Airway management: Difference between revisions
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'''Airway management''' is the medical process of ensuring there is an open pathway between a patient’s [[lung]]s and the outside world, as well as reducing the risk of [[Pulmonary aspiration|aspiration]]. Airway management is a primary consideration in [[cardiopulmonary resuscitation]], [[anaesthesia]], [[emergency medicine]], [[intensive care medicine]] and [[first aid]]. |
'''Airway management''' is the medical process of ensuring there is an open pathway between a patient’s [[lung]]s and the outside world, as well as reducing the risk of [[Pulmonary aspiration|aspiration]]. Airway management is a primary consideration in [[cardiopulmonary resuscitation]], [[anaesthesia]], [[emergency medicine]], [[intensive care medicine]] and [[first aid]]. |
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==Non-invasive airway management== |
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==Airway maneuvers== |
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===Head-tilt chin-lift=== |
===Head-tilt chin-lift=== |
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== Invasive airway management == |
== Invasive airway management == |
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{{main|Invasive airway management}} |
{{main|Invasive airway management}} |
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Unlike non-invasive airway management such as head-tilt or jaw-thrust maneuver, invasive airway management relies on the use of [[medical device]]s. Invasive airway management can be performed [[Blind insertion airway device|"blind"]] or with visualization of the [[glottis]] e.g. by the use of a [[laryngoscope]]. |
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In roughly increasing order of invasiveness: |
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In roughly increasing order of invasiveness are the use of supraglottic devices such as [[Oropharyngeal airway|oropharyngeal]] or [[nasopharyngeal airway]]s, followed by infraglottic techniques such as [[tracheal intubation]] and finally surgical methods. |
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===Supraglottic techniques=== |
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A tube is introduced into the pharynx, ensuring the upper respiratory tract remains open, without passing through the [[glottis]]. |
A tube is introduced into the pharynx, ensuring the upper respiratory tract remains open, without passing through the [[glottis]]. |
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====Oropharyngeal airway==== |
=====Oropharyngeal airway===== |
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{{Main|Oropharyngeal airway}} |
{{Main|Oropharyngeal airway}} |
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[[File:Oropharyngeal Airways.jpg|thumb|left|Oropharyngeal airways in a range of sizes]] |
[[File:Oropharyngeal Airways.jpg|thumb|left|Oropharyngeal airways in a range of sizes]] |
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Oropharyngeal airways (OPA) (also known as Guedel airways)<ref>Guedel A. E. J. Am. Med. Assoc. 1933, 100, 1862 (reprinted in “Classical File”, Survey of Anesthesiology 1966,10, 515)</ref> are rigid plastic curved devices used to maintain an open airway. It does this by preventing the [[tongue]] from covering the [[epiglottis]], which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.<ref name="brady">{{cite book |author=Ed Dickinson; Dan Limmer; O'Keefe, Michael F.; Grant, Harvey D.; Bob Murray |title=Emergency Care (11th Edition) |publisher=Prentice Hall |location=Englewood Cliffs, N.J |year=2008 |pages=157–9 |isbn=0-13-500524-8 |oclc= |doi= }}</ref> An OPA should only be used in a deeply unresponsive patient because in a responsive patient they can cause vomiting and aspiration by stimulating the [[Pharyngeal reflex|gag reflex]].<ref name=anaUK2010>{{cite web|title=Guedel airway|url=http://www.frca.co.uk/article.aspx?articleid=101120|work=AnaesthesiaUK|accessdate=23 May 2013|date=14 May 2010}}</ref> |
Oropharyngeal airways (OPA) (also known as Guedel airways)<ref>Guedel A. E. J. Am. Med. Assoc. 1933, 100, 1862 (reprinted in “Classical File”, Survey of Anesthesiology 1966,10, 515)</ref> are rigid plastic curved devices used to maintain an open airway. It does this by preventing the [[tongue]] from covering the [[epiglottis]], which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.<ref name="brady">{{cite book |author=Ed Dickinson; Dan Limmer; O'Keefe, Michael F.; Grant, Harvey D.; Bob Murray |title=Emergency Care (11th Edition) |publisher=Prentice Hall |location=Englewood Cliffs, N.J |year=2008 |pages=157–9 |isbn=0-13-500524-8 |oclc= |doi= }}</ref> An OPA should only be used in a deeply unresponsive patient because in a responsive patient they can cause vomiting and aspiration by stimulating the [[Pharyngeal reflex|gag reflex]].<ref name=anaUK2010>{{cite web|title=Guedel airway|url=http://www.frca.co.uk/article.aspx?articleid=101120|work=AnaesthesiaUK|accessdate=23 May 2013|date=14 May 2010}}</ref> |
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====Nasopharyngeal airway==== |
=====Nasopharyngeal airway===== |
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{{Main|Nasopharyngeal airway}} |
{{Main|Nasopharyngeal airway}} |
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[[File:USMC-080531-M-8776A-001.jpg|thumb|right|Learning to insert a nasopharyngeal airway]] |
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The nasopharyngeal airway (NPA) (also known as a nasal trumpet) is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx. Patients tolerate NPAs more easily than OPAs, so NPAs can be used when the use of an OPA is difficult, such as when the patient's jaw is clenched or the patient is semiconscious and cannot tolerate an OPA.<ref name="pmid15911941">{{cite journal| author=Roberts K, Whalley H, Bleetman A| title=The nasopharyngeal airway: dispelling myths and establishing the facts | journal=Emerg Med J | year= 2005 | volume= 22 | issue= 6 | pages= 394–6 | pmid=15911941 | doi=10.1136/emj.2004.021402 | pmc=1726817 }}</ref> NPAs are generally not recommended if there is suspicion of a fracture to the base of the skull, due to the possibility of the tube entering the cranium.<ref name=EMJ2006>{{Cite doi|10.1136/emj.2006.036541}}</ref> However, the actual risks of this complication occurring compared to the risks of damage from hypoxia if an airway is not used are debatable.<ref name=EMJ2006/><ref name=EMJ2004>{{Cite doi|10.1136/emj.2004.021402}}</ref> |
The nasopharyngeal airway (NPA) (also known as a nasal trumpet) is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx. Patients tolerate NPAs more easily than OPAs, so NPAs can be used when the use of an OPA is difficult, such as when the patient's jaw is clenched or the patient is semiconscious and cannot tolerate an OPA.<ref name="pmid15911941">{{cite journal| author=Roberts K, Whalley H, Bleetman A| title=The nasopharyngeal airway: dispelling myths and establishing the facts | journal=Emerg Med J | year= 2005 | volume= 22 | issue= 6 | pages= 394–6 | pmid=15911941 | doi=10.1136/emj.2004.021402 | pmc=1726817 }}</ref> NPAs are generally not recommended if there is suspicion of a fracture to the base of the skull, due to the possibility of the tube entering the cranium.<ref name=EMJ2006>{{Cite doi|10.1136/emj.2006.036541}}</ref> However, the actual risks of this complication occurring compared to the risks of damage from hypoxia if an airway is not used are debatable.<ref name=EMJ2006/><ref name=EMJ2004>{{Cite doi|10.1136/emj.2004.021402}}</ref> |
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===Supraglottic airway=== |
====Supraglottic airway==== |
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{{Main|Laryngeal mask airway}} |
{{Main|Laryngeal mask airway}} |
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[[File:ProSeal Laryngeal Mask Airway inflated 001.jpg|thumb|left|ProSeal Laryngeal Mask Airway inflated 001]] |
[[File:ProSeal Laryngeal Mask Airway inflated 001.jpg|thumb|left|ProSeal Laryngeal Mask Airway inflated 001]] |
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Other variations include devices with oesophageal access ports, so that a separate tube can be inserted from the mouth to the stomach to decompress accumulated gases and drain liquid contents.<ref name=Hernandez2011 /> Some devices can have an endotracheal tube passed through them into the trachea (intubating LMA).<ref name=Hernandez2011 /> |
Other variations include devices with oesophageal access ports, so that a separate tube can be inserted from the mouth to the stomach to decompress accumulated gases and drain liquid contents.<ref name=Hernandez2011 /> Some devices can have an endotracheal tube passed through them into the trachea (intubating LMA).<ref name=Hernandez2011 /> |
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===Infraaglottic techniques=== |
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====Tracheal intubation==== |
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{{Main|Tracheal intubation}} |
{{Main|Tracheal intubation}} |
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[[File:Intubasion boru.jpg|thumb|right|A cuffed endotracheal tube used in tracheal intubation]] |
[[File:Intubasion boru.jpg|thumb|right|A cuffed endotracheal tube used in tracheal intubation]] |
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Revision as of 15:24, 19 December 2014
| Airway management | |
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| MeSH | D058109 |
Airway management is the medical process of ensuring there is an open pathway between a patient’s lungs and the outside world, as well as reducing the risk of aspiration. Airway management is a primary consideration in cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.
Non-invasive airway management
Head-tilt chin-lift
Head-tilt chin-lift — The head-tilt chin-lift is the primary maneuver used in any patient in whom cervical spine injury is not a concern. The simplest way of ensuring an open airway in an unconscious patient is to use a head tilt chin lift technique, thereby lifting the tongue from the back of the throat. This is taught on most first aid courses as the standard way of clearing an airway.
Jaw-thrust maneuver
Jaw-thrust maneuver — The jaw-thrust maneuver is an effective airway technique, particularly in the patient in whom cervical spine injury is a concern. The jaw thrust is a technique used on patients with a suspected spinal injury and is used on a supine patient. The practitioner uses their index and middle fingers to physically push the posterior (back) aspects of the mandible upwards while their thumbs push down on the chin to open the mouth. When the mandible is displaced forward, it pulls the tongue forward and prevents it from occluding (blocking) the entrance to the trachea, helping to ensure a patent (secure) airway.
The International Liaison Committee on Resuscitation no longer advocates use of the jaw thrust by lay rescuers,[1][failed verification] even for spinal-injured victims, although health care professionals still maintain the technique for specific applications. Instead, lay rescuers are advised to use the same head-tilt for all victims.
Cervical spine immobilization
Cervical spine immobilization — Most airway maneuvers are associated with some movement of the cervical spine (c-spine).[2][3] Even though collars for holding the head in-line can cause problems maintaining an airway and maintaining a blood pressure,[4] it is unrecommended to remove the collar without adequate personnel to manually hold the head in place.[5]
Invasive airway management
Unlike non-invasive airway management such as head-tilt or jaw-thrust maneuver, invasive airway management relies on the use of medical devices. Invasive airway management can be performed "blind" or with visualization of the glottis e.g. by the use of a laryngoscope.
In roughly increasing order of invasiveness are the use of supraglottic devices such as oropharyngeal or nasopharyngeal airways, followed by infraglottic techniques such as tracheal intubation and finally surgical methods.
Supraglottic techniques
Supraglottic tubes
A tube is introduced into the pharynx, ensuring the upper respiratory tract remains open, without passing through the glottis.
Oropharyngeal airway
Oropharyngeal airways (OPA) (also known as Guedel airways)[6] are rigid plastic curved devices used to maintain an open airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.[7] An OPA should only be used in a deeply unresponsive patient because in a responsive patient they can cause vomiting and aspiration by stimulating the gag reflex.[8]
Nasopharyngeal airway
The nasopharyngeal airway (NPA) (also known as a nasal trumpet) is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx. Patients tolerate NPAs more easily than OPAs, so NPAs can be used when the use of an OPA is difficult, such as when the patient's jaw is clenched or the patient is semiconscious and cannot tolerate an OPA.[9] NPAs are generally not recommended if there is suspicion of a fracture to the base of the skull, due to the possibility of the tube entering the cranium.[10] However, the actual risks of this complication occurring compared to the risks of damage from hypoxia if an airway is not used are debatable.[10][11]
Supraglottic airway
Supraglottic airways (also called extraglottic[12]) are a family of devices that are inserted through the mouth to sit on top of the larynx. Supraglottic airways are used in the majority of operations performed under general anaesthesia.[13] Compared to a cuffed tracheal tube (see below), they give less protection against aspiration but are easier to insert and cause less laryngeal trauma.[12]
The best-known example is the Laryngeal Mask Airway (LMA). A laryngeal mask airway is an airway placed into the mouth and set over the glottis and inflated.[14] This tube does not enter the trachea.[14]
Other variations include devices with oesophageal access ports, so that a separate tube can be inserted from the mouth to the stomach to decompress accumulated gases and drain liquid contents.[12] Some devices can have an endotracheal tube passed through them into the trachea (intubating LMA).[12]
Infraaglottic techniques
Tracheal intubation
Tracheal intubation, often simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction. The most widely used route is orotracheal, in which an endotracheal tube is passed through the mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea.
Surgical methods
A surgical incision is made below the glottis in order to achieve direct access, bypassing the upper respiratory tract.
Cricothyrotomy
A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma.[15] A cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications.[16]]
Tracheotomy
A tracheotomy is a surgically created opening from the skin of the neck down to the trachea (windpipe).[17] A tracheotomy may be considered where a person will need to be on a mechanical ventilator for a long time.[17] The advantages of a tracheotomy include less risk of infection and damage to the trachea such as tracheal stenosis.[17]
Removal of vomit and regurgitation
In the case of a patient who vomits or has other secretions in the airway, these techniques will not be enough. Suitably trained clinicians may elect to use suction to clean out the airway, although this may not always be possible. An unconscious patient who is regurgitating stomach contents should be turned into the recovery position when there is no suction equipment available, as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea.
Airway management in specific situations
Cardiopulmonary resuscitation
The best method of airway management during CPR is controversial.[18] There has been less emphasis on airway management (including simple mouth-to-mouth or invasive methods) during CPR, since it was shown that people receiving initial chest-compression-only CPR were more likely to survive than those who had standard CPR.[18] People who are resuscitated with basic bag-mask ventilation may also be more likely to survive than those who are intubated or have a supraglottic airway inserted.[18] However, in children, or where the cause of the arrest was an airway or breathing problem, or where the arrest is prolonged, airway management is still important.[18]
In basic life support, many people can be reluctant to start mouth-to-mouth resuscitation.[19] The American Heart Association now supports "Hands-only"™ CPR, which advocates chest compressions without any airway management for teens or adults.[19] Bystanders who see an adult suddenly collapse should call for help and move to chest compressions straight away.[19] It is likely that later in resuscitation care by trained professionals, simple methods as well as supraglottic and tracheal airways each have a role, depending on the skills of the person performing them and the equipment or environment they are working in.[12][18]
Trauma
In prehospital environments, airway management is controversial, with intubation and supraglottic airways each having advantages and disadvantages. Trauma victims are often not fasting so there is an increased risk of aspiration, but blood and other material may make it difficult to see the larynx to intubate.[12]
See also
- Tracheal intubation
- Laryngeal mask airway
- Laryngeal tube
- Combitube
- Endotracheal tube
- Ventilation
- Cardioversion
References
- ^ Part 2: Adult Basic Life Support - 112 (22 Supplement): III-5 - Circulation
- ^ Donaldson WF, Heil BV, Donaldson VP, Silvaggio VJ (1997). "The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study". Spine (Phila Pa 1976). 22 (11): 1215–8. doi:10.1097/00007632-199706010-00008. PMID 9201858.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Brimacombe J, Keller C, Künzel KH, Gaber O, Boehler M, Pühringer F (2000). "Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers". Anesth Analg. 91 (5): 1274–8. doi:10.1213/00000539-200011000-00041. PMID 11049921.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Kolb JC, Summers RL, Galli RL (1999). "Cervical collar-induced changes in intracranial pressure". Am J Emerg Med. 17 (2): 135–7. doi:10.1016/S0735-6757(99)90044-X. PMID 10102310.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Mobbs RJ, Stoodley MA, Fuller J (2002). "Effect of cervical hard collar on intracranial pressure after head injury". ANZ J Surg. 72 (6): 389–91. doi:10.1046/j.1445-2197.2002.02462.x. PMID 12121154.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Guedel A. E. J. Am. Med. Assoc. 1933, 100, 1862 (reprinted in “Classical File”, Survey of Anesthesiology 1966,10, 515)
- ^ Ed Dickinson; Dan Limmer; O'Keefe, Michael F.; Grant, Harvey D.; Bob Murray (2008). Emergency Care (11th Edition). Englewood Cliffs, N.J: Prentice Hall. pp. 157–9. ISBN 0-13-500524-8.
{{cite book}}: CS1 maint: multiple names: authors list (link) - ^ "Guedel airway". AnaesthesiaUK. 14 May 2010. Retrieved 23 May 2013.
- ^ Roberts K, Whalley H, Bleetman A (2005). "The nasopharyngeal airway: dispelling myths and establishing the facts". Emerg Med J. 22 (6): 394–6. doi:10.1136/emj.2004.021402. PMC 1726817. PMID 15911941.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ a b Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1136/emj.2006.036541, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
|doi=10.1136/emj.2006.036541instead. - ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1136/emj.2004.021402, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
|doi=10.1136/emj.2004.021402instead. - ^ a b c d e f Hernandez, MR; Klock, A; Ovassapian, A (2011). "Evolution of the Extraglottic Airway: A Review of Its History, Applications, and Practical Tips for Success". Anesthesia and Analgesia. 114 (2): 349–68. doi:10.1213/ANE.0b013e31823b6748. PMID 22178627.
- ^ Cook, T; Howes, B. (2010). "Supraglottic airway devices: recent advances". Continuing Education in Anaesthesia, Critical Care and Pain. 11 (2): 56. doi:10.1093/bjaceaccp/mkq058.
- ^ a b Davies PRF, Tighe SQM, Greenslade GL, Evans GH (1990). "Laryngeal mask airway and tracheal tube insertion by unskilled personnel". The Lancet. 336 (8721): 977–979. doi:10.1016/0140-6736(90)92429-L. PMID 1978159. Retrieved 25 July 2010.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Mohan, R; Iyer, R; Thaller, S (2009). "Airway management in patients with facial trauma". Journal of Craniofacial Surgery. 20 (1): 21–3. doi:10.1097/SCS.0b013e318190327a. PMID 19164982.
- ^ Katos, MG; Goldenberg, D (2007). "Emergency cricothyrotomy". Operative Techniques in Otolaryngology. 18 (2): 110–4. doi:10.1016/j.otot.2007.05.002.
- ^ a b c Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1002/14651858.CD007271.pub2, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
|doi=10.1002/14651858.CD007271.pub2instead. - ^ a b c d e Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1097/MCC.0b013e328360ac5e, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
|doi=10.1097/MCC.0b013e328360ac5einstead. - ^ a b c Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1161/CIRCULATIONAHA.107.189380, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
|doi=10.1161/CIRCULATIONAHA.107.189380instead.
Further reading
- Daniel Limmer; Keith J. Karren; Brent Q. Hafen; John Mackay; Michelle Mackay (2006). Emergency Medical Responder (Second Canadian Version). Brady. pp. 92–97. ISBN 0-13-127824-X.
