Manging airway
Airway Anatomy
Learning objectives
By the end of this article you will be able to:
•Explain factors thats affect airway patency and the step-wise appriach to airway management.
•Explain how to perfome a range of manual airway manoeuvres.
•Describe the equipment required for suction and its safe use.
Introduction
More often than not, you patient will ve concious and able to talk,scream or cry, indication that they have a patent airway. For some, however, you will need to assisst them in opening and maintaining their airway. Basic manoeuvres with nothing more than your hands are often enough to open and keep open a patient's airway, but things can changes and its is important that you frequently reassess airway patency.
In this section , you are going to explore the following airway manoeuvres,which may be familiar if you have undertaken a first aid :
•Head tilt-chin lift
•Jaw thurst
•Jaw thrust with head tilt
•Recovery position
•Once these have been covered , we will move on to more invasive procedures:
•Suction
•Oropharyngeal airway
•Superaglottic devices.
Manual airway manoeuvres
Manual airway manoeuvres can be achived with your ( or a colleague's) hands. They are great for the intial mangagement of the airway , and in some cases may be all thats is required .
Head tilt-chin lift
When to do it(indications)
• If the patient has a suspected spinal injury.
Advantages
•no equipment id required .
•Technique is simple and non-invasive.
Disadvantages
•Does not protect the airway from aspiration
•No suitable for the patients with cervical spinal injury.
Procedure :
I.with your patient laying on their back(supine) , position yourself at the patient's side . Place the hand closer to the patient's head on their forehead and gently tipt the head backwards.
II. Place two fingers on the bony part of the chin and gently lift upwards.
Jaw thrust
When to do it(indication)
•An unresponsive patient who has an airway obstruction caused by loss of pharyngeal muscle tone.
When not to do it (contra-indications)
•An responsive patient unless they have a fractured jaw.
Advantages
•No equipment is required
•technique is sample and non-invasive
•maintains neutral alignment of the head when cervical spinal injury suspected.
Disadvantages
•Does not ptotect the airway from adpiration
•Difficult to maintain for prolonged priods
•Requires second person to provude ventilations is required.
Procedure: take the following steps to perfom a jaw thrust,
•With your patient laying on their back(supine), position yourself at the patient head.
•identify the angle of the mandible
•place your fingers behind the mandible and lift in an upwards and forwards direction.
•Using your thumb , open the patient mouth.
Jaw thurst with head tilt when to do it(indications)
•An unresponsive patient who has an airway obstruction caused by loss of pharyngeal muscle tone and jaw thurst alone is most sufficient to open the airway.
When not to do it( contra-indications)
•A responsive patient .
Advantages
•No equipment is required.
•Technique is simple and non-invasive.
Disadvangtes
•Does not protect the airway from aspiration
•Difficult to maintain for prolonged periods
•Requires second person to provide ventilations, is required.
Procedure:
Take the following steps to perform a jaw thurst with head tilt;
•with your patient laying on their back ( supine), position yourself at the patient's head
•identify the angle of the mandible
•place your fingers behind the mandible and lift is an upwards and forwards direction
•Using your thumbs open the patient's mouth
•Tilt the head backwards.
Recovery position :
There are a number of variations of the recovery position. This is the method that the european resuscitation council recommend.
Procedure;
Take the following step to place a patient in the recovery position :
•Kneel beside the patient and strighten both of their legs
• place the arm nearer to you at right angles to their body,with the arm bent at the elbow and palm of the hand facing upwards.
•Bring the other arm across the chest and hold the back of their hand against the cheek that is nearer to yoy .Don't let go.
•With your other hand, grasp the leg futher away from you just above the knee and lift upwards so the leg flexes. Keep the foot on the ground.
•while supporting the head, pull the leg towrds you,so that the patient rolls to face you.
•adjust the upermost leg so that the patient's hip and knee are bent at right angles.
•Tilt the head back to ensure the airway remains open .
• Adjust the patient's hand that is under their cheek,if required,to maintain head tilt and keep the patient facing slightly downwards, to allow free drainage of secretions from the mouth , reassess frequently.
Suction
If you can hear gurgling in the airway,than you should think suction. Suctioning an airway involves removing vomit,blood and secretions with suctioning equipment. On your ambulance, you will usually have a mains operated/battery powered suction unit and hand-operated devices. Make sure your are familiar with the operating instructions for the devices you carry.
Suction catheters
You are likely to have two types of suction catheters on the ambulance : a rigid,wide-bore catheter ( sometimes called a Yankeur) and a smaller ,flexible catheter which can fit down an oropharyngeal or nasopharyngeal airway, but is limited by its small size and is unsuitable for blood and vomit.
When do it(indications)
•In patients who cannot maintain and clear their own airway and in whom vomit, blood or secretions are at risk of entering the lower respiratory tract.
When not to do it( contra-indication)
•In patients who can maintain and clear their own airway.
Advantages:
•prevents aspiration of vomit,blood and secretions.
Disvantages:
•suctioning removes air as well as secretions,keep suction times short.
Procedure:
Take the following step to perform suction using a mechnical suction devices;
1. Prepare your equipment .you will need;
•suction unit .
•Yankeur and aoft-tip catheters and suction tubing.
•Gloves
•Protective eyewear.
•Oxygen.
2.explain the procedure to patient and obtain consent if concious .
3.pre-oxygenate if possible .
4.put on gloves and eyewear.
5.attach suction tubing and catheters and switch on suction unit if using a mechnical device.
6.open the patient's mouth and insert the catheter into their mouth without auctioning . Make sure you can visulaise the end of the suction catheter at all times.
7.apply suction by occluding the control vent on the catheter (mechnical device) or squeezing the handle (hand-operated device) and genlty withdraw the catheter . Suction for no more than 15 seconds.
8. Re-oxygenate the patient and reassess the airway. Further suction attempts may be required .
Note:
There is no clear guidance on suction pressure for the emergency mangement of patients. If you only need a clear small amounts of saliva, than a suction pressure 150-200mmHg is sufficient . However,in cases where there is a large amount of blood or vomit , turn the suction up to maximum intially and adjust downwards. Is cases of sever bleeding or active vomiting, positioning the patient to allow for postural drainage is more important: for example ,turning a patient onto their side when they are immobilised on a spinal board. Altough prolonged suctioning will cause hypoxia ( which is why suctioning for no more than 15 seconds is suggested), an airway obstructed by blood or vomit will not allow any air exchange and is likely to result in aspiration. In this case patient positioning and aggressive suction will be required untill the airway is at least partially clear, re-oxygenation can then be performed and suction repeated as required . Follow the guidance of the clinician on scene.
Airway adjuncts
Airway adjucts are devices thats assist in the airway management . Probably the most commonly used airway adjuncts is the oropharyngeal airway,but there are others such as the nasopharyngeal airway and bougie,which you may see clinicians using.
Oropharyngeal Airway(OPA)
When to do it(indications)
•An unresponsive patient with an absent gag reflex.
When not do it(contra-indications)
•Any patient who has a gag reflex.
Advantages:
•Easy to place
•Technique is simple and non-invasive.
Disadvantages:
•Tongue can be pushed back during insertion , making obstruction worse.
•Does not protect against vomiting.
Procedure:
Take the following step to insert an oropharyngeal airway.
1.Slect the correct size OPA by measuring the vertcal distance between the patient's incisors and the angle of the jaw.
2.Open the patient's mouth and check it is clear of foreign bodies,vomit,blood or secretions . Suction if required .
3. Insert the airway 'upside down' along the roof the mouth until it reaches the soft palate.
4. Rotate the OPA through 180°
5.Advance the OPA until it rests in the pharynx. Remove immediately if the patient gags. Continue to provide manu manoeuvres such as head tilt-chin or jaw thrust as appropriate.
Tracheostomies
Learning objectives
By the end of this article you will be able to :
* diff b/w laryngectomy and trachacheostomy
*Describe how to manage the airway of a patient with laryngectomy or a trachacheostomy.
Introduction:
A tracheostomy is an opening made into the trachea through the neck . Patients have them insterted for a number of reasons including.
• Following Trauma or surgery to the head and neck which leads to an airway obstruction.
•Bypassing a tumour which obstructs the upper airway .
•For prolonged ventilation.
• For some types of chornic disease where minimising the anatomical dead space is beneficial.
• To provide access to chest secretion in the event to respiratory insufficiency.
•To protect from aspiration in the event of impaired swallow reflex (for example, neuromuscular disorder).
As name suggests, a laryngectomy is the removal of the larynx. This is typically due to involvement of the larynx in oral, pharyngeal and laryngeal cancers. If the patient requires a total laryngeal , the larynx is removed and the trachea cut and stitched to the front of the neck . This is important for subsequent management, because these patients cannot be ventilated from the mouth and/or nose .
Tracheostomy tubes
There are a wide variety of tracheostomy tubes, which can seem rather overwhelming. However, tube are broadly classified into the following categories;
• Cuffed/uncuffed
• with/without inner cannula
• Fenestrated/unfenestrated
Cuffed/uncuffed tube :
As wuth adult endotracheal tubes, a cuffed tracheostomy tube has a soft ballon around the distal end, which is inflated by injecting air into the pilot ballon via the injection port. These are used when patient's require positive pressure ventilation (PPV) and/or when the patient cannot protect their own airway from secretions. Note that if the cuffed tube is inflated and the lumen become blocked or occludes, the patient will not ge able to breathe!
Uncuffed tubes tend to be used in longer-term patients,but since they lack the cuff, it is important that these patients have an effective cough and gag reflex to minimize the chance of aspiration. These tube are not suitable for positive pressure ventilation.
Inner cannulas:
Tracheostomy tubes with an inner cannula (sometimes called double-cannula or double-lumen tubes) consist of an outer tube or cannula which maintain airway patency,and an inner cannula,which can be removed for cleaning and/or disposed of and replaced. Uncuffed ,double-cannula tracheostomy tubes are the saftest type to use in the community.
Fenestrated tubes:
These tracheostomy tubes have an opening on the outer cannula which allows air to pass through the patient's oropharynx and nasopharynx. This is helpful because it allows the patient to talk and produce an effective cough. However, fenestrations increase the risk of aspiration and prevent positive pressure ventilation unless a non-fenestrated inner cannula is used . Non-fenestrated inner cannulas should also be used if the patient requires suction.
Management of the tracheostomy patient:
Patients with tracheostomy have a potentially patent upper airway, since the upper airway and trachea are anatomically connected. However, it is quite possible that the reason the patient had a tracheostomy in the first place is that their upper airway is difficult or impossible to manage.
Help and equipment:
The clinician will not be able to manage on their own and you assisstance is vital . If a relative or carer is present , it is quite possible that they know more about tracheostomy management than you do , so listen to their advice and encourage them to help.
Patient may well have equipment to hand , such as replacement tubes, but you can manage with the equipment from your vehicle:
•Airway adjuncts such as oropharyngeal and nasopharyngeal airways
•Bag-valve-mask
•Supraglottic airway devices
•Laryngoscope and endotracheal tubes
•Gum-elastic bougie
•Monitor capable of waveform capnograpy.
Airway and Breathing:
Check and open the upper airway as normal . Look ,listen and feel for breathing at the face and tracheostomy site for no more than 10 seconds. Apply waveform capnograpy to the tracheostomy tube as soon as possible.
If the patient is breathing, apply high-flow oxygen to both face and trachacheostomy. This may require two cylinders, or the addition of a flowmeter into the Schrader valve of the oxygen cylinder. If tge patient is not breathing, making agonal gasps or there are no signs of life, start chest compressions and follow the basic / advanced life support (BLS/ALS) Algorithms while continuing to troubleshoot the tracheostomy, since this may be the cause of the cardic arrest .
Tracheostomy patency :
Start by checking for and removing the following:
•Decannulation caps (used when removing tracheostomies) block the end of the trachacheostomy
•Obturators (inserted inside the trachacheostomy when first inserting a tube into the patient).
•Speaking valves , which should not be used with an inflated cuffed tube.
•Blocked humidification devices such as Swedish noses.
If the trachacheostomy tube is a double-cannula design , remove the inner cannula, but remember that which some types of tubes the connector required for bag-mask ventilation is mounted on the inner cannula. Pass a suction catheter through the tube and into the trachea to check patency. Its should pass easily through the tube. Don't use a gum-elastic bougie at this stage as it is more rigid than a suction catheter and might create a false passage in cases where the tube is misplaced. If the suction catheter passes through the tube, suction the tube and attempt to ventilate the patient. If this fails and the tube has a cuff, deflate it and reassess the patient using the same look,listen and feel technique as before at both the face and the stoma site.
Next step :
If everything attempted thus far has failed to improve the patient's condition, remove the tube. Reassess the patient again and hopefully they will be breathing. If the patient is in cardic arrest continue with BLS/ALS . Attempt to oxygenate tje patient via the oral route , but don't forget to cover the stoma site with swabs or a gloved hand. Use standard airway adjuncts to vehicle effective ventilation. Alternatively , paediatric face-mask or supraglottic airway devices (SAD) can be placed over the stoma and the patient ventilated. If there is a large air leak from the mouth and/or nose ,occlude them both during PPV.
If it is possible to effectively ventilate the patient than a suitable clinician will need to attempt endotracheal intubation. This may be possible via the oral route , although they should expect it to be difficult. Use an uncut tube as it will need to be inserted further than normal in order to bypass the stoma.
In patients with an established tracheostomy or who have a known upper Airway problem that is going to make intubation difficult , it can actually be more straightforward to simply insert another , smaller diameter tracheostomy or endothracheal tube into the stoma . Always use capnograpy as well as bilateral chest rise to confirm correct placement
Choking in adults
Learning objectives
By the end of this article you will able to:
•Define choking and list some common causes
•State the sign that an adult is choking
•Describe the procedure for managing the choking adult.
Introduction:
Choking is a mechnical obstruction of the airway occurring anywhere between the mouth and carina (where the left and right bronchi split from the trachea). Common cause include:
•Foreign bodies
•Blood
•Secretions
•Teeth
•Vomit
It is not known how common choking is in adults. Death from choking in thankfully rare, mostly because choking episode are witnessed. In england and Wales, around 370 people die each year as a result of a foreign body in the respiratory tract. Most of these are over 65 years of age.
Recognition:
The sign of choking in an adult depends on the severity of the airway obstruction that has occurred. Typically, the episode will have occurred while eating,and of the patient is still concious they may cluth their neck.
In the case of mild airway obstruction,if you ask the patient if they are choking,they will still be able to speak and confirm that this is the case. They will also be able to breathe and cough. However,in case of sever airway obstruction, the patient will be unable to speak,so may only be able to respond to you by nodding their head in response to your question about whether they are choking. Any attempts at coughing will be silent,and if this continues the patient will lose consciousness, possibly before your arrival.
Management:
Start by determining the severity of the obstruction. In adult, this is typically determined by the patient's response to the question" are you choking? A patient who can reply"yes" i.e. can speak , cough and breathe, is classified as mild, whereas the patient who is clutching their throat, is unable to speak and who cannot breathe falls into the severe category.
Conscious and choking:
If the patient is coughing,do not perfom any intervention other than encouraging the patient to continue coughing.
If the obstruction is severe, administer up to five back blows, by standing just to the side and slightly behind the patient, leaning them forward, and than administering sharps blows between the shoulder blades with the heel of one hand.
If this fails , move on to abdominal thrusts. Position yourself behind the patient and place a clenched fist just under the xiphisternum. Grasp the fist with your other hand and pull sharply upwards and inwards up to five times.
Repeat the back blows/abdominal thrusts until the obstruction in relieved, or the patient become unconcious.
Unconscious and choking:
Lay the patient on their back and start chest compressions and ventilations at a rate of 30:2. If you are working with paramedic,they may decide to attempt laryngoscopy in order to directly view the obstruction and clear it with forceps or suction. Before each set of ventilation check the mouth to see whether the chest compressions have expelled the foreign body, enabling you to remove it.
Adult choking management algorithm:
Figure 6. shows the choking treatment algorithm,which summarieses the explanation provided in pervious article.
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