1.2a Resuscitation (A - Airway)

Question 1

Describe the pyramid of airway management.

Answer 1

• Aiway management is always prioritised except for in cardiac arrest
  
  1. First, assess, then consider manoeuvres, e.g. chin lift and jaw thrust
  2. Then consider airway adjuncts
     
     • Oropharyngeal/Nasopharyngeal
  3. If the patient is not spontaneously breathing, then use bag-valve mask ventilation
  4. Have a plan for the obstructed airway

The laryngeal airway is used as a rescue airway - first point of call in the case of a failed intubation.

Question 2

How do you assess an airway?

Answer 2

Approach –> Look –> Listen –> Feel

Approach

DR - Danger, Response (COWS)

If no response, call for help.

Look

Any damage, obstruction to the airway itself, e.g. FB, vomit, burns.

Any signs of airway compromise, e.g. chest movements, cyanosis.

Listen

Normal sounds of breathing, or other abnormal noises, e.g. stridor (upper airway obstruction), wheeze (lower airway obstruction), gurgling (fluid)

Feel

Feel chest rise and fall.

Feel pulses.

Question 3

What are the signs of an obstructed airway?

Answer 3

The signs of the obstructed airway depend on:

1. Partial vs. Complete Obstruction
2. Conscious vs. Unconscious

In a conscious patient with partial obstruction, there may be gasping, coughing, anxiety, vocal changes, cyanosis.

In an unconscious patient, you may not realise there is obstruction until you attempt ventilation, you may hear snoring or there may be no chest rise.

Specifically, here are 5 signs you may see in the obstructed airway.

1. Increased work of the diaphragm
2. Movement of abdomen in and out
   
   • This is often accompanied by no chest rise, i.e. despite increased work of diaphragm, no air comes in due to obstruction.
3. Loss of chest rise
4. Intercostal in-drawing
5. Paradoxical movements
   
   • This is where in a flail chest, when the patient breathes in, the normal chest expands while affected region sucks in.
   • When the patient breathes out, the normal chest falls, while the affected region expands.

Question 4

What are the 4 main airway manoeuvres?

Answer 4

1. Open mouth
2. Head tilt
3. Chin lift
4. Jaw thrust

Question 5

Describe the ‘open mouth’ manoeuvre.

Answer 5

Use the ‘pistol grip’ to open the mouth.

Thumb on the chin, index finger on the mandible.

Question 6

Describe the ‘head tilt’ manoeuvre.

Answer 6

‘Head tilt’ helps to align the airway.

Upper cervical spine is extended, lower cervical spine is flexed.

Tragus of the ear should be above the sternal notch.

Question 7

Describe the chin lift manoeuvre.

Answer 7

Use the pistol grip to lift the chin and simultaneously open the mouth.

Use an alternative manoeuvre if there is suspected spinal injury.

Question 8

Describe the jaw thrust manoeuvre.

Answer 8

This manoeuvre is preferable, especially if there is suspicion of cervical spine damage.

Correct Jaw Thrust Technique (Type 1)

1. Thumbs placed on chin
2. Index fingers curl around mandible
3. Mouth opened and thumbs and jaw is lifted with the index fingers.

Note! Your index fingers should only be touching the mandible, not pressing into the soft tissues as this can make the obstruction worse!

Correct Jaw Thrust Technique (Type #2)

1. Place the thumbs on the maxilla.
2. Index finger on the mandible.
3. Mouth opened with thenar of thumb.

Question 9

Name the 2 basic airway adjuncts.

Answer 9

1. Oropharygneal
2. Nasopharyngeal

Question 10

Explain how the oropharyngeal (Guedel) airway works.

Name the different parts of it.

Answer 10

It has several parts:

1. Curve (fits over the tongue)
2. Bite block (the incisors sit on these)
3. Flange (stops the airway migrating backwards into the mouth)

It is used to help passage of air from mouth over the tongue and soft tissues of mouth (which may be causing obstruction) into the region above the larynx.

Question 11

What are the contraindications for a Guedel airway?

Answer 11

Conscious patient.

Gag reflex intact.

This is because they may gag and aspirate, further worsening obstruction.

Question 12

How do you determine the correct size for a Guedel airway?

Answer 12

See the attached image.

Be prepared to increase/decrease the size if it makes no difference or makes the obstruction worse. A functioning airway is the priority.

Question 13

How do you insert an oropharyngeal airway?

Answer 13

If the patient fights or gags, be prepared to remove the airway immediately.

Suction should always be at hand when managing airway.

You can also use a laryngoscope to help insert the airway.

Question 14

Describe the indications and contraindications for a nasopharyngeal airway.

Answer 14

If the patient is more awake, it is better tolerated.

Contraindications - #basal skull fracture.

Question 15

How do you determine the correct size for a nasopharyngeal airway?

Answer 15

1. Diameter
   
   • Tubing should be the diameter of the little finger of the patient
   • It may slide in one nostril better than the other when lightly lubricated
   • Should fit without blanching the nostril.
2. Length
   
   • Measured from nostril to tragus of the ear

Question 16

How do you insert a nasopharyngeal airway?

Answer 16

1. Lightly lubricate.
2. Insert with light pressure. If you need more than this, try a smaller airway.
3. Should be at an angle perpendicular to face. Rotate from side to side gently while inserting.
4. Flange should go to nostril. Can consider pinning in place.

Question 17

Explain how the nasopharyngeal airway conduits air.

Answer 17

It conduits air form the tip of the nose to the nasopharynx.

Question 18

Describe when you should use a laryngeal airway.

What are the risks?

Answer 18

The laryngeal airway is not an airway adjunct, it is a rescue airway. It is the first port of call for failed intubation or ventilation patients.

Risks include:

1. Leak fraction: This is the leak volume (difference between inspired/expired air with the airway) divided by inspired air.
2. Insufflation of stomach (gas into stomach)

https://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-016-0291-1

Question 19

Describe the main parts of the laryngeal airway.

Answer 19

LMA has inflatable mask that fits anteriorly over the larynx. The tube is connected to a ventilator.

Question 20

Determine how to determine the correct size for a laryngeal airway.

Answer 20

The size is on the tube.

Memorise these sample sizing guidelines.

These are not universal. Be aware of sizing specifications in your particular emergency department.

Question 21

Explain how a laryngeal mask airway (LMA) is inserted.

Answer 21

1. Slightly deflate if required by pushing the mask down on a flat surface and aspirating with syringe.
2. Lubricate backplate.
3. Use pencil grip at proximal area of cuff with mask opening facing anteriorly.
4. Use your left hand to open the mouth slightly with pistol grip with a little chin lift, use right hand to insert the mask.
5. Push until a resistance is felt.
6. Attach the ventilation, e.g. bag-valve mask.
7. As you ventilate, auscultate and watch for good air entry and bilateral air movement.

Question 22

What course of action do you take in the community for obstructed airway?

Answer 22

5x back blows, 5x chest thrusts.

Alternate between the two and check for removal of foreign body between each set of 5.

Question 23

Explain the algorithm for managing an obstructed airway.

Answer 23

Remember to start thinking of methods for removing a foreign body from airway if implicated.

Question 24

What strategies can be used to remove a foreign body from the obstructed airway?

Answer 24

Supraglottic Foreign Bodies

1. Wall suction
2. Yankauer suction
3. Magill forceps

Infraglottic Foreign Bodies

• Intubated, but can’t ventilate
• Call for help - e.g. bronchoscopy may be required
• Consider pushing it into the right main bronchus