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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.

Last updated: 24 May, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Airway Assessment

Assessing airway Airway ABCDE Assessment, breathing, and circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment is essential in the approach to treating critically ill patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.

  • 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 can be functional (e.g., unconscious Unconscious Those forces and content of the mind which are not ordinarily available to conscious awareness or to immediate recall. Psychotherapy patient) or mechanical (e.g., foreign body Foreign Body Foreign Body Aspiration).
  • Many conditions can cause 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:
    • Congenital Congenital Chorioretinitis/genetic:
      • Enlarged tonsils Tonsils Tonsillitis and/or adenoids
      • Macroglossia Macroglossia The presence of an excessively large tongue, which may be congenital or may develop as a result of a tumor or edema due to obstruction of lymphatic vessels, or it may occur in association with hyperpituitarism or acromegaly. It also may be associated with malocclusion because of pressure of the tongue on the teeth. Wilms Tumor
      • Micrognathia Micrognathia Abnormally small jaw. Pierre Robin Sequence
    • Infectious Infectious Febrile Infant:
      • Tonsillitis Tonsillitis Tonsillitis is inflammation of the pharynx or pharyngeal tonsils, and therefore is also called pharyngitis. An infectious etiology in the setting of tonsillitis is referred to as infectious pharyngitis, which is caused by viruses (most common), bacteria, or fungi. Tonsillitis
      • Peritonsillar abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
      • Pretracheal abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
      • Retropharyngeal abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
      • Epiglottitis Epiglottitis Epiglottitis (or “supraglottitis”) is an inflammation of the epiglottis and adjacent supraglottic structures. The majority of cases are caused by bacterial infection. Symptoms are rapid in onset and severe. Epiglottitis
      • Laryngitis Laryngitis Laryngitis is an inflammation of the larynx most commonly due to infection or trauma that can be either acute or chronic. In this condition, the 2 folds of mucous membranes that make up the vocal cords become inflamed and irritated. The inflammation results in a distortion of the voice produced, resulting in a hoarse sound or aphonia. Laryngitis
      • Ludwig angina

Airway Airway ABCDE Assessment patency

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

Patent airway Airway ABCDE Assessment:

  • No obstruction present
  • Able to speak clearly and swallow normally
  • No abnormal airway Airway ABCDE Assessment sounds
  • Able to clear secretions

Partially obstructed airway Airway ABCDE Assessment:

  • 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 or stridor Stridor Laryngomalacia and Tracheomalacia
      • Gurgling
      • Coughing
    • Increased work of breathing Work of breathing Respiratory muscle contraction during inhalation. The work is accomplished in three phases: lung compliance work, that required to expand the lungs against its elastic forces; tissue resistance work, that required to overcome the viscosity of the lung and chest wall structures; and airway resistance work, that required to overcome airway resistance during the movement of air into the lungs. Work of breathing does not refer to expiration, which is entirely a passive process caused by elastic recoil of the lung and chest cage. Pulmonary Examination
      • Increased respiratory rate Respiratory rate The number of times an organism breathes with the lungs (respiration) per unit time, usually per minute. Pulmonary Examination
      • Use of accessory/abdominal muscles
      • Inability to complete sentences
    • Hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage and/or hypercapnia Hypercapnia A clinical manifestation of abnormal increase in the amount of carbon dioxide in arterial blood. Neonatal Respiratory Distress Syndrome anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, weakness, fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, shortness of breath Shortness of breath Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea

Complete obstruction: 

  • Obstruction is present, and no air is able to pass.
  • Unable to speak, cough, or clear throat Throat The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx: Anatomy
  • Paradoxical chest and abdominal movements
  • Accessory muscle retractions
  • Absence of breath sounds (“silent chest”)
  • Significant hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage → altered mentation, confusion, obtundation, or coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma

Respiratory effort

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

  • Spontaneous breathing:
    • Individuals may be conscious or unconscious Unconscious Those forces and content of the mind which are not ordinarily available to conscious awareness or to immediate recall. Psychotherapy.
    • Adequacy of respiratory effort can be gauged by observing:
      • Respiratory rate Respiratory rate The number of times an organism breathes with the lungs (respiration) per unit time, usually per minute. Pulmonary Examination
      • Depth of breathing
      • Respiratory pattern
  • Respiratory arrest: complete cessation of breathing

Airway Opening Maneuvers

Note: During the ongoing COVID-19 COVID-19 Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that mainly affects the respiratory system but can also cause damage to other body systems (cardiovascular, gastrointestinal, renal, and central nervous systems). pandemic, and especially in areas of high disease prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency, appropriate safety precautions are recommended to protect against inhalation of aerosolized viral particles which can be produced by airway Airway ABCDE Assessment manipulation; this is particularly true for endotracheal intubation Endotracheal Intubation Neonatal Respiratory Distress Syndrome.

Maneuvers for spontaneous breathers

Unconscious Unconscious Those forces and content of the mind which are not ordinarily available to conscious awareness or to immediate recall. Psychotherapy individuals with spontaneous breaths and a patent airway Airway ABCDE Assessment 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 Airway ABCDE Assessment 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. Lips and Tongue: Anatomy 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: Anatomy and legs to stabilize the individual.
    • Lift the chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma up to maintain epiglottis Epiglottis A thin leaf-shaped cartilage that is covered with laryngeal mucosa and situated posterior to the root of the tongue and hyoid bone. During swallowing, the epiglottis folds back over the larynx inlet thus prevents foods from entering the airway. Larynx: Anatomy 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 Airway ABCDE Assessment

These maneuvers are typically performed on unconscious Unconscious Those forces and content of the mind which are not ordinarily available to conscious awareness or to immediate recall. Psychotherapy 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. Lips and Tongue: Anatomy occluding the glottis Glottis The vocal apparatus of the larynx, situated in the middle section of the larynx. Glottis consists of the vocal folds and an opening (rima glottidis) between the folds. Larynx: Anatomy).

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. Lips and Tongue: Anatomy and aligns the oral cavity with the pharyngeal and laryngeal pathway → relieves upper airway Airway ABCDE Assessment 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 Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma.
    • 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: Anatomy, gently put pressure on the lower lip to open the mouth.
  • Contraindicated if there is suspicion of a C-spine injury

Jaw-thrust maneuver:

  • Goal: moves the mandible Mandible The largest and strongest bone of the face constituting the lower jaw. It supports the lower teeth. Jaw and Temporomandibular Joint: Anatomy 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. Lips and Tongue: Anatomy anteriorly to relieve upper airway Airway ABCDE Assessment 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 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: Anatomy, with the palms of the hands resting on either cheek.
    • Move the 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: Anatomy 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. Lips and Tongue: Anatomy.
Jaw-thrust maneuver

Jaw-thrust maneuver:
The 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: Anatomy 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 thrust Jaw Thrust ABCDE Assessment maneuver” by Another-anon-artist-234. License: Public Domain

Airway Adjuncts

Airway Airway ABCDE Assessment adjuncts are devices used to enhance and maintain an open airway Airway ABCDE Assessment, and can also aid in better bag-mask ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing (BMV). These devices are used in:

  • Unconscious Unconscious Those forces and content of the mind which are not ordinarily available to conscious awareness or to immediate recall. Psychotherapy individuals with spontaneous respirations
  • Upper airway Airway ABCDE Assessment soft-tissue obstruction

Oropharyngeal airway Airway ABCDE Assessment (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. Lips and Tongue: Anatomy from obstructing the airway Airway ABCDE Assessment
  • 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 Gag Reflex Cranial Nerve Palsies.

Nasopharyngeal airway Airway ABCDE Assessment (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. Nose and Nasal Cavity: Anatomy into the nasopharynx Nasopharynx The top portion of the pharynx situated posterior to the nose and superior to the soft palate. The nasopharynx is the posterior extension of the nasal cavities and has a respiratory function. Pharynx: Anatomy
  • 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 Gag Reflex Cranial Nerve Palsies

Bag-Mask Ventilation

Indications

Technique to provide assisted breaths and deliver oxygen for:

  • Rescue ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing
    • 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 CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest
  • A bridge to intubation Intubation Peritonsillar Abscess

Requirements

  • Patent airway Airway ABCDE Assessment, which can be established with:
    • Proper positioning: 
      • Supine
      • Head elevated and tilted to keep parallel to the bed while the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess is flexed (sniffing position)
      • Airway-opening maneuvers
    • Airway Airway ABCDE Assessment 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 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: Anatomy 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: Anatomy (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. Nose and Nasal Cavity: Anatomy 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: Anatomy to squeeze the bag to deliver breaths; squeeze gently and slowly (over 1 second).
  • Allow the bag to fully recoil Recoil Vessels can stretch and return to their original shape after receiving the stroke volume of blood ejected by the left ventricle during systole. Arteries: Histology 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 Oxygen Saturation Basic Procedures (if the individual is hooked up to a pulse oximeter).
Resuscitator operation (psf)

Schematic depiction of bag-mask ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing:
Hold the mask to the individual’s face while lifting the 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: Anatomy. 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: Anatomy to deliver breaths by squeezing the bag.

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

Advanced Airway

Supraglottic airway Airway ABCDE Assessment device

  • Devices used to temporarily maintain a patent airway Airway ABCDE Assessment above the glottis Glottis The vocal apparatus of the larynx, situated in the middle section of the larynx. Glottis consists of the vocal folds and an opening (rima glottidis) between the folds. Larynx: Anatomy:
  • 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:
    • For certain elective, short-duration anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts cases
  • Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation
    • Not to be used in conscious patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship (intact gag reflex Gag Reflex Cranial Nerve Palsies)
    • 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 Limitations Conflict of Interest
  • 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 Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma lifted (sniffing position).
    • Lubricate the cuff and insert gently (cuff side first).
    • Stop once you’ ve VE Ventilation: Mechanics of Breathing 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. Lips and Tongue: Anatomy ( resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing 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 Airway ABCDE Assessment (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 Endotracheal Intubation Neonatal Respiratory Distress Syndrome

  • A definitive airway Airway ABCDE Assessment 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 Airway ABCDE Assessment
    • Impending airway Airway ABCDE Assessment compromise
  • Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation
    • Distortion Distortion Defense Mechanisms of the upper airway Airway ABCDE Assessment 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 100% Oxygen Cluster Headaches, targeting an SpO2 of 100% (usually for 3 minutes)
    • Medications:
      • Sedation (e.g., propofol Propofol An intravenous anesthetic agent which has the advantage of a very rapid onset after infusion or bolus injection plus a very short recovery period of a couple of minutes. Propofol has been used as anticonvulsants and antiemetics. Intravenous Anesthetics)
      • Neuromuscular blockade Neuromuscular Blockade The intentional interruption of transmission at the neuromuscular junction by external agents, usually neuromuscular blocking agents. It is distinguished from nerve block in which nerve conduction (neural conduction) is interrupted rather than neuromuscular transmission. Neuromuscular blockade is commonly used to produce muscle relaxation as an adjunct to anesthesia during surgery and other medical procedures. It is also often used as an experimental manipulation in basic research. It is not strictly speaking anesthesia but is grouped here with anesthetic techniques. The failure of neuromuscular transmission as a result of pathological processes is not included here. Aminoglycosides (e.g., succinylcholine Succinylcholine A quaternary skeletal muscle relaxant usually used in the form of its bromide, chloride, or iodide. It is a depolarizing relaxant, acting in about 30 seconds and with a duration of effect averaging three to five minutes. Succinylcholine is used in surgical, anesthetic, and other procedures in which a brief period of muscle relaxation is called for. Neuromuscular Blockers)
    • Select appropriate length (men: 8–9 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma; women: 7–8 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma)
    • Inflate cuff to ensure no leak and then deflate.
    • Pick a mode of visualization:
      • Laryngoscopy
      • Video laryngoscopy
    • Place the individual in the supine position with their head extended.
    • Gently open the mouth.
    • With laryngoscope in the left 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: Anatomy, insert the blade on the right side of the individual’s mouth (this pushes 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. Lips and Tongue: Anatomy toward the left for better visualization)
    • Slide in the blade until the epiglottis Epiglottis A thin leaf-shaped cartilage that is covered with laryngeal mucosa and situated posterior to the root of the tongue and hyoid bone. During swallowing, the epiglottis folds back over the larynx inlet thus prevents foods from entering the airway. Larynx: Anatomy is in view.
    • Lift the epiglottis Epiglottis A thin leaf-shaped cartilage that is covered with laryngeal mucosa and situated posterior to the root of the tongue and hyoid bone. During swallowing, the epiglottis folds back over the larynx inlet thus prevents foods from entering the airway. Larynx: Anatomy with the laryngoscope blade to visualize the vocal cords Vocal cords A pair of cone-shaped elastic mucous membrane projecting from the laryngeal wall and forming a narrow slit between them. Each contains a thickened free edge (vocal ligament) extending from the thyroid cartilage to the arytenoid cartilage, and a vocal muscle that shortens or relaxes the vocal cord to control sound production. Larynx: Anatomy.
    • To expose the larynx Larynx The larynx, also commonly called the voice box, is a cylindrical space located in the neck at the level of the C3-C6 vertebrae. The major structures forming the framework of the larynx are the thyroid cartilage, cricoid cartilage, and epiglottis. The larynx serves to produce sound (phonation), conducts air to the trachea, and prevents large molecules from reaching the lungs. Larynx: Anatomy, pull the handle 90 degrees to the blade (pulling back could result in fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the central incisors Incisors Any of the eight frontal teeth (four maxillary and four mandibular) having a sharp incisal edge for cutting food and a single root, which occurs in man both as a deciduous and a permanent tooth. Teeth: Anatomy).
    • Advance the blade, but avoid an overly deep insertion.
    • 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: Anatomy.
    • End-tidal carbon dioxide End-Tidal Carbon Dioxide Malignant Hyperthermia monitor (ETCO2) (gold standard)
    • Postintubation chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests → 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
  12. Tintinalli, J.E., Stapczynski, J.S., Stephan, J., et al. (2015). Noninvasive Airway Management and Intubation and Mechanical Ventilation. In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th ed., pp 782-861.

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