Airway Management in Patients

DISCUSS AIRWAY MANAGEMENT IN THE INJURED AND CRITICALLY ILL PATIENTS IN THE CONTEXT OF PREHOSPITAL CARE AS PER YOUR ECT SCOPE

Airway management is one of the first priorities in the emergency care. Failure to manage the airway in a given time approximately 6 minutes can lead to hypoxic brain injury or even death. First step for airway management differs in terms of trauma emergency or medical emergency. Medical emergency method of establishing a patent airway is head tilt chin lift maneuver in an unresponsive patient.

For trauma emergencies, patient are highly suspected of cervical spine injuries therefore the method used to establish a patent airway is jaw thrust maneuver while providing in line cervical spine immobilization. Airway management includes assessment, establishment and protection of the airway in combination with effective oxygenation and ventilation.

Assessment of airway patency focuses on determining whether the airway is open (meaning that there are no obstructions or secretions in the mouth) and the airway is protected.

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Observing the level of consciousness of the patient is also important during airway management, to assess the level of consciousness Glasgow coma scale is used. Airway management also focuses on determining whether breathing is present, spontaneous and adequate. If spontaneous breathing is noted the IPAP method is used for assessment. Inspection for bilateral chest rise and fall, inspect the color of the mouth or lips, percussion for normal resonance or dullness or hyper/hypo- resonance, palpate the chest for deformities and auscultate for equal air entry and breath sounds.

INDICATIONS OF AIRWAY MANAGEMENT

• Respiratory failure (hypoxic or hypercapnic)
• Apnea
• A reduced level of consciousness
• Rapid change of mental status
• Airway injury or impending airway compromise
• High risk of aspiration or trauma to the box which includes penetrating injuries to the abdomen or chest cavity
• Inability to maintain or protect the airway" (Mahandevan S.
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  V, Garmel Gus M, page 23, 2012)

• Failure of oxygenation and ventilation
• Patient safety and protection
• Potential for deterioration based on the patients clinical presentation

CONSIDERATIONS OF AIRWAY MANAGEMENT

1. Cervical spine immobilization for trauma patients
2. Positioning patient in a sniffing position
3. Assessing for a difficult airway
4. Assessing the anatomical structure of the airway
5. Obese patients
6. Stomas
7. Penetrating neck trauma

THE THREE AXIS ALIGNMENT THEORY IN AIRWAY MANAGEMENT

"Good alignment of the airway that comes out of optimal positioning of the head and neck is essential for an adequate laryngeal view during direct laryngoscopy. The combination of flexion at the atlanto-axial joint and extension at the atlanto-occipital joint is also known as the sniffing position. Sniffing position is known to providing better laryngeal view. It is the accepted maneuver for aligning the three axis (oral, laryngeal and pharyngeal). It also helps to maintain airway patency, facilitating good bag mask ventilation".

Sniffing position is considered as it helps extend the head and flex the neck for aligning so as to be able to see the axis from the oropharynx to the glottis. This is important to use in obese patient and apneic patient who have narrow pharyngeal airways.

VORTEX APPROACH

Is a tool used and designed to monitor management of difficult airway. The vortex is simple which is designed to be used by paramedics in real time during airway emergencies. It is used to recognize failing's airway crisis during management. The vortex model is used to guide the airway practitioner through the non-surgical airway techniques i.e. face mask, LMA,SGA and endotracheal intubation.

Use of strategies like manipulation e.g. jaw thrust, sniffing position, use of adjuncts e.g. NPA,OPA, changing the size and type of device and suctioning of the airway to remove blood, secretions or foreign materials can be used before attempting the use of face mask, intubation and supraglottic devices.

"If one of the airway techniques result in confirmation of oxygen delivery, one moves out of the vortex into the green zone. The green zone is conceptualized as an airway "time out" during which alternative options can be explored including waking the patient or establishing a definitive airway via noninvasive or surgical means. If practitioner is unable to establish adequate oxygenation and ventilation by facemask, SGA or ETT within three attempts at any technique, the practitioner proceeds down the vortex". (Page 16, 2015, Berkow and Sakles)

FEATURES OF THE VORTEX

THE GREEN ZONE

The green zone is when the patient is able to protect his or her airways or the airway is patent. The patient is no longer at a risk of oxygen desaturation. There is adequate alveolar oxygen deliver therefor the clinician is advised to maintain the airway in the green zone and to replace oxygen levels in the alveoli.

THE FUNNEL

The funnel symbolizes that the patient is not able to protect their airway meaning the airway is not patent either there are obstructions or secretions in the mouth.it also means that the patient is not safe and has limited time if the problem is not fixed immediately which can lead to hypoxia. As the funnel narrows it shows that the patient status is compromised and there is desaturation which will lead to use of surgical means in order to maintain the airway.

BASIC AIRWAY ADJUNCTS

FACE MASK

SIMPLE FACE MASK

A basic disposable mask which delivers oxygen at a rate of 6-10 liters per minute.

NASAL CANNULA

Has two prongs projecting from a hollow face piece and delivers oxygen at a lower rate compared to simple face mask.

NONREBREATHER MASK

This are mask that delivers oxygen at a rate of 10-15 liters per minute and have an elongated reservoir bag.

INDICATIONS OF FACE MASK

• Conscious patient who have a difficult in breathing
• Patients with low SpO2

CONTRAINDICATIONS

• Unconscious patient who cannot ventilate
• Cardiac arrest

BAG MASK VENTILATION

Is a consideration in every airway management as it provides positive pressure ventilation. BVM can be used for resuscitation of patients with respiratory distress or difficult airway following the vortex approach.

INDICATIONS

• Unconscious patient
• Apnea
• Respiratory failure or respiratory distress" (page 37,2010, Gregory and Mursell)

CONTRAINDICATIONS OF BMV

• complete upper airway obstruction
• paralysis and induction(because of the increased risk of aspiration)
• severe facial trauma and eye injuries

ADVANTAGES OF BMV

• easier to use
• provides positive pressure ventilation
• delivers 100% oxygen at all times

DISADVANTAGES OF BMV

• requires a reservoir to deliver 100% oxygen
• will inflate even without adequate seal

COMPLICATIONS OF BMV

• hyperventilation
• gastric distention
• aspiration
• claustrophobia
• barotrauma

LITERATURE REVIEW

According to my understanding I strongly believe that BVM is the quickest in performing ventilations and also believe that it provides positive pressure ventilation. If ventilations are exceeded it can cause accumulation of air in the stomach.

OROPHARYNGEAL AIRWAY (OPA)

"Is a curved plastic device that is inserted over the tongue into the posterior pharynx. OPA is used when unconscious patient is at risk of developing airway obstruction or is used to prevent the tongue or the epiglottis from falling back against the posterior pharynx and occluding the airway in an unconscious patient or heavily sedated patient". (Page 79, 2013, Hammond and Zimmermann)

INDICATIONS OF OPA

• Absent gag reflex
• Unconscious patient

Patient at risk of airway obstruction because their upper airway muscles have relaxed or the airway is blocked by the tongue

CONTRAINDICATIONS OF OPA

• Present gag reflex
• Conscious patient
• Obstructions in the airway

ADVANTAGES OF OPA

• Prevents the tongue from falling back and occluding the airway
• Prevents patient from biting their tongue or grinding their teeth" (page 7,2013,Hammond and Zimmermann)
• Easy placement
• Can be suctioned through

DISADVANTAGES OF OPA

• Unexpected gag reflex can cause vomiting
• Does not prevent aspiration
• Pharyngeal and dental trauma with poor technique

LITERATURE REVIEW

According to me, I think OPA helps in maintaining a patent airway as it avoids the tongue from falling back and help deliver oxygen when used with BVM.

NASOPHARYNGEAL AIRWAY (NPA)

"Are made of soft semi rigid rubber and are inserted through a non-obstructed nostril to provide air passage between the nose and nasopharynx" (page 79, 2013, Hammond and Zimmermann)

INDICATIONS OF NPA

• Unconscious patient
• Altered mental status with suppressed gag reflex

CONTRAINDICATONS OF NPA

• Suspected basal skull fractures
• Epiglottitis
• Apnea/ impending respiratory arrest
• Patients prone to epistaxis

• Patients undergoing anticoagulation or antiplatelet therapy" (page 62, 2017, Wiegand)
• Patients who have nasal fractures or an active bleeding nose

ADVANTAGES OF NPA

• Can be suctioned through
• Ease and rapidity of insertion
• Increased comfort and the tolerance in a conscious patient" (page 62, 2017, Wiegand)

DISADVANTAGES OF NPA

• Does not protect the airway from aspiration
• Poor technique can results in severe bleeding

COMPLICATIONS OF NPA

• Epistaxis
• Laryngospasm
• vomiting

LITERATURE REVIEW

"According to K Roberts, H Whalley and A Bleetman the NPA is a simple equipment that is easily used as it does not require much knowledge and it is cheap".

SUCTIONING

"Is used when patients are unable to control or mobilize their secretions such as blood or saliva, vomitus and also to remove foreign objects. To maintain a patient airway suctioning of the nasopharynx and trachea is required."

INDICATIONS OF SUCTIONING

• Clearance of secretions, foreign objects, vomitus or blood in the airway
• Suspected aspirations of gastric content or secretions
• Increased work of breathing or respiratory distress
• To clear secretions via endotracheal tube" (page 85, 2013, Hammond and Zimmermann)

CONTRAINDICATIONS OF SUCTIONING

Severe bleeding disorder, unexplained hemoptysis

Severe bronchospasm or laryngeal spasm

• Epiglottitis
• Basal skull fractures
• Hemodynamic instability
• Nasal bleeding
• Increased intra-cranial pressure

ADVANTAGES OF SUCTIONING

• improves breath sounds
• Decreases work of breathing
• Improves SaO2
• Removal of pulmonary secretions

DISADAVANTAGES OF SUCIONING

• Increased intracranial pressure
• atelectasis
• hypoxia
• cardiovascular changes

COMPLICATIONTS OF SUCTIONING

• Hypoxaemia
• Laryngospasm
• Bronchospasm

Damage to the mucosa, leading to risk of bleeding

LITERATURE REVIEW

I think suctioning is the best when it comes to aspirating secretions from the mouth or blood but can cause complications when ones suction the mouth for more than 10 seconds.

ADVANCED AIRWAY ADJUNCTS

LARYNGEAL MASK AIRWAY

ADVANTAGES OF LMA

• Increased speed and ease placement
• Improved hemodynamic stability during insertion
• Avoids compression of facial nerves
• Does not require manipulation of the patients head, neck and jaw
• Less skill is required to achieve and maintain effective positive pressure ventilation (PPV)
• Less hand fatigue

DISADVANTAGES OF LMA

• Gastric insufflation and aspiration
• Inadequate alveolar ventilation
• Impossibility of suctioning the airway or administering drugs endotracheal

INDICATIONS OF LMA

• Resuscitation of an unconscious patient
• Management of a known or unexpected difficult airway" (
• Correction of hypoxemia or hypercarbia
• Provision of controlled hyperventilation
• Provision of a secure airway in the presence of obstructions

CONTRAINDICATIONS OF LMA

• Patient at risk of aspiration of gastric contents, such as patients with a full stomach or symptomatic gastro esophageal reflux disease.
• Patient with decreased respiratory system compliance
• Patients with intact upper airway reflexes because insertion can precipitate laryngospasm".
• Patients with a mouth opening inadequate to permit insertion
• Patients who have ingested caustic substances" ( page 53, 2017, Wiegand)

LITERATURE REVIEW

• According to Emma Flavell BN, RN Dr Malcolm J Boyle LMA is most effective at ventilating overtime during CPR in adults as it indicates less risk gastric regurgitation and pulmonary aspiration".

NEEDLE CRICOTHYROTOMY

• The delivery of oxygen to the lungs through an over the needle catheter inserted through the skin into the trachea using a high pressure gas source".
• An incision made through the skin and cricothyroid membrane to establish a patent airway during certain life threatening situations such as airway obstruction by a foreign body, angioedema or massive facial trauma".

INDICATIONS

• Inability to maintain the airway with noninvasive standard airway procedures
• Respiratory failure
• Airway obstruction proximal to the sub glottis
• Inability to maintain SpO2>90%
• Severe traumatic injury that prevents oral or nasal tracheal intubation

CONTRAINDICATIONS

• Laryngeal cancer
• Tracheal rupture
• Laryngeal injury with known damage to the cricoid cartilage
• Airway obstruction distal to sub glottis
• Inability to identify surface landmarks (thyroid cartilage, cricoid, cricothyroid membrane) due to e.g. obesity, cervical trauma

COMPLICATIONS

• Subcutaneous emphysema
• Pulmonary barotrauma

CONCLUSION

Airway management is considered the first priority in the pre hospital care of critically ill and injured patients because failure to obtain patent airway or protect patient's airway can lead to many complications and eventually death. A patent airway can be established either by head tilt chin maneuver (medical patients) and jaw thrust (trauma patients). The three axis alignment (oral ,laryngeal and pharyngeal axis) which is also known as the sniffing position is used to provide a patent airway and it also gives a better view in the larynx, it is best at maintaining good bag mask ventilations. Providing patent airway and protecting it can be managed using the vortex approach which is used to choose which airway adjuncts will best protect and maintain a patent airway and if the chosen adjuncts fails to do so which other option can be used. OPA (oropharyngeal airway), NPA (nasopharyngeal airway), BMV (bag mask ventilation) and suctioning are known as the basic airway adjuncts used in airway management. The advanced airway adjuncts includes the LMA (laryngeal mask airway) and needle cricothyrotomy.

REFERENCES

1. Mahadevan S.V, Garmel Gus M, 2012, second edition, Introduction to clinical emergency medicine, Cambridge University
2. Hammond B. Belinda, Zimmermann Polly Gaber, 2013, seventh edition, Sheely's manual of emergency care
3. Debra L Wiegand, 2017, seventh edition, Procedure manual for high acuity, progressive and critical care
4. Nicholas Chrimes, Peter Fritz, 2013, The vortex approach: management of the unanticipated difficult airway
5. Emma Flavell BN, RN Dr Malcolm J Boyle, 2010, vol 8, Journal of Emergency Primary Health Care
6. Lauren C. Berkow, John C. Sakles, 2015, Cases in emergency airway management
7. Pete Gregory, Ian Mursell , Manual of clinical paramedic procedures
8. Ron M. Walls, Michael F. Murphy, 2012, Manual of emergency airway management