Airway & Ventilation

Question 1

Causes of airway problems:

Answer 1

1. Blockage in airway - FB, blood, vomitus, secretions
2. Infection & oedema - direct trauma, epiglottitis
3. Narrowing airway - laryngospasm, bronchospasm
4. CNS depression - head injury, hypercapnia, metabolic (hypoglycaemia), drugs (alcohol, opioids, GA)

Question 2

If a patient is unconscious, the commonest cause of airway obstruction is:

Answer 2

1. Soft palate obstructing the passage of oxygen

Question 3

How to check for airway problems:

Answer 3

1. Look
2. Listen
3. Feel

Question 4

Checking for airway problems - Look - What to look for?

Answer 4

1. Chest & abdominal movement

Question 5

Checking for airway problems - Look - How does normal breathing look?

Answer 5

1. Chest expands outwards
2. Abdomen expands outwards

Question 6

Checking for airway problems - Look - How does obstructed breathing look?

Answer 6

1. Chest tries to expand
2. Abdomen pulled inwards
3. See Saw breathing
4. Use of accessory muscles

Question 7

Checking for airway problems - Listen - What to listen for?

Answer 7

1. Listen to breathing

Question 8

Checking for airway problems - Listen - What does normal breathing sound like?

Answer 8

1. Quiet

Question 9

Checking for airway problems - Listen - What does partial obstruction sound like?

Answer 9

1. Noisy - snoring, wheezing, gurgling, stridor

Question 10

Checking for airway problems - Listen - What does complete obstruction sound like?

Answer 10

1. Silence
2. No air flowing in or out

Question 11

Checking for airway problems - Feel - What to feel for?

Answer 11

1. Feel for airflow at the mouth and nose.

Question 12

What to do when an airway obstruction is recognised?

Answer 12

1. Airway manoeuvres to relieve obstruction

Question 13

What are the manoeuvres for relieving airway obstruction?

Answer 13

1. Head tilt
2. Chin lift
3. Jaw thrust

Question 14

Manoeuvres for relieving airway obstruction - How to perform Head Tilt?

Answer 14

1. Place one hand on the pt’s forehead
2. Tilt the head back gently.

Question 15

Manoeuvres for relieving airway obstruction - How to perform Chin Lift?

Answer 15

1. Place the fingertips of other hand under the point of the chin
2. Gently lift upwards to stretch the ant. neck structures
3. Look, listen & feel again to see if the obstruction is resolved

Question 16

Manoeuvres for relieving airway obstruction - How to perform Jaw Thrust?

Answer 16

1. Identify the angle of the mandible.
2. Place your index & other fingers behind the angle of the mandible & lift upward
3. Keep the mouth slightly open
4. Recheck to see if there are any signs of airway obstruction

Question 17

Types of simple airway adjuncts:

Answer 17

1. OP airway
2. NP airway

Question 18

Where are oropharyngeal airways are designed to fit & how do they work?

Answer 18

1. Fit - Between the tongue & hard palate
2. Work - Hold the tongue out of the way.

Question 19

What if OP airway used in semi-conscious patient?

Answer 19

1. Could provoke vomiting
2. Or laryngospasm

Question 20

When can NP airway be used?

Answer 20

1. In patients who are not deeply unconscious
2. Better tolerated than OP airways

Question 21

When to be cautious of using NP airway?

Answer 21

1. Suspected base of skull fracture

Question 22

Which patients require ventilatory support?

Answer 22

1. Pt’s with no or poor respiratory effort

Question 23

How to perform BMV?

Answer 23

1. Best performed with 2 people
2. 1 person holds the face mask + performs jaw thrust
3. Other person squeezes the bag 10 times/min

Question 24

Matt is 62 years old and has been brought into the Emergency Department with a suspected head injury; his c-spine has been cleared. He is now unresponsive on the ACVPU scale. You use an ABCDE approach to assess Matt.

How do you initially assess his airway?

Answer 24

1. Look, listen and feel for signs of airway obstruction

Question 25

Which of the following signs indicate that Matt has an obstructed airway? | Seesaw movements/ snoring sounds/ quiet breath sounds/ he is unconscious

Answer 25

1. **See saw** movements of the abdomen 2. **Snoring** sounds

Question 26

Matt is showing signs of airway obstruction. You are concerned that due to his low conscious level the soft tissues of his palate are obstructing airflow. Which of the following steps are most appropriate? | Call for help/ Apply high flow O2 via NRBM/Perform jaw thrust/ All of the above

Answer 26

1. **All** of the above should be carried out. ## Footnote Pt. with an **obstructed airway - always call for help** as the pt. could deteriorate very quickly. High-flow oxygen via a **NRBM** - ensures the pt. receives a **high concentration of O2**. This prolong the amount of time until the pt. desaturates. **Jaw thrust** - **lifting** the **soft tissues** that are obstructing airflow.

Question 27

You call for help, perform a jaw thrust and apply high-flow oxygen. However, the signs of airway obstruction are still present. What else should you do? ## Footnote Raise O2 level/ Insert OP airway/ Ventilate pt. with self-inflating bag/ wait for help

Answer 27

1. **Insert OP** airway ## Footnote An OP airway would be an appropriate airway adjunct. You are already delivering high-flow O2 to the pt.; this cannot be increased further. The pt. needs the obstruction to be relieved so that the O2 can reach the lungs. Currently the pt. is making adequate respiratory effort & does not require ventilation using a self-inflating bag.

Question 28

Help has now arrived but after inserting the oropharyngeal airway, you notice that Matt's chest is no longer rising, and he is not breathing. You check for signs of life and confirm he is in cardiac arrest. A cardiac arrest call has gone out; chest compressions are commenced, and the defibrillator is attached. How do you now manage Matt's airway? ## Footnote Leave the oropharyngeal airwav and oxygen mask in place/ Remove the oropharyngeal airway and ventilate with a self-inflating bag/ Leave the oropharyngeal airway in place & ventilate with a self-inflating bag using a 2-person technique/ Leave the oropharyngeal airway in place & ventilate with a self-inflating bag using

Answer 28

1. **Leave** the **OP airway** in place & ventilate with a **self-inflating bag** using a 2-person technique ## Footnote Matt is in cardiac arrest and is therefore not making any respiratory effort; he needs ventilating. Leaving the O2 mask in place would not provide ventilation. The **OP airway** should be left in place as it helps to **overcome any airway obstruction**. The best technique for ventilating with a self-inflating bag is a **2-person technique** as it means you can achieve a **better seal** with the face mask.

Question 29

General signs of choking:

Answer 29

1. Occurs while **eating** 2. Pt. may **clutch neck**

Question 30

Chocking - signs of mild airway obstruction:

Answer 30

1. Able to **speak** 2. Able to **cough** 3. Able to **breathe**

Question 31

Chocking - signs of severe airway obstruction:

Answer 31

1. **Can't speak** 2. **Can't breathe** 3. Breathing sounds **wheezy** 4. May only **respond** by **nodding** 5. **Coughing** attempts are **silent** 6. Pt. may be **unconscious**

Question 32

Adult choking guidelines:

Answer 32

Question 33

Choking - How to give back blows:

Answer 33

1. Stand slightly **behind pt.** 2. **Support chest** w/ 1 hand 3. **Lean** pt. well **forwards** 4. Give **5** sharp **blows** **between scapulae** 5. W/ **heel** of other **hand** 6. If **fails** - move to **abdominal thrusts**

Question 34

Choking - How to give abdominal thrusts:

Answer 34

1. Stand **behind pt.** 2. Put **both arms around** upper part of their **abdomen** 3. Place **clenched fist** just **under xiphisternum** 4. Place **other hand on top** of clenched fist 5. **Pull** sharply **inwards** & **upwards** 6. **Repeat 5 times** 7. **Alternate** between **back slaps** & **abdominal thrusts**

Question 35

How to estimate size of OP airway?

Answer 35

1. Measure **length** from pt's **incisors** 2. To **angle of the jaw**

Question 36

Sizes of OP airways:

Answer 36

1. **Small** - size **2** - ISO **8.0** 2. **Medium** - size **3** - ISO **9.0** 3. **Large** - size **4** - ISO **10.0**

Question 37

How to insert OP airway?

Answer 37

1. **Open** pt's **mouth** 2. Introduce airway **past teeth** in **"upside-down"** position 3. Then **rotate** through **180 °** 4. **Pass** airway beyond hard palate into **oropharynx**

Question 38

Suitable size of NP airway for adults:

Answer 38

1. 6-7 mm

Question 39

How to insert NP airway?

Answer 39

1. **Lubricate** airway 2. **Insert** airway **bevel end first** 3. **Vertically along floor** of nose w/ slight twisting action 4. Try **R. nostril 1st** 5. If obstruction, try **L. nostril 2nd**

Question 40

Size of i-gel: 1. Most adults: 2. Small females: 3. Tall males

Answer 40

1. Most adults - size 4 2. Small females - size 3 3. Tall males - size 5

Question 41

How to insert i-gel?

Answer 41

1. **Lubricate** all sides 2. Pt. in **sniffing position** - neck flexed, head extended 3. Press down on chin to **open mouth** 4. Introduce **soft tip** into mouth in **direction** towards **hard palate** 5. Glide **downwards & backwards** along hard palate 6. Push until **resistance felt** 7. **Tip** - located at upper **oesophageal opening** 8. **Cuff** - located against **larynx** 9. **Incisors** - resting on **bite-block** 10. **Horizontal black line** - level of the **teeth**

Question 42

Limitations of i-gel:

Answer 42

1. Risk of significant **leak** - if **high airway resistance** / poor lung compliance 2. **Leak** - uninterrupted chest **compressions** 3. Risk **aspiration** of stomach content 4. **Coughing, laryngeal spasm** - pt. **not deeply unconscious**