Emergency Airway Management
Recognition of Airway Obstruction
Additional Signs and Symptoms
1. Labored respirations are typified by a rate that is forcefully rapid, irregular, or gasping.
2. Unusual sounds or noisy respirations may be present.
3. Accessory muscles of the chest wall, shoulders, neck, and abdomen strain with the effort. If respiratory effort causes chest wall retractions, there may be increased work of breathing and respiratory distress.
4. In the obstructed airway, expiration tends to be prolonged.
5. Partial obstruction can be recognized by the following:
a. Decreased volume exchange (decreased air entry by auscultation or decreased chest rise by inspection)
6. No pause between breaths is an ominous sign. This suggests that there is a significant airway obstruction.
Head and Tongue Positioning
The most common causes of upper airway obstruction are the following:
1. A floppy tongue and lax pharyngeal muscles from decreased muscle tone of the genioglossus muscle, which contracts to move the tongue forward during inspiration and dilate the pharynx
2. Soft tissue enlargement from infection, edema, or hypertrophy
3. Teeth. These play an important role in preserving the size and patency of the oropharynx. Edentulous persons (the young, older adults, persons with poor dentition, and recently traumatized persons) are vulnerable to upper airway obstruction.
Treatment of Airway Obstruction
1. Open the mouth of an unconscious person.
2. Note the position of the tongue and the presence of vomitus, foreign debris, or pooled secretions. Suction the airway if required and available (see Suctioning, later).
3. Listen to the quality and consistency of lung and airway sounds.
4. In the obtunded infant or small child, the site of upper airway obstruction is usually between the tip of the tongue and the hard palate in the front of the mouth.
5. In an obtunded adult, the site of upper airway obstruction is usually between the base of the tongue and the posterior oropharynx (Fig. 10-1).
6. When the tongue is retrodisplaced, it causes the epiglottis to fold over and close off the tracheal opening, which results in a secondary site of upper airway obstruction.
7. Relief of both of these sources of obstruction can be obtained by lifting the jaw forward (Fig. 10-2) to simultaneously open the mouth and move the tongue from obstructing the oropharynx.
8. The optimal head position for airway alignment and patency varies with age. However, no matter the person’s age, the most desirable posture is maintaining a “neutral” (neither flexion nor hyperextension) head position with the chin jutted forward: nose in the “sniffing” position, mouth open, tongue resting on the floor of the mouth, and angle of the mandible perpendicular to the ground.
9. The least desirable head position in any age-group is with the neck flexed and chin pointed toward the chest. Flexion also increases unfavorable stresses on a potentially unstable cervical spine.
10. Extreme hyperextension of the head in any age-group stresses ligaments and angulates the airway and is to be avoided.
11. Because of prominence of the cranial occiput in an infant, an infant’s airway is best supported with a shoulder roll or built-up surface for the back.
12. The child does best without a pillow or with a built-up cushion for the back and only a small pad for the occiput.
13. The adult’s airway is best supported in the “sniffing” position with a small pillow under the head, the chin pointed in the air, and preserved natural lordosis of the cervical spine.
14. If the mechanism of injury or physical examination suggests a possible cervical spine injury, efforts to stabilize the neck and head should be undertaken. The patient should be spared neck flexion, hyperextension, or lateral rotation. Fortunately, the best head position for the airway is also good for the cervical spine. If a cervical spine immobilization method is employed, the airway should be evaluated for obstruction both before and after application.
Body Positioning
The supine position may be neither desirable nor achievable. Because of gravity, some airways are better maintained in a side-lying or prone position. Nontraditional positioning for stabilization and transport may be necessary because of burns, vomiting, management of secretions, or location of impaled objects. Principles of transport for patients in nonsupine positions relate to preservation of good perfusion and mechanical alignment in all body parts under pressure, maintaining neck straightness, and ensuring the ability of the rescuer to monitor airway patency. In a nonsupine position, the same airway posture is desireable: minimal torsion of the cervical spine, neck in a sniffing position, mouth open, and tongue on the floor of the mouth (Fig. 10-3).
Manual Airway Techniques
1. The simplest is the head tilt, chin lift. The heel of one of the rescuer’s hands is pressed down on the patient’s forehead, and the fingers of the other hand are placed under the chin to lift it up. The intended result is the sniffing position. Problems arise if the mouth is closed or soft tissues are folded inward because of the chin lift. In addition, downward pressure on the forehead tends to lift the eyebrows and open the eyelids, so measures may need to be taken to protect the eyes. This technique should not be employed in patients suspected of having a cervical spine injury.
2. A second maneuver is the jaw thrust (Fig. 10-4, A). Pressure is applied to the angle of the mandible to move it upward while forcefully opening the mouth. This is painful, and the conscious or semiconscious patient will object by clamping down or writhing.
FIGURE 10-4 A, External jaw thrust. B, Internal jaw lift.
3. A third maneuver is the internal jaw lift (Fig. 10-4, B). The rescuer’s thumb is inserted into the patient’s mouth under the tongue, and the mandibular mentum (chin) is lifted, thus stretching out the soft tissues and opening the airway. This is the best maneuver for the unconscious patient with a shattered mandible. The internal jaw lift is dangerous to the rescuer if the patient is semiconscious and can bite.
4. A fourth noninvasive airway maneuver takes some practice but serves several purposes and is the best maneuver if done correctly. In this two-handed maneuver, the head is held between two hands to prevent lateral rotation and maintain neck control. The fourth and fifth fingers are hooked behind the angle of the mandible to dislocate the jaw upward, and the thumbs ensure that the mouth is maintained open (see Fig. 10-2). The third finger may be positioned over the facial artery as it comes around the mandible so that the pulse can be monitored at the same time. For greatest stability, the rescuer’s elbows should rest on the same surface on which the patient is lying.
Improvised Tongue Traction Technique
If the patient is unconscious, the airway may be opened temporarily by attaching the anterior aspect of the patient’s tongue to the lower lip with one or two safety pins (Fig. 10-5). An alternative to piercing the lower lip is to pass a string through the safety pins and exert traction on the tongue by securing the end of the string to the patient’s shirt button or jacket zipper (Fig. 10-6).
Mechanical Airway Adjuncts
Oropharyngeal Airway
The oropharyngeal airway (OPA) is an S-shaped device designed to hold the tongue off the posterior pharyngeal wall (Fig. 10-7). When properly placed, it prevents the tongue from obstructing the glottis. These devices are most effective in unconscious and semiconscious patients who lack a gag reflex or cough. The use of an OPA in a patient with a gag reflex or cough is contraindicated because it may stimulate retching, vomiting, or laryngospasm.
