BEH Airway

Question 1

Define airway management

Answer 1

The provision of a free and clear passage for airflow. An obstruction may be PARTIAL or COMPLETE and may occur at any level from the nose to the trachea.

Question 2

Name the 3 sections of the pharynx and describe their position.

Answer 2

Nasopharynx: located behind the nasal cavity and above the soft palate.

Oropharynx: between the soft palate and the epiglottis

Laryngopharynx (Hypopharynx): from the upper border of the epiglottis to the lower border of the cricoid cartilage

Question 3

What are the upper airway differences between adults and paeds?

Answer 3

The paediatric airway is generally smaller, therefore there is a greater risk of obstruction.

The airway is also funnel shaped (compared to a cylinder in adults).

Trachea is softer and can more easily collapse (kink)

Question 4

What is the purpose of a gag reflex?

Answer 4

• A gag reflex helps prevent the lower airway from aspiration,
• entry of solids or fluids into the trachea, bronchi and lungs by expelling objects from the upper airway.
• An intact gag, therefore, is essential to protecting the airway from obstructions and aspiration.

Question 5

What happens when a patient’s conscious level decreases?

Answer 5

A decrease in conscious level causes the muscles of the tongue to become lax causing the tongue to fall posteriorly and obstruct the oropharynx, or the epiglottis tofall posterio-inferiorly and obstruct the glottic opening.

The gag reflex deteriorates blow GCS 9, where the patient can choke on foreign objects. An absent gag reflex can also cause vomiting into the upper airway and aspiration into the lungs.

Question 6

What are the 3 components of the TRIPLE AIRWAY MANOEUVER

Answer 6

Head tilt

Chin lift

Jaw thrust

Question 7

Why is hyperextending the neck in the triple airway manoeuver not advised?

Answer 7

It can flatten or kink the airways making future ventilation difficult.

It is also potentially damaging for suspected neck injuries.

Question 8

What is the appropriate head positioning for adults, children and infants?

Answer 8

Adults: The preferred head placement option for adults has the occiput elevated on a folded towel to a height of 2-5 cm from surface. This is preferred even in spinal injury and is considered natural neutral anatomical position.

Children (1 - 14): The child aged 1 to 14 is likely best managed supine with the head in the same surface plane as the body. Therefore, padding may not be required.

Infant: Infants are best managed with a small towel (2cm) underneath their shoulders. This is opposite to adult patient management.

INfants are primarily nose breathers

Question 9

What is the purpose of placing a patient in the lateral position?

Answer 9

After the pt’s airway has been assessed and patency has been assured, the pt can be moved into a stable side position to protect airway. Pt’s with a potential spinal cord injury must at all times be managed supine, unless deemed necessary to clear airway (i.e. blood, vomitus, submersion). Gravity assists in clearing the airway.

By placing pt in a stable side position, there is less potential for the tongue to obstruct oropharynx, and thereby impede oxygen delivery to lungs.

Question 10

What is the purpose of an Oropharyngeal airway (OPA)?

Answer 10

Their use is to simply block the tongue from falling backwards and occluding the oropharynx.

aka “glorified tongue depressor”

Question 11

What are the advantages and disadvantages of an OPA?

Answer 11

• *Advantages**
• Prevents tongue from falling backwards and occluding the oropharynx.
• Hard plastic helps to prevent teeth clenching.
• Larger diameter to allow for better oxygenation.
• *Disadvantages**
• OPA must be measured correctly to avoid either not working effectively if too small (don’t work as they are intended to) or damaging the soft posterior structures if too big.

Question 12

What are the indications for and OPA?

Answer 12

The OPA is only indicated in unconscious pts; otherwise it is likely to initiate gagging and vomiting.

As a bite block to support an endotracheal tube (to prevent pt biting of the ETT and occluding this soft tube)

Question 13

What are the contraindications for an OPA?

Answer 13

Pt’s with an intact gag reflex (even a weak one – it should be removed). Gag responses increase ICP which impact on CPP

** Remember: CPP = MAP – ICP **

Pt’s that have trismus (clenched jaws).

Question 14

How do you select the correct size for an OPA?

Answer 14

Select the correct sized OPA by measuring the distance from the pt’s lips to the angle of their jaw.

Question 15

How is an OPA inserted?

Answer 15

• Suction oropharynx if required.
• Open the pt’s mouth and remove dentures if loosley fitted. If firmly adhered to gums, leave in-situ.
• Hold the OPA with the curve facing upwards.
• Advance the OPA towards the hard palate and into the rear of the oropharynx.
• Rotate the OPA 180 degrees over the base of the tongue and into the oropharynx.
• Recheck the size and position of OPA.
• Verify patency of airway.

Paeds dont require to turn the OPA 180 degrees, because you may damage their soft palate.

Question 16

What are the advantages of using a nasopharyngeal airway (NPA)?

Answer 16

• Better tolerated than the OPA in the semi-conscious pt and is less likely to induce vomiting in pts with an intact gag reflex.
• Able to be used in pts with trismus (clenched jaws) or dental trauma.
• Rapidly inserted.
• No pre-set age, but length of NPA protruding from nostril should not be excessive as to be kinked by the application of the rigid facemask.

Question 17

What are the disadvantages of using a nasopharyngeal airway (NPA)?

Answer 17

• May cause epistaxis (nosebleed).
• Smaller internal diameter than OPA.
• May be difficult to suction through.
• Does not isolate trachea.
• May obstruct post insertion.
• Difficult to insert in the presence of nasal trauma, or established nasal deformity.

Question 18

What are the indications of using a NPA?

Answer 18

The patient in an altered conscious state in the presence of trismus.

Question 19

What are the contraindications of using a NPA?

Answer 19

Middle third facial fracture

Possibility of introducing the NPA into the brain!
Also risk of infection – keep NPA as clean as possible.

Significant nasal trauma.
– Difficult insertion and Likelihood of making the injury worse.

• *Traumatic brain injury and neurological event where airway is patent and tidal volume is adequate despite trismus.**
• Likelihood of eliciting a gag response and subsequently increasing ICP.

Question 20

What are some of the precautions for NPA?

Answer 20

• Base of skull fractures and Facial Fractures.
• Cerebrospinal fluid (CSF) from nares or ears.
• Strong possibility of compromised skull integrity therefore there is a risk of inserting NPA into brain. Proper insertion technique however will reduce chances.
• May require removal if view in intubation attempts are affected.

Question 21

How is the NPA measured?

Answer 21

• The NPA is measured from the tip of the nose to the ear lobe.
• Therefore it does not automatically go ALL the way up the nostril up to the flange.
• However, choose an appropriate sized NPA which when measured will not result in the flange being too distant from the nare as this may cause complications with ventilation later on.

Question 22

Why are OPA contraindicated in OPAs?

Answer 22

Stimulation of the gag reflex can cause gagging and vomiting. Both actions increase intra-cranial pressure (ICP), and, in the unconscious pt vomiting severely threatens the patency of the airway.

An increase in ICP can have detrimental effects in pts with a traumatic brain injury or neurological event (i.e. stroke) as it can increase damage to the brain as a result of the increased pressure.

Question 23

How do you correctly apply the BVM?

Answer 23

Question 24

How long should suction be applied?

Answer 24

• Recommended that each suction procedure should last no longer than 5 secs and the suction should be applied continuously rather than intermittently.
• Recommended to pre-oxygenate pt for at least 30 sec prior and after suctioning.

Question 25

What are some of the issues with suction?

Answer 25

• Hypoxia (insufficient levels of oxygen in blood or tissue) due to prolonged suctioning.
• If suction catheter is inserted too deeply can touch carina (bifurcation of trachea into bronchi), thus initiating cough reflex.
• Damage to mucous membranes.
• Introducing infection

Question 26

What is the contraidication of using a laryngoscope?

Answer 26

Intact gag reflex

Question 27

When are Magills forceps used?

Answer 27

• Magill’s forceps assist in the removal of impacted foreign body in the upper airway.
• For the most part, only utilised in pt’s with an absent gag reflex and with the aid of a laryngoscope.
• The foreign body must be seen before attempting removal. Magill forceps are not used to probe.

Question 28

What is FBAO?

Answer 28

Foreign body airway obstruction (FBAO) is defined as the unintentional inhalation or ingestion of food or other objects that result in the obstruction of respiration.

aka CHOKING!

Question 29

When can misdiagnosis of FBAO occur?

Answer 29

– This is more common in paeds where symptoms are similar to other respiratory symptoms i.e. croup, asthma.

– Young children may not be able to provide history of events.

– In adults - FBAO has been misdiagnosed as acute myocardial infarction (AMI) in adults

• Can be confused with faints
• Seizures and
• Other conditions that cause cyanosis and respiratory

distress.

Question 30

What are the signs and symptoms of a choking patient?

Answer 30

• Universal choking sign - Clutching at neck.
• Sudden onset of respiratory distress.
• Sudden onset of persistent cough, laboured or absent breathing.
• Gagging, stridor, wheeze or drooling.
• The absence or near absence of breath sounds.
• Cyanosis or mottled skin.
• In severe case, altered consciousness or unconsciousness.
• In cases of complete airway obstructions “see saw” breathing - paradoxical abdominal and chest movement during respiratory effort.

Question 31

Identify the 2 groups at high risk of choking? Describe why they are at a higher risk.

Answer 31

Elderly

The elderly may have weakened airway reflexes and muscle tone required to expel an object from the airway.

There is greater incidence of choking with pts with neurological impairment such as:

1. muscular weaknesses (eg. MS)
2. Past stroke
3. Dysphagia
4. Depressed gag / cough reflexes

Children (under 4)

Children has smaller airways that are more easily obstructed

Are more likely to explore their environment and put things in their mouths.

Swallowing and clearing mechanisms are less developed

Question 32

Describe the steps untaken to manage a choking patient.

Answer 32

Question 33

What is the first line in assisting a choking patient?

Answer 33

In a patient that is conscious and has an ineffective cough, the first step for paramedics is 5 back blows.

Back blows are contraindicated in newborns.

• Back blows attempt to create an ‘artificial cough’. If possible, position the pt in a head down position to allow gravity to assist with removal of the obstruction.
• Adult pt’s can be asked to lean forward.
• Children may lean forward, lie across a chair or over the paramedics lap.

Question 34

If back blows fail to clear the obstruction, what next?

Answer 34

If the patient is still conscious with an ineffective cough the next step is 5 chest thrusts.

• Position patient with their back against a firm vertical surface.
• Pt can be standing or sitting.
• Paramedic position themselves to the side of the patient.
• One hand on the lower half of sternum
• Thrust into the pt’s chest –up to 5 times.
• Similar force to CPR compression but at a slower rate.
• Continuously monitor for clearance as all 5 thrusts may not be required.

Question 35

When should abdominal thrusts be used?

Answer 35

NEVER!!

they can damage the xyphoid process of the sternum and may cuase internal injuries

Question 36

What do you do if both chest thrusts and back blows fail to clear the obstruction?

Answer 36

Continue to alternate between back blows and chest thrusts checking the airway to see if the object has been removed.

Question 37

What happens if the choking patient becomes unconscious?

Answer 37

Manual airway techniques, including the use of the laryngoscope, Magill’s forceps and suctioning should be utilised to clear the obstruction.

If unable to clear the obstruction attempt 5 ventilations (this is done to blow some air passed the object and oxygenate the patient).

The next step is 5 chest compressions (simial to CPR compressions only slower). Check airway and if obstruction is still not clear, continue to alternate between ventilation and chest compressions

If the obstruction becomes visible attempt to remove the obstruction using the Magill’s forceps or suction. If the pt loses cardiac output, treat as per cardiac arrest protocols.