirm it periodically by observing the oxygen
saturation

Are ventilation and oxygenation adequate? Assess the clinical criteria (cyanosis and chest rise ),
quantitative wave form capnography 35 – 45 mmHg,
and oxygen saturation > 94

Are quantitative waveform capnography and Monitor oxygen saturation to maintain it 94% or
O2 saturation monitored more,100% in case of cardiac patients by
administering supplemental O2.
XII. PROVIDING VENTILATION WITH AN ADVANCED AIRWAY

Selection of an advanced airway device depends on the training, scope of practice and
equipment of the providers on the high performance team. Advanced airway includes but not
limited to
• Laryngeal mask airway
• Laryngeal tube
• Esophageal- tracheal tube
• ET tube

1. Laryngeal Mask Airway

The LMA is an advanced airway alternative to ET

intubation and provides comparable ventilation.
It is acceptable to use the laryngeal mask as an
alternative to an ET tube for airway management
in cardiac arrest. Only experienced providers
should perform laryngeal mask airway insertion.
2. Laryngeal Tube

The advantages of the laryngeal tube are similar

to those of the esophageal-tracheal tube; however,
the laryngeal tube is more compact and less
complicated to insert. Healthcare professionals
trained in the use of the laryngeal tube may consider
it as an alternative to bag-mask or ET INTUBATION
FOR AIRWAY management in cardiac arrest.
Only experienced providers should perform laryngeal tube insertion.
3. Esophageal- Tracheal Tube

The esophageal – tracheal tube is an advanced

airway alternative to ET intubation. This device
provides adequate ventilation comparable to an ET
tube. It is acceptable to use the ETT tube as an
alternative to an ET tube for airway management
in cardiac arrest. Only experienced with its use
should perform esophageal- tracheal tube insertion.
4. Endotracheal Tube

Prepare for intubation by assembling the necessary equipment. Perform ET

intubation. Inflate cuff or cuff of the tube. attach the ventilation bag. Confirm correct
placement by physical examination and a confirmation device. Continuous waveform
capnography is recommended as most reliable method of confirming and monitoring
correct placement of an ET tube. Secure the tube in place and monitor for
displacement.
XIII. ADVANCED AIRWAY ASSESSMENT SCORING
• LEMON method is used for the prediction of the difficulty in
airway intubation.
• The score with maximum 10 points is calculated by assigning 1
point for each LEMON criteria.
 ARTERIAL
BLOOD GAS
 ARTERIAL BLOOD GAS
ABGs are the primary method for evaluating
oxygenation/ventilation and acid-base status

An arterial blood gas (ABG) test measures the acidity

(pH) and the levels of oxygen and carbon dioxide in the
blood from an artery. This test is used to check how well
your lungs are able to move oxygen into the blood and
remove carbon dioxide from the blood.
 ABG Components
PaO2 Partial pressure of O2
PaCO2 Partial Pressure of
Normal: 80 - 100 mmHg pH
CO2
Measures the effectiveness of the Normal 7.35 - 7.45
Normal: 35 - 40 mmHg
lungs in oxygenating the blood. The pH measures
Reflects effectiveness of
Reflects ability of lungs to diffuse hydrogen ions (H+) in
ventilation (movement of air
inspired oxygen across the blood. The pH of blood
into and out of lungs).
alveolar membrane into the is usually between 7.35
circulating blood and 7.45. A pH of less
HCO3
than 7.0 is called acid
Normal: 22 - 26 mEq/l
SaO2 Oxygen saturation and a pH greater than
Bicarbonate is a chemical
Normal: 95-100% 7.0 is called basic
(buffer) that keeps the pH of
% of hgb that is saturated with (alkaline). So blood is
blood from becoming too
oxygen. slightly basic.
acidic or too basic.
 Contraindication
Absolute Contraindication
1. Local infection or distorted anatomy at the potential puncture site (eg, from
previous surgical interventions, congenital or acquired malformations, or burns),
2. The presence of arteriovenous fistulas or vascular grafts, in which case arterial
vascular puncture should not be attempted
3. Known or suspected severe peripheral vascular disease of the limb involved

Relative contraindications
1. Severe coagulopathy
2. Anticoagulation therapy with warfarin, heparin and derivatives, direct thrombin
inhibitors, or factor X inhibitors; aspirin is not a contraindication for arterial
vascular sampling in most cases
3. Use of thrombolytic agents, such as streptokinase or tissue plasminogen
activator
 ABG SAMPLING TECHNIQUE
BEFORE SAMPLING

1. Confirm the need for the ABG and identify any contraindications

2. Always record details of , therapy and respiratory support

3. Unless results are required urgently, allow at least 20 minutes after any
change in U2 therapy before sampling (to achieve a steady state).

4. Explain to the patient why you are doing the test, what it involves and the
possible complications (bleeding, bruising, arterial thrombosis, infection and
pain); then obtain consent to proceed.
 ABG SAMPLING
TECHNIQUE
BEFORE SAMPLING

4. Prepare the necessary equipment

(heparinized syringe with cap, 20-22G
needle, sharps disposal container, gauze)
and don universal precautions.

5. Identify a suitable site for sampling by

palpating the radial, brachial or femoral
artery. Routine sampling should, initially,
be attempted from the radial artery of the
non-dominant arm
 ABG SAMPLING TECHNIQUE
RADIAL ARTERY SAMPLING

1. Perform a modified Allen test to ensure adequate collateral circulation

from ulnar artery

2. Position the patient's hand as shown in Figure 19 with the wrist

extended 20-30". Greater extension of the wrist may impede arterial
flow.
3. Identify the radial artery by palpating the pulse; choose a site where the
pulse is prominent.

4. Clean the sampling site with an alcohol wipe.

5. Expel the heparin from syringe.

 ABG SAMPLING TECHNIQUE
RADIAL ARTERY SAMPLING

4. Steady your hand on the patient's hand, as shown, then insert the needle at
45*, bevel facing up.* Be sure to insert the needle slowly to minimize the
risk of arterial spasm.

5. When the needle is in the artery a flash of pulsatile blood will appear in
the barrel of the needle. Most ABG syringes will then fill under arterial
pressure (see info box over page).Obtain at least 3 mL of blood before
withdrawing
 ABG SAMPLING TECHNIQUE
AFTER SAMPLING
1. Once adequate blood has been obtained, remove the needle and apply
firm, direct pressure to the sample site for at least 5 minutes and until
bleeding has ceased.
2. Dispose of all sharps and contaminated materials appropriately.
3. Ensure that no air bubbles are present in the sample, as they may
compromise results. Any sample with more than very fine bubbles
should be discarded
4. The sample should be analyzed promptly: if the transit time is likely to
exceed 10 minutes, then the syringe should be stored on crushed ice.
5. If sampling is unsuccessful it is often advisable to repeat the test on the
opposite wrist as even slight irritation of the artery on the first attempt
may have provoked arterial spasm, thwarting further attempts at
puncture
 ABG
Interpretation
INTUBATION
 Intubation
ENDOTRACHEAL INTUBATION is the
placement of a special tube in the trachea. The
breathing tube is inserted into the trachea through
the vocal chords. This is normally performed under
direct vision with the aid of a laryngoscope. The
tube is usually passed through the mouth (oro-
tracheal intubation) occasionally it is passed
through the nose (naso-tracheal intubation).
 Indication of Intubation
1. To secure the airway

2. To supply oxygen

3. General Anesthesia

4. Cardiopulmonary Resuscitation

5. Ventilatory Therapy in the ICU

EQUIPMENTS
 LARYNGOSCOPE AND BLADES
Laryngoscope is a device used to visualize the vocal
cords to facilitate intubation

USE
• Visualization the vocal cords to allow insertion of
an endotracheal tube
• Also useful for insertion of a gastric tube by lifting
the larynx forwards.
 Description
• Base of blade (attaches to handle and makes an electrical
connection when extended)
• Hook of blade
• Curved or Straight blade
• Flange (containing web and light source) – proximal flange
to sweep the tongue aside
• Tip
• Handle tip containing electrical connection and connection
for hook
• Green line
• Handle containing batteries
 Method of Insertion/Use
• with a curved blade the tip is placed in the
vallecula behind the epiglottis

• with a straight blade the tip is used to lift the

epiglottis directly to reveal the cords (useful in
pediatrics as small children have long floppy
epiglotti
 Handles
• Standard size handle
• Short handle — useful for short necks, barrel
chests and large breasts such as obstetric or
obese patients (often with a Kessel blade)

Penlight
• thinner diameter, works better with smaller
blades
 Blades
• MACINTOSH (commonest; blade attaches to handle
at 90 degrees)
• KESSEL (like the MacIntosh but the blade attaches
at 110 degrees)
• MCCOY (MacIntosh like blade with a moveable
distal tip segment, flexed by a lever controlled by the
thumb of the hand holding the handle to displace the
larynx forwards)
• MAGILL (straight blade with U-shaped cross
section)
 Blades
• MILLER AND WISCONSIN BLADES (straight
blades with curved tips)

• Disposable metal and plastic blades available

• Right-handed blades available for left handed people
Mccoy

Magill
Kessel
 PREPARING THE PATIENT
1. Inform the patient of the procedure.
2. Pre-oxygenate the patient. Intubation should take no longer than
30 seconds and should be preceded by ventilation with a high
concentration of oxygen, ideally at least 85%, for a minimum of 15
seconds. In a controlled environment pre-oxygenation generally
takes longer. The aim is to maximize the patient’s KPaO2 (partial
pressure of oxygen) as the patient will be unable to maintain any
respiratory effort.
3. This is often the most frightening time for the patient. To ensure
they stay calm they have a hand-held facial mask over the nose and
mouth, medical/nursing staff standing behind them issuing
instructions, and a change of position to facilitate the process.
 PREPARING THE PATIENT
4. The bed head should be removed and the patient’s position flat
with their face at the level of the xiphoid cartilage of the standing
person performing the procedure. A small pad/pillow should be
placed under the occiput.

5. Extend the head at the atlanto-occipital joint, which aligns the

oral, pharyngeal, and laryngeal axis so that the passage from the
lips to the glottic opening is virtually a straight line and the patient
adopts the classic ‘sniffing the morning air’ position
 THE CRICOID PRESSURE
Before the procedure, the team
should discuss applying cricoid
pressure. This compresses the
cricoid cartilage against the
cervical vertebrae, preventing
gastric reflux and aspiration.
The cricoid cartilage lies just
below the Adam’s apple and
may be difficult to find.
 Nursing Intervention

Indicate when the patient last ate, and

whether a nasogastric tube is in situ,
when it was aspirated and what volume
of gastric contents the patient has
produced.
 Precautions
1. Once cricoid pressure is applied, it must not be removed without the
consent of the person intubating, even if the ET tube appears to be
inserted. The tube may be in the wrong place and removal of cricoid
pressure may lead to vomiting.

2. Do not apply cricoid pressure to a vomiting patient, as this can cause

damage to the esophagus

3. Do not remove cricoid pressure prematurely. Aspiration during

intubation is disastrous for the patient.

4. If you are right-handed it is easier to stand to the patient’s right and

apply cricoid pressure with the right hand.
5. The patient’s chest should be observed for equal expansion and
auscultation performed at the mid-axillary line (ERC, 2001). Be
suspicious if only one side of the chest expands, as this may indicate
that the tube has been pushed in too far. This is more likely to occur
into the right main bronchus, due to its anatomical position.
6. The tube should be secured, the patient attached to an appropriate
ventilator and a check X-ray ordered. A high concentration of
oxygen should continue and arterial blood gases should be taken.
7. Appropriate humidification is required, as the tube bypasses the
upper airway - responsible for warming, moistening and filtering
inhaled air. 8. Finally, the patient should be cared for on a one-to-one
basis and closely monitored.
 POST-INTUBATION COMPLICATIONS
a. Trauma to lips, teeth, vocal
chords
b. Transient cardiac arrhythmia
related to vagal or sympathetic
nerve traffic
c. Hypertension, tachycardia or
raised intracranial pressure
d. Aspiration
e. Esophageal intubation
f. Infection g. Reduced cough
reflex h. Tracheal ulceration
I. Tracheal stenosis
j. Hypersalivation
k. Laryngeal edema
l. Bronchospasm
m. Reduced ability to
communicate
n. Biting on tube
o. Discomfort
p. Tube kinked or damaged
on insertion, resulting in
perforation and leaks