Covers basic airway anatomy physiology and airway management

1. BASIC AIRWAY MANAGEMENT
Rafal Banek CRNA

2. Learning Objectives
● Anatomy of the airway and respiratory
system
● Fundamentals of Airway Management
● Familiarity with airway adjuncts

3. IF YOU CAN’T BREATH,
NOTHING ELSE MATTERS !!!
● Airway management is one of the most critical
aspect of trauma care.
● Airway compromise may quickly result in
fatality yet, it may be easy to treat
● Unrecognized airway compromise may lead to
patient deterioration and death within minutes.
● No trauma interventions should be
undertaken before addressing the airway
status……….ANY EXCEPTIONS TO THIS ?

4. AIRWAY ANATOMY
TWO MAJOR COMPONENTS
1.Upper airway
 Humidification, filtration and warming of the
inhaled air
 Filtration of bacteria (Tonsils/Adenoids)
 Phonation
2.Lower airway
 Exchange of O2, CO2 with blood
 Phonation

5. UPPER AIRWAY
1. Nasal cavity
 Warms, filters, humidifies
air
2. Nasopharynx
 From the internal nostrils to
lower edge of soft palate
3. Oral cavity,
4. Oropharynx
 Soft palate to epiglottis
5. Laryngopharynx
(hypopharynx)
 From epiglottis to cricoid
cartilage
Nasal Cavity
Oral
Cavity
Oral cavity

6. LOWER AIRWAY
1. Trachea
2. Bronchi
 Two mainstem
 Secondary, tertiary
3. Bronchioles
4. Alveolar ducts
5. Alveolar sacs
4. Alveoli
 “Balloon-like” clusters
 Actual sites of gas exchange
Carina

7. Basic Airway Techniques
• Everyone involved in trauma care should be
familiar with and proficient in their use
• These should be executed before advanced airway
management is undertaken
1. Head tilt/chin lift
2. Jaw thrust (known or suspected c-spine injury)
3. Nasopharyngeal airway
4. Oropharyngeal airway
5. Bag valve mask assist or PPV

8. Key points to remember during initial
airway evaluation
Airway is patent if the victim is able to speak
Muscular tone of the head and neck muscles keeps the
airway open in awake conscious patient
As LOC decreases, the airway muscle tone decreases leading
to partial or complete obstruction
The tongue is the most common cause of airway obstruction
in an unconscious adult.
Unconscious victim’s respirations may be sufficient to
maintain life but death may result from airway obstruction
Patients with head, face, neck, chest and inhalational injury
have higher likelihood of airway compromise

9. Conscious victim

10. Airway obstruction in unconscious victim
Obstruction

11. Types of airway obstruction
Partial
Snoring
Stridor
Abnormal phonation
Paradoxical motion of the
abdominal and chest walls
Complete
Absent air movement
Aphonia
Rapidly ensuing hypoxia
Paradoxical motion may
continue

12. Airway Evaluation
• If patient is conscious and speaking normally-provide
supplemental 02, assess BS, continue close monitoring
• If patient is unconscious
 Head tilt/chin lift or forward thrust the mandible if
known or suspected c-spine trauma
 If facial trauma present, may need to inspect the mouth
for blood, bone fragments and other foreign objects-
remove or suction if necessary
 Look for chest movement, assess for exhaled air
 Consider placing simple airway adjunct to maintain the
airway patency

13. Head tilt/chin lift
Jaw thrust
• One hand on forehead
• Second grasping the bony
portion of mandible
• Avoid pressing on the soft
tissue !!!
• Tilt the head and lift the
chin at the same time.
• This lifts the tongue and
creates a pocket for
oxygen to travel.
• Assess for air movement

14. Jaw thrust
• Safest maneuver if c-spine
injury is suspected
• Avoids c-spine extension
• Stand behind the patient
• Heels of the hands on the
temporal areas
• Locate angle of the mandible
• Displace jaw forward while
maintaining neutral head
position
• Reassess for air movement

15. Nasopharyngeal Airway (NPA)
• Better tolerated in semi-
conscious patient with intact
airway reflexes
• Properly sized from NPA
extends from the nostril to
the angle of the mandible
• Do not use with facial
trauma or suspected skull
fracture
• Epistaxis not uncommon
from NPA use
(coagulopathic patients???)

16. NPA insertion
• Lubricate-KY or Lidocaine jelly
• Perpendicular to the face
• Twisting motion
• Avoid forcing in the device
• Once placed, reassess the
airway patency

17. Oropharyngeal airway (OPA)
• Do not use in semiconscious patient
with intact airway reflexes (vomiting,
aspiration, laryngospasm !!!)
•Properly sized from OPA extends from
the mouth to the angle of the mandible

18. OPA insertion
•Begin inserting from the
inverted position
•When advancing, gently rotate
the device 180 degrees
•Tongue blade may be used to
aid the passage of the OPA
•Reassess airway patency

19. Oxygenation and ventilation must be reassessed
after airway patency has been re-established
Indicators of inadequate ventilation and
oxygenation
Central cyanosis
Rapid shallow respirations
Accessory muscle use
Retractions
Abdominal paradoxical respirations
SpO2<90%

20. Bag-Valve mask (BVM) ventilation (“bagging”)
• Critically important airway skill
• Always the first response to inadequate oxygenation and
ventilation
• The first “bail-out” maneuver to a failed intubation
attempt
• Attenuates the urgency to intubate

21. Golden Rules of “Bagging”
• Almost anybody can be oxygenated and ventilated
with a bag and a mask
• Manual ventilation skill with proper equipment is
a fundamental premise of basic and advanced
airway management
• The art of bagging should be mastered before the
learning advanced airway skills

22. BVM Ventilation
• Requires practice to master
• One hand to
– maintain face seal
– position head
– maintain patency
• Sniffing position if c-spine clear
• Thumb + index to maintain face
seal
• Middle finger under mandibular
symphysis
• Ring/little finger under angle of
mandible
• Other hand ventilates
ALL fingers rest on the bony
portion of the mandible

23. “Bagging” with C-spine precautions
• Two person maneuver
• Primary maintains the seal and
neutral head postition
• Assistant provides jaw thrust
• NPA or OPA may be helpful

24. Predictors of difficult “bagging”
•Upper airway obstruction
•Lack of dentures
•Beard
•Midfacial trauma
•Facial burns, dressings, scarring
•Poor lung mechanics-resistance or compliance

25. Algorithm for difficulty “Bagging”
• Reassess for blood, fractured teeth and foreign
bodies –suction or remove if applicable
• Triple maneuver if c-spine clear
– Head tilt, jaw thrust, mouth opening
• Nasal or/and oropharyngeal airways
• Two-person, four-hand technique

26. Two-person, four-hand technique
OPA and 2 NPA’s in place
Two hands on the mask and face for optimal
seal/position
Two hands on the bag to ventilate

27. Excessive gastric distention from “bagging”
• Possible consequences
Gastric contnents regurgitation and aspiration
Restricted diaphragmatic movement
In rare cases gastric rupture
• Minimizing the risks
Minimize the duration of “bagging”
Avoid excessive tidal volumes
Minimize the positive pressure (<20 cm H2O) if possible
Consider cricoid pressure
Decompress the stomach with NGT or OGT after the airway is
secured

28. What if “bagging” is difficult or
impossible????
• Rescue devices
Laryngeal Mask Airway (LMA)
Combitube

29. LMA
• Can be inserted blindly by
unskilled personnel
• Creates seal around the laryngeal
inlet, enabling ventilation from
immediately above the cords,
• Bypasses proximal upper airway
obstruction- mostly tongue
• >90% rescue success rate in
impossible or difficult face mask
ventilation situations

30. LMA placement
1. Lubricate posterior part of the cuff
2. Place the tip behind pt’s upper teeth
3. Place the finger in pt’s mouth, while
advancing push your finger against
the palate and forward against the
cuff
4. Continue advancing till resistant is
felt
5. Inflate the cuff
6. Attach the bag and watch for the
chest movement after each manual
breath

31. Combitube
• Inserted blindly
• Easy to use by the unskilled
rescuers
• Esophageal placement is most
likely (90% of the insertions)
• Easy to use by the unskilled
rescuers
• Provides better esophageal
seal than LMA
• Success rate 75-100% in pre-
hospital setting

32. Combitube insertion
• Head tilt (clear C-spine?) with
lower jaw lift
• Advance gently with other hand
trying to follow curvature of the
tongue, until transverse lines are
adjacent to the teeth
• If this is emergency airway, inflate
both lumens
•

33. Combitube insertion
• Inflate proximal cuff (#1) first (80-10mL) then distal (5-15mL)
• Attempt ventilation via #1, assess for CO2, BS, chest movement
• If no CO2 return and no breathsounds are present from #1
endotracheal placement has occurred, switch to #2 and ventilate
• Congratulations!!!, you have just placed ETT, may deflate cuff #1
>90% placements <10% placements
#1
#2

34. Combitube troubleshooting
• If ventilations are ineffective, through either
lumen, the tube is to deep in esophagus
• Withdraw at 1cm increments
• Reassess BS, CO2, chest movement as you
withdraw

35. Exhaled CO2 (ETCO2)monitoring
• Golden standard to ascertain patent airway and
correct placement of advance airway device
• 2 types of monitors
Capnograph – bedside monitoring
“Easy cap”-Responds quickly to exhaled CO2 with a
simple color change, breath-to-breath response,
highly portable,
What color
if CO2 is present?
• Golden standard to ascertain patent airway and
correct placement of advance airway device
• 2 types of monitors
Capnograph – bedside monitoring
“Easy cap”-Responds quickly to exhaled CO2 with a
simple color change, breath-to-breath response,
highly portable,

36. Key points
• Airway compromise can be quickly fatal but in most
cases is easy to correct
• Tongue is the most frequent cause of airway
obstruction
• In the absence of severe extremity hemorrhage,
airway is evaluated and treated first, regardless of
severity of other injuries
• Bag-valve mask ventilation is the most critical airway
management skill set, the first responders must learn
• ETCO2 monitoring is the golden standard for
ascertaining the airway patency

37. References
1. Kovacs G, Law JA. Airway Management in
Emergencies. McGraw Hill Medical; 2008:33-51

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