Airway Management, Adjuncts and the Choking Patient

Question 1

‘Initial Examination of Airway’ - steps

Answer 1

Danger
Response - AVPU
Airway
Look for and remove obvious obstructions
Aspirate if necessary
Ensure patient airway

Question 2

what are the ‘Signs of normal breathing’

Answer 2

Even, bilateral rise and fall of the chest

Sound of air entering and leaving the nose and/or mouth

Feeling of air movement on your cheek

Normal skin colouration

Rate and depth of breathing adequate to sustain life

Question 3

(Upper airway obstruction) Foreign body airway obstruction (FBAO) - cause

Answer 3

Tongue - most common cause in an unconscious patient

Foreign bodies - most common cause in a conscious patient: Blood, Saliva, Vomit, Displaced dentures, Food, Chewing gum, Extraneous small objects

Question 4

Lower airway obstruction - cause

Answer 4

Excessive bronchial secretions

Pulmonary haemorrhage

Aspiration of regurgitated gastric contents

Question 5

Partial Airway Obstruction - signs

Answer 5

Their is usually reduced air movement, the noise produced depends upon the nature and site.

Upper airway is more noticeable during inhalation whilst an obstruction of the lower airway is usually more apparent during exhalation.

Question 6

Other airway noises: Gurgling

Answer 6

May indicate liquid or semi-solid material in the airway

Question 7

Other airway noises: Snoring

Answer 7

May indicate a partial occlusion by the tongue

Question 8

Other airway noises: Complete obstruction

Answer 8

No air movement will be heard or felt. But there may still be abdominal and chest movement

Question 9

opening airway: head tilt/ chin lift

Answer 9

brings the tongue forward and upwards and so ensuring an open airway.

Question 10

opening airway: Triple airway manoeuvre

Answer 10

Similar to jaw thrust manoeuvre except you maintain traction of the head using the heels of your hands

Question 11

opening airway: Jaw thrust

Answer 11

For trauma patients.
Hold mouth open by downward movement of the chin with thumbs.
Using index fingers apply steady pressure upwards and forwards at the angles of the jaw to lift it.

Question 12

Finger sweep

Answer 12

Open and inspect the mouth, carefully sweep two fingers from the side to the back, and hook out any foreign matter found, remove also any loose or broken dentures ONLY when clearly visible and very near to the lips.

Question 13

Suction

Answer 13

Remove any blood/liquids/light solids by aspirating with appropriate catheter.

Question 14

Mild airway obstruction

Answer 14

in response to “are you choking?”
patient answers “yes”
other signs - can speak, cough, breathe

Question 15

Severe airway obstruction

Answer 15

in response to “are you choking?”
patient is unable to speak and may respond by nodding.
other signs - Unable to breathe, wheezy, attempts at coughing are silent, may be unconscious.

Question 16

universal sign of choking

Answer 16

clutching the neck

Question 17

management for: Mild airway obstruction - Adults

Answer 17

Encourage to cough and do nothing else.
Monitor carefully
Rapid transport to hospital

Question 18

management for: Severe airway obstruction - Adults

Answer 18

Back Blows

Abdominal Thrusts

Question 19

How to do: Back Blows

Answer 19

Stand to the side and slightly behind.
Support the chest (hold shoulder) and with one hand lean the patient forwards.
Give up to five sharp back blows between the scapulae.

Question 20

How to do: Abdominal Thrusts

Answer 20

Stand behind the patient and place both arms around the upper part of the abdomen, clench your fist and grasp with the other hand.

Pull sharply & upwards with the aim of producing sudden expulsion of air and foreign body form the airway.

Question 21

Airway obstruction: adult unconscious

Answer 21

if a patient is or becomes unconscious begin basic life support.

During CPR check the mouth for any foreign body that has been partly expelled.

Question 22

Airway obstruction: children and infants.

Suspect that a child may be choking if there is:

Answer 22

Sudden respiratory compromise with associated coughing, gagging or stridor (creaking or grating noise).

No other signs of illness.

Other clues - eating, playing with small toys immediately prior

DO NOT PERFORM BLIND FINGER SWEEPS. airway obstruction may also occur with acute epiglottis or croup

Question 23

General signs of airway obstruction:

Answer 23

witnessed episode
coughing or choking
sudden onset
recent history of playing with, or eating, small objects

Question 24

Signs of ineffective cough

Answer 24

unable to vocalise
quiet or silent cough
unable to breath
cyanosis
decreasing level of consciousness

Question 25

Signs of effective cough

Answer 25

Crying or verbal response to questions
loud cough
able to breath before coughing
fully responsive

Question 26

Airway obstruction: back blows for infant and child

Answer 26

Position in the prone position with the head lower then the chest.

Deliver up to 5 back blows to the middle of the back between the scapulae.

With an infant hold them across your forearm and a child across your thigh whilst sitting.

Question 27

Airway obstruction: chest thrusts for infant or child

Answer 27

Turn the child into a supine position again with head lower than the chest and the airway in an open position.

Give up to five chest thrusts to the sternum - the technique for chest thrusts is similar to that for chest compression.

Chest thrusts should be sharper and more vigorous than compressions and carried out at a rate.

Question 28

FBAO

Answer 28

foreign body airway obstruction

Question 29

FBAO child - effective coughing

Answer 29

encourage to cough. do nothing else
monitor continuously
rapid transport to hospital

Question 30

FBAO child - ineffective coughing or cough becomes ineffective

Answer 30

Summon help if appropriate.
Determine child’s conscious level

IF CONSCIOUS: give back blows. if they do not relieve FBAO chest thrusts for infants. abdo thrusts for children

alternate until obstruction is relieved or patient loses consciousness.

Question 31

FBAO child - unconscious STEP 1

Answer 31

place them on a firm flat surface
OPEN THE AIRWAY
check the mouth for any obvious object. if on can be seen and easily grasped make an attempt to remove with a single finger sweep.

DO NOT ATTEMPT BLIND OR REPEATED FINGER SWEEPS

Question 32

FBAO child - unconscious STEP 2

Answer 32

Attempt Ventilations:
Open the airway and make 5 attempts to ventilate the lungs.
Assess the effectiveness of each ventilation.
If the chest does not rise, reposition the head before next attempt.

Question 33

FBAO child - unconscious STEP 3

Answer 33

Commence CPR:
CPR for 1 minute - start with compressions.
When ventilating check for foreign body.
If seen attempt a single finger sweep
If obstruction is relieved open and check mouth.
Ventilate if not breathing.
If child regains consciousness and effective breathing place in recovery position.
Monitor breathing and LOC and transport to hospital.

Question 34

Abdominal thrusts and infants

Answer 34

NOT RECOMMENDED in infants because they may rupture the abdominal viscera.

Perform cycles of 5 back blows and 5 chest thrusts only.

Repeat the cycles until the airway is cleared or the infant breathes spontaneously.

Question 35

Clearing the airway in neck breathers

Answer 35

Check the neck:
Lie patient on their back.
Remove clothing form around the neck, including the stoma cove, but DO NOT remove any tube that is in place.

Clear the neck:
Wipe any mucus from the stoma or tube, aspirate with appropriate size catheter if necessary.
Make sure that the stoma or tube is clear.

Check for breathing:
Listen and feel for air from the stoma.
Watch for movement of the chest and abdomen.

Question 36

Purpose & Limitation of OP airways

Answer 36

Every unconscious patient is in danger of death by asphyxia. This is because the tongue may fall back and obstruct the entrance to the trachea.

OP airway helps to control the lips, teeth and tongue and should be used in most unconscious patients - manual control must also be used.

An OP airway enables breathing to continue for those who are breathing, allows easier oro-pharyngeal suction and can reduce the risk of asphyxia.

An OP airway will only prevent obstruction by the relaxed tongue. It will not prevent stomach contents, saliva or blood form obstruction the patients airway.

Question 37

OP airway Sizing.

Answer 37

Measure form the middle of the patients lips to the angle of their jaw.

4. large adults
5. adults
6. small adults
7. children (para only)
8. infants (para only)

Question 38

OP airway method of insertion

Answer 38

They are curved to follow the contour of the upper surface of the tongue.

Hold the flanged end and then turn the airway upside down so that the curved surface is facing upwards towards to roof of the mouth.

When you have inserted approximately half the length rotate 180 degrees

Question 39

Purpose and Limitations of Naso-Pharyngeal airways

Answer 39

The NP airway, once in situ, is often better tolerated then the OP airway particularly by patients in the following circumstances:
Fitting or Seizures
Suspected cervical spine injury
Awake or semi conscious state
Active gag reflex

Question 40

NP airway indications

Answer 40

Patients aged 12yrs or over
Upper airway obstruction due to backward displacement of the tongue in patients with clenched jaws, seizures, jaw fractures or awkward/loose teeth.

Question 41

NP airway Contra-indications

Answer 41

Bilaterally obstructed or deformed nasal passages.

Severe mid-face fractures, in particular maxillary fractures.

CAUTION: suspicion of base skull fracture

Question 42

NP airway sizing

Answer 42

The lumen should approximate to the size of the patients little finger. The length is measured from the nares to the angle of the jaw.

Size 7. Adult male
Size 6. Adult female

Question 43

NP airway method of insertion

Answer 43

Ensure airway is clear.
Lubricate the airway.
Insert gently into largest nostril (usually the right).
Do not force the airway, rotating slightly may ease insertion.
Slide the airway into the nostril until the flange rests against the nasal opening.
Ensure air can pass through airway.