Airway Management

An airway, breathing, and circulation (ABC) assessment is the mainstay for evaluating and treating critically ill individuals. The airway assessment helps identify individuals with potential obstruction of the airway, which may benefit from airway management techniques to ensure adequate ventilation and oxygenation. Measures to relieve and prevent soft-tissue obstruction in an unconscious individual can include special positioning maneuvers and airway adjuncts (such as oropharyngeal or nasopharyngeal airways). By relieving obstruction, assisted breathing with a bag-mask is more effective. Endotracheal intubation provides a more definitive way to ensure airway patency and protection.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Airway Assessment

Assessing airway, breathing, and circulation is essential in the approach to treating critically ill patients. The following factors will guide management based on the airway assessment:

Airway patency

Visualization of the airway and observation of the individual can help determine the following:

Patent airway:

  • No obstruction present
  • Able to speak clearly
  • No abnormal airway sounds
  • Able to clear secretions

Partially obstructed airway:

  • Obstruction is present, but some air is able to pass
  • Signs or symptoms include:
    • Abnormal breathing sounds
      • Snoring
      • Wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing
      • Gurgling
    • Increased work of breathing
      • Increased respiratory rate
      • Use of accessory/abdominal muscles
      • Inability to complete sentences
    • Hypoxia and/or hypercapnia

Complete obstruction: 

  • Obstruction is present, and no air is able to pass.
  • Unable to speak, cough, or clear throat
  • Paradoxical chest and abdominal movements
  • Accessory muscle retractions
  • Absence of breath sounds
  • Significant hypoxia

Respiratory effort

Determining whether an individual is breathing will also guide management options.

  • Spontaneous breathing:
    • Individuals may be conscious or unconscious.
    • Adequacy of respiratory effort can be gauged by observing:
      • Respiratory rate
      • Depth of breathing
      • Respiratory pattern
  • Respiratory arrest: complete cessation of breathing

Airway Opening Maneuvers

Maneuvers for spontaneous breathers

Unconscious individuals with spontaneous breaths and a patent airway can be placed in a recovery position (also known as semi-prone or lateral recumbent). This is generally used in the prehospital setting.

  • Goal: 
    • To prevent obstruction of the airway by the tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue or relaxed soft tissues 
    • To prevent aspiration
  • Procedure:
    • Turn individual gently onto the left side.
    • Lock arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm and legs to stabilize the individual.
    • Lift the chin up to maintain epiglottis patency.
  • Do not perform if there is a possible C-spine injury
  • Continuously monitor breathing pattern and use a pulse oximeter (when available).
Carotidian pulse and recovery position

An individual in the recovery position

Image: “Checking carotidian pulse in recoversy position (simulated car accident)” by Michal Maňas. License: Public Domain

Maneuvers for an obstructed airway

These maneuvers are typically performed on unconscious individuals with evidence of an upper airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction ( tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue occluding the glottis).

Head-tilt/chin-lift maneuver:

  • Goal: lifts the tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue and aligns the oral cavity with the pharyngeal and laryngeal pathway → relieves upper airway soft-tissue obstruction
  • Procedure:
    • Place individual in supine position.
    • Lift head up and tilt posteriorly at 10‒25 degrees.
    • Use the 1st 2 fingers to lift the chin.
    • With the thumb of the same hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand, gently put pressure on the lower lip to open the mouth.
  • Contraindicated if there is suspicion of a C-spine injury

Jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint-thrust maneuver:

  • Goal: moves the mandible and tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue anteriorly to relieve upper airway soft-tissue obstruction
  • Can be used in individuals with a potential C-spine injury
  • Procedure:
    • Place individual in the supine position.
    • Place fingers at either angle of the jaw, with the palms of the hands resting on either cheek.
    • Move the jaw anteriorly. 
    • Use the thumb to open the mouth by applying gentle pressure under the lips Lips The lips are the soft and movable most external parts of the oral cavity. The blood supply of the lips originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue.
Jaw-thrust maneuver

Jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint-thrust maneuver:
The jaw is moved anteriorly to relieve an upper airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction.

Image: “ Jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint thrust maneuver” by Another-anon-artist-234. License: Public Domain

Airway Adjuncts

Airway adjuncts are devices used to enhance and maintain an open airway, and can also aid in better bag-mask ventilation (BMV). These devices are used in:

  • Unconscious individuals with spontaneous respirations
  • Upper airway soft-tissue obstruction

Oropharyngeal airway (OPA)

  • A rigid, curved device is inserted into the mouth (with the curved side facing up or laterally).
  • Prevents the tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue from obstructing the airway
  • The size is chosen based on the distance from the corner of the mouth to the earlobe.
  • Avoid in cases of oral trauma.
  • Should not be used in individuals with a gag reflex.

Nasopharyngeal airway (NPA)

  • A long tube inserted from the nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose into the nasopharynx
  • Should be lubricated and inserted gently and slowly through the wider nostril
  • Avoid use in facial fractures.
  • Can be used in individuals with a gag reflex

Bag-Mask Ventilation

Indications

Technique to provide assisted breaths and deliver oxygen for:

  • Rescue ventilation
    • Apnea
    • Respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure
  • CPR
  • A bridge to intubation

Requirements

  • Patent airway, which can be established with:
    • Proper positioning: 
      • Supine
      • Head elevated and tilted to keep parallel to the bed while the neck is flexed (sniffing position)
      • Airway-opening maneuvers
    • Airway adjuncts
  • Proper mask seal

Procedure

  • Ideally, the provider is at the head of the bed.
  • With the 3rd, 4th, and 5th fingers forming an E, the jaw is lifted.
  • Using the same hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand (index finger and thumb), make a C to squeeze the mask on the face, ensuring a tight seal. 
  • The nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose and mouth must be covered by the mask.
  • Use the other hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand to squeeze the bag to deliver breaths; squeeze gently and slowly (over 1 second).
  • Allow the bag to fully recoil before delivering another breath, aim for 10–12 breaths/min (1 breath every 5–6 seconds).
  • Observe for a rise in the chest and maintenance of oxygen saturation (if the individual is hooked up to a pulse oximeter).
Resuscitator operation (psf)

Schematic depiction of bag-mask ventilation:
Hold the mask to the individual’s face while lifting the jaw. Use the other hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand to deliver breaths by squeezing the bag.

Image: “ Operation of bag valve mask” by Pearson Scott Foresman. License: Public Domain

Advanced Airway

Supraglottic airway device

  • Devices used to temporarily maintain a patent airway above the glottis:
    • Laryngeal mask airway (LMA)
    • Laryngeal tube airway (LTA)
  • Indications:
    • Respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure or arrest:
      • Quickly secures airway in prehospital setting or while awaiting arrival of trained personnel for intubation
      • Can be used if intubation is unsuccessful
    • For certain elective, short-duration anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts cases
  • Contraindications: 
    • Not to be used in conscious patients (intact gag reflex)
    • Upper airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction that cannot be bypassed
  • Limitations: 
    • Not to be used as a “definitive” airway
    • Does not protect against aspiration
  • Procedure:
    • Select appropriate size (average adult size is #4)
    • Inflate the cuff to ensure there is no leak and then deflate, 
    • Place individual in a supine position with chin lifted (sniffing position).
    • Lubricate the cuff and insert gently (cuff side first).
    • Stop once you’ve crossed the base of the tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue (resistance is felt).
    • Inflate the cuff.
    • Ventilate using a bag attached to the tubing.
    • Assess for correct placement (equal breath sounds bilaterally and good chest rise).
Laryngeal mask

Laryngeal mask airway (LMA):
The cuff is the wide, beige part that is inserted in the supraglottic region.

Image: “Laryngeal mask” by Chrisjw37. License: CC BY 3.0

Endotracheal Intubation

  • A definitive airway using an endotracheal tube (ET)
  • Used in emergency situations by trained professionals (as it requires the use of medications as well as monitoring) 
  • Can be performed prehospital
  • Indications: 
    • Respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure or arrest
    • Partial or complete obstruction 
    • Inability to protect the airway
    • Impending airway compromise
  • Contraindications: 
    • Distortion of the upper airway anatomy
    • Complete upper airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction that cannot be safely bypassed
  • Procedure:
    • Preoxygenate with 100% oxygen, targeting an SpO2 of 100% (usually for 3 minutes)
    • Medications:
      • Sedation (e.g., propofol)
      • Neuromuscular blockade (e.g., succinylcholine)
    • Select appropriate length (men: 8–9 mm; women: 7–8 mm)
    • Inflate cuff to ensure no leak and then deflate.
    • Place individual in the supine position.
    • Gently open the mouth. 
    • Visualize the arytenoid cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage and vocal cords, which can be done with:
      • Laryngoscopy
      • Videolaryngoscopy
    • Insert the ET tube past the cords and inflate,
    • Tape and secure the ET tube.
    • Attach to bag or ventilator.
  • Confirm correct placement:
    • Auscultate for bilateral equal breath sounds and no gas in the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach.
    • End-tidal carbon dioxide monitor (ETCO2) (gold standard)
    • Postintubation chest X-ray → approximately 2‒5 cm above the carina

References

  1. Mouri, M.I., Krishnan, S., Maani, C.V. (2021). Airway assessment. StatPearls. Retrieved December 4, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK470477/
  2. Avva, U., Lata, J.M., Kiel, J. (2021). Airway management. StatPearls. Retrieved December 4, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK470403/
  3. ​​Simon, L.V., Torp, K.D. (2021). Laryngeal Mask Airway. StatPearls. Retrieved December 5, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK482184/
  4. Alvarado, A.C., Panakos, P. (2021). Endotracheal tube intubation techniques. StatPearls. Retrieved December 5, 2021, from: https://www.ncbi.nlm.nih.gov/books/NBK560730/
  5. Brown, III, C.A. (2020). Approach to advanced emergency airway management in adults. UpToDate. Retrieved December 12, 2021, from https://www.uptodate.com/contents/approach-to-advanced-emergency-airway-management-in-adults
  6. Wittels, K.A. (2021). Basic airway management in adults. UpToDate. Retrieved December 12, 2021, from https://www.uptodate.com/contents/basic-airway-management-in-adults
  7. Habrat, D. (2021). How to do head tilt-chin lift and jaw-thrust maneuvers. [online] MSD Manual Professional Version. Retrieved December 12, 2021, from https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-basic-airway-procedures/how-to-do-head-tilt-chin-lift-and-jaw-thrust-maneuvers
  8. Habrat, D. (2021). How to do bag-valve-mask (BVM) ventilation. Merck Manual Professional Version. Retrieved December 12, 2021, from https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-basic-airway-procedures/how-to-do-bag-valve-mask-bvm-ventilation
  9. Chappell, B. (2021). How to insert a laryngeal mask airway. Merck Manual Professional Version. Retrieved December 12, 2021, from https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-other-airway-procedures/how-to-insert-a-laryngeal-mask-airway?query=supraglottic%20airway
  10. Habrat, D. (2021). How to insert a nasopharyngeal airway. Merck Manual Professional Version. Retrieved December 12, 2021, from https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-basic-airway-procedures/how-to-insert-a-nasopharyngeal-airway
  11. Habrat, D. (2021). How to insert an oropharyngeal airway. Merck Manual Professional Version. Retrieved December 12, 2021, from https://www.msdmanuals.com/en-au/professional/critical-care-medicine/how-to-do-basic-airway-procedures/how-to-insert-an-oropharyngeal-airway

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