Beyond the Basics: Airway MANAGEMENT

CEU Review Form Airway MANAGEMENT (PDF)Valid until March 6, 2007

An experienced real estate agent will tell you that, when purchasing a home, there are three important things to consider: location, location, location. An experienced EMS provider will tell you that, when treating a patient, the three most important considerations are: airway, airway, airway.

     As our EMS profession grows in number of providers, calls for service and increasing technology, the reality is that the most basic of assessments-proper assessment of the airway-is still critical to the outcome and survivability of any patient we encounter.

     Shortly after 9:30 p.m., you and your partner are dispatched to the report of a man stabbed with a knife at a local convenience store. After the police have secured the scene, they direct you to the patient-the 46-year-old male store owner, who is supine on the ground with an approximately 2" laceration and puncture wound to the right side of his leg, near the medial aspect of his thigh. The patient is conscious and in obvious respiratory distress (pale, diaphoretic and a respiratory rate of approximately 36). In a raspy voice he asks you, "Am I going to die?"

     You know his airway is intact because he is talking to you, so you quickly cover his wound with a gloved hand, and your partner applies high-flow oxygen through a non-rebreather.

     Situations like this play out every day. Providers must ask themselves: Is the scene truly safe? Should I cover the open wound with a gloved hand? Should I quickly activate the trauma center? There are a hundred more questions and considerations for care. We learn ways to quickly make these decisions. We are often taught that if the patient is talking, the airway is intact. This may be true, but the more difficult and often neglected question is, "Will it remain that way?"

     This patient has several critical needs, but one that may be overlooked is the raspy voice. Indeed, his voice tells us that he is able to breathe and that he is conscious. But what about the raspy sound? Is this normal, or will his airway soon become a problem? Will you gamble that the patient is pale, diaphoretic and tachypneic because of his possible blood loss, or will you more carefully examine his airway to see if there is another stab wound in his neck? The raspy voice may be the biggest initial clue you have to alert you to a life-threatening problem.

     Early in our EMS careers we are taught the ABCs of prehospital care: airway, breathing and circulation. We recite it like a mantra in continuing education classes, but it helps keep our priorities in perspective. We can continue to use the ABCs to evaluate the airway. The ABCs of airway are simply assessment, basics and control.

Assessment
     Airway assessment is not as simple as talking to your patient or asking the examiner, "How's her airway?". It involves all of the ABCs. Since we lack x-ray vision to visualize all of the airway's structures, we must evaluate the result of airway problems: their effect on breathing. To thoroughly assess a patient's airway, we must assess:

     Adequacy of breathing

     Blockages

     Concerns that set off our alarms.

     Adequacy of the airway can be measured through evaluation of the depth and effort of breathing. Many providers fail to properly assess depth of breathing because it is best assessed by exposing the chest. Retractions and intercostal muscle use may be hidden by clothing, and heavy layers may prevent any assessment at all. Remember, you cannot treat what you can't see. Expose the chest in an appropriate setting, if possible, for evaluation, and re-cover the patient afterwards. Using trauma shears is an option, but careful removal (or unbuttoning) of clothes may allow for adequate assessment without destroying the patient's property. Additionally, assess the effort of breathing by noting the way in which patients position themselves. Are they lying on their backs, feet crossed, with the appearance of a vacationer on a beach, or are they sitting bolt upright, straining to get every last ounce of oxygen? Pursed lips, tripod position, arched shoulders and retractions should be ominous signs.

     Evaluate the airway for blockages. Blockages are categorized as severe (complete obstruction) or mild (partial obstruction). A mild blockage can quickly lead to a severe blockage. Our goal is to ensure a patent and clear airway. Obstructions may be the result of trauma (e.g., crushing injuries), foreign bodies (e.g., a piece of food) or pathological processes (e.g., tumors or edema). Patients with a severe airway obstruction need immediate and aggressive intervention. Those experiencing a mild obstruction need vigilant attention to ensure that it does not worsen.

     One method for examining the airway for blockages is to shine a penlight into the mouth to reveal any potential complications. Loose or missing teeth are a potential complication, but it is important to attempt to find out how many teeth the patient began his day with to compare to the number left intact when he called for help. Dentures should be removed only if they cause an obstruction, as they help give form to the face and lips during bag-valve mask ventilation efforts. Piercings in the mouth, cheeks, nares or tongue may also pose complications, so it is important to ensure they are intact and not loose or causing trauma themselves. The patient may be able to remove them himself, but airway management needs and patient condition may necessitate the provider removing them. This should be done only if they interfere with a patent airway or ventilation efforts.

     EMS providers have a keen sixth sense, and any alarms triggered during airway assessment should not be disregarded. Using our senses of looking and listening may be our best technology. Findings of noisy respirations or vocal sound changes must be closely examined. A patient with gurgling, stridor or crowing will need considerable airway management.

     Your general impression of a patient may provide clues to potential airway difficulties, such as a short, fat neck; anatomical distortions; or cervical immobility. One useful assessment tool is the Mallampati Airway Classification, which grades an airway from I to IV based on the structures (base of the uvula, faucial pillars, and soft palate) visible with maximal mouth opening and tongue protrusion. A class I patient will tend to pose few potential complications during advanced airway procedures, whereas a class IV patient may pose significant problems. This classification is based on a patient who is sitting upright and relatively quiet, so it may need to be modified for the patient in respiratory arrest on the floor or the patient with copious oral secretions. Regardless of method, it is far better, when possible, to evaluate the patient before advanced airway procedures are attempted, thus allowing you to prepare for complications.

     Visualize the exterior structures around the airway, inspecting for swelling, trauma or tracheal shifting. (Recall that tracheal shifting is often a late sign of pneumothorax, and the airway structures will shift away from the site of the injury.)

     Palpate the cervical spine, as reduced neck mobility through existing medical conditions, trauma and/or the application of cervical immobilization may affect the ability to properly open a compromised airway.

Basics
     Working a night shift as the EMS supervisor, you are checking your equipment in your chase vehicle when you are dispatched to a local college for an unconscious female in her fourth floor dorm room. Upon arrival, you find a 21-year-old female prone on her bed, with significant amounts of vomit near her head on the bed and floor. She is unresponsive and you see no obvious signs of trauma. Her roommate states she has been drinking heavily tonight and "just passed out." The responding ambulance has not yet arrived, so, with the help of a security officer, you carefully roll her onto her side. Airway assessment shows that her mouth is full of vomitus, and you can hear shallow, gurgling respirations. You begin to consider using a BVM and intubation for the patient when you realize that the suction unit is still in the chase car.

     Regardless of provider level, the basics of airway management do not change. An organized approach and use of the least invasive methods to effectively control an airway will result in better recovery times for patients and fewer complications during care. Such methods include positioning of the airway, airway adjuncts and suctioning.

     Proper positioning of the airway hinges on both body position and head/neck position. A provider treating a patient who is prone will have a difficult time properly assessing the patency of the airway. Again, you cannot treat what you cannot see. Carefully moving the patient to a supine or lateral recumbent position allows for better visualization and access. Enlist bystanders or other emergency responders to help protect the cervical spine when needed.

     The two most often used methods of opening an airway directly are the head-tilt/chin-lift and the modified jaw-thrust. Both are effective in opening the airway to allow assessment and care, but providers must remember to maintain these positions during every ventilation. The head-tilt/chin-lift is most often used for the patient with a closed airway and no indication or suspicion of cervical spine trauma. The modified jaw-thrust is used when there is concern about cervical spine injury. One disadvantage of the modified jaw-thrust is the effort required to open and maintain the opened airway. Providers often have difficulty holding the airway open for any length of time, and hence, may not adequately open the airway to allow ventilation. Current research indicates that some cervical spine motion occurs with both head-tilt/chin-lift and modified jaw-thrust methods, and the American Heart Association recommends that, although the modified jaw-thrust is the preferred method, providers should use the head-tilt/chin-lift maneuver even in cases of cervical spine injury if the modified jaw-thrust does not open the airway. What does this mean for you as a provider? Simply that the potential cervical spine injury should not outweigh the definite airway problem!

     Providers have joked that airway adjuncts like oropharyngeal airways (OPA) and nasopharyngeal airways (NPA) are just party tricks. In practical use, both are excellent methods to help provide a patent airway. The key to this concept is that both the NPA and OPA help and help only. The names of these devices are the most misleading, implying that they are actual airways; however, neither will provide a secure patent airway, and their use still requires a head-tilt/chin-lift or modified jaw-thrust during every ventilation! Insertion of either will provide better passage of ventilation and exhalation, but neither will help lift the tongue, as this can only be accomplished with manual opening techniques. Using an OPA or NPA without manual opening techniques is no more useful than ventilating an unopened airway without the device. Additionally, their proper use, especially insertion of the OPA, indicates a general lack of a gag reflex, and consequently should raise multiple red flags regarding the patient's overall respiratory system. The use of an adjunct such as the OPA or NPA demands the application of a bag-valve mask. If the patient cannot protect his airway (indicated by the absence of a gag reflex), then his ability to provide his own effective ventilation should be cast into serious doubt.

Control
     As you and your partner enter the room, you are greeted by the sight of the engine company sweating and looking completely exhausted as they perform CPR on the patient on the floor. The lieutenant looks up and says, "We've done two minutes of CPR, defibrillated once and put in an oral airway. According to his nurse, he collapsed about four minutes ago." You hear the words, but they seem only to echo in your head as you look at perhaps the largest patient you have ever cared for. He's easily over 450 pounds and you're wondering how you'll ever start the IV when your partner tosses you the airway bag and says, "I'll get the line; you're on airway." Groaning, you open the airway kit and wonder what your best option is to provide a secure airway to this patient.

     Our assessment of and basic interventions to a patient's airway sets the stage for the most critical function: control of the airway. EMS providers, typically advanced levels, must strive to provide the most patent and secure airway possible, completely replacing and taking over the normal physiological process of breathing. The most common airway tools at our disposal that can secure an airway are the endotracheal tube, alternate airways (such as the laryngeal mask airway and Combitube) and invasive airway procedures.

     Endotracheal intubation is the gold standard for airway control. Correct placement of an endotracheal tube allows for effective ventilation, exhalation, deep tracheal suctioning and, in some cases, medication administration. Endotracheal intubation does not have any limitations as to the patient's age, weight, height or prior activities (eating, medical conditions, etc.). Most commonly used endotracheal tube sizes are 7.5 to 8.5 for adult males and 7.0 to 8.0 for adult females. Tubes can generally be found in the range of 2.0 (premature infants) to 10.0 (extremely large adults). Endotracheal tubes should be selected based on the largest size possible that will not cause trauma during insertion. A factor that is particularly important during insertion is use of a laryngoscope and associated blades. Blades are usually a Macintosh (curved) or Miller (straight), but other blades do exist. A common problem is many providers' insistence upon using a blade that "works for them." Laryngoscope blade selection is based on the patient, not the provider, with curved blades used for shorter, fatter necks and straight blades for longer, more anterior tracheas. The well-prepared provider will have both immediately available during the procedure in case a different view is needed. Some commercially available options for intubation include specialty blades, such as the Viewmax and Grandview, while other options like the Howland lock alter a standard blade setup. These devices are designed to change, and in many cases improve, your view of the trachea to allow for more successful intubations.

     Newer options exist for many providers today, with devices like the laryngeal mask airway and Combitube becoming increasingly commonplace. A strong feature of these devices is their simplicity of insertion, with no need for laryngoscope blades or handles. Both offer rapid and relatively easy insertion and ventilation. You do need to realize that both devices are back-ups to endotracheal intubation, and their use may be limited by patient size (the Combitube is not for use on pediatric patients), height (the Combitube cannot be used on patients less than 5 feet tall, or 4 feet with Combitube SA) and weight (the LMA is sized specifically by weight of the patient, and some models only go to patients weighing less than 100 kg). In cases of failed endotracheal attempts (due to poor visualization of landmarks) or the provider's inability to perform endotracheal intubation (from equipment failure or scope of practice), the LMA and Combitube can provide a temporary airway to allow effective ventilation. In all cases, the provider must have at least considered attempts at endotracheal intubation, as both manufacturers indicate the devices are not a substitute for endotracheal intubation. Both manufacturers also do not recommend use in patients with any gag reflex, esophageal disease or those who have ingested caustic substances.

     The laryngeal mask airway (LMA), in use since 1988, has proven to be an effective method of airway control, especially in nonemergency settings. Originally designed for operating room use, its ability to serve as a back-up airway device has led to its use by a large number of prehospital services. It is included as a class IIa device in the current ACLS guidelines as an "intervention that is safe, useful and acceptable." The blind insertion technique allows for application in airway management complicated by poor landmark visualization, or in a high Mallampati class. The LMA comes in six different models, the most common prehospital model being the LMA Unique, which is disposable, but is limited in use to a maximum of a 100-kg patient. The LMA is also available in up to eight different sizes (1, 1½, 2, 2½, 3, 4, 5, 6) and consists of a silicone cuff attached to a wide single lumen tube, with a standard 15mm connector on the end. The cuff is inflated with varying amounts of air, depending on the size selected (4 ml to 50 ml). An approach that allows use of both the speed and ease of LMA insertion and the secure airway an endotracheal tube provides can be found in the LMA Fastrach, which allows insertion of an endotracheal tube after LMA insertion. Insertion of the LMA requires the patient to be placed in the "sniffing" position, as in tracheal intubation. Be cautious when inserting the LMA, as the tip of the cuff may inadvertently fold over during improper insertion, causing a path for vomitus to exit the esophagus, deflect off the LMA and directly enter the trachea. Following the manufacturer's instructions for insertion will help prevent this.

     The Combitube is similar in application to the LMA, in that it is a back-up to endotracheal intubation. The Combitube design is similar to an endotracheal tube; however, it is a dual lumen device and is inserted blindly. The lumens are clearly marked #1 (with a blue pilot bulb) and #2 (with a white pilot bulb). Each lumen has a cuff, with lumen #1 holding 100 ml of air and lumen #2 holding 15 ml of air. The Combitube feels and seems to many providers to be closer in design to a standard ET tube, and may provide a measure of comfort in how to handle and insert the device, compared with the LMA. The Combitube comes in two sizes: the Combitube (for patients 5' or taller) and Combitube SA (for patients 4' to 5½'). One major drawback of the Combitube is that the device may enter the trachea or the esophagus (although the esophagus is much more likely). When it's placed into the esophagus, you must ventilate through port #1, as ventilations through port #2 will cause significant gastric distension and no air exchange in the lungs. If the device is inserted into the trachea, you must ventilate through port #2, as the reverse would happen if you ventilate through the wrong port. You should be very cautious and clearly indicate which port to use during ventilations, especially during transfer of care. Combitube use is rapid and relatively easy, and does not require manipulation of the cervical spine (it can be done from a neutral position).

     The final airway control option to discuss is an invasive airway, which includes surgical and needle cricothyrotomy. Some jurisdictions allow one, both or neither of these options, so follow local protocols carefully. The location and indications for these procedures are identical; the procedures performed during actual insertion are the only difference. Cricothyrotomy is an option only after all other methods have been attempted to ventilate a patient. If you are unable to control the airway with endotracheal intubation or an alternate airway, but are still able to effectively ventilate the patient with a BVM, this procedure is not indicated.

     Needle cricothyrotomy is performed by inserting a 14-gauge (typically 2" in length) needle through the cricothyroid membrane. The patient is then ventilated through one of several methods, which include a trans-laryngeal jet ventilator, the connector from a 3.5 ET tube or the barrel of a 3cc syringe. To use a 3.5 ET tube, remove the ET tube from the 15/22mm connector, attach the connector to the hub of the catheter, and then connect the BVM. To use a 3cc syringe, cut the barrel of the syringe in half with trauma shears, attach the luer lock to the catheter, and the BVM will fit over the cut end of the syringe barrel. Commercial kits are also available that may save time and fumbling for supplies. The major drawback to this method is that ventilatory volumes are significantly reduced, as all inhalation and exhalation must now pass through the very small diameter of the 14-gauge catheter. The risk of barotrauma is very high, and ventilation through a needle cricothyrotomy is a temporary solution at best, working for perhaps 20-30 minutes at most. It is far less desirable in effectiveness than a surgical (or open) cricothyrotomy, but also has fewer complications during the procedure itself.

     For any provider who has ever attempted a surgical (open) cricothyrotomy, the first image that springs to mind is usually a lot of blood. This is a seldom-used paramedic-level skill, and for good reason. Paramedics rarely wield a scalpel, and cutting into a patient's neck is an option not to be considered lightly. The procedure of a surgical cricothyrotomy involves making an incision over the cricothyroid membrane, then puncturing through it to insert a larger diameter tube through the membrane to ventilate the patient. Alcohol or Betadine wipes, a scalpel (usually with a #11 blade) and an ET tube (usually a 5.5 or 6.0) are all that are needed, but many commercial kits provide for an excellent prepackaged set-up. The major benefit of a surgical cricothyrotomy is that the provider is utilizing a nearly full-size ET tube to allow ventilation and exhalation. Once in place, the airway acts just as a typical endotracheal tube. The major disadvantage is the necessary anatomical knowledge. One small slip may result in significant trauma and hemorrhage, so precision, care and caution are critical. This procedure is not easy to do for a patient without an airway in a critical situation.

The Suction Unit-A Powerful Tool
     Anytime a patient may have a compromised airway (nearly any patient we encounter), all of the tools in the jump kit will be of little to no use without a suction unit. Oftentimes banished to the back of the compartment, neglected in its battery checks and suction tubing connections, the suction unit can make the difference between an airway that is relatively easy to immediately control and a complete respiratory arrest. Suction units can help quickly clear an airway, but some confusion does exist over their use.

     Whether you use a manually powered, battery powered or vehicle-mounted suction unit is of little consequence, as all have their pluses and minuses. What is important is correct use. A suction catheter is measured in the same manner as an OPA: Place the tip of the catheter at the corner of the patient's jaw and measure back to the corner of the mouth. This indicates the maximum depth to which the catheter should be inserted during suctioning. Further insertion may cause vocal cord damage. Suction should be applied (turned on) after insertion and as the catheter is slowly pulled back. This should not exceed 15 seconds. If the patient has a clear airway, provide ventilations until suctioning is required again. But what if the airway is not clear? If the patient's airway is still filled with fluid, suction another 15 seconds. There is no value in attempting to ventilate through a fluid-filled airway. Use the 15-second rule as a guide to stop and re-evaluate the airway, and then make a clinical decision to ventilate or continue suctioning. When suctioning thick secretions, consider rinsing the tip of the catheter and suctioning up some sterile water or saline in between uses, as this can help clear the "junk" in the catheter itself.

Summary
     Airway management is as easy as your ABCs: Assess the airway for adequacy, blockages and sixth-sense concerns; use basic skills to position, utilize adjuncts and suction the airway; and control the airway with endotracheal intubation, alternative airways, or, when all else fails, invasive and surgical airways. It is the responsibility of every provider, regardless of certification level, to manage a patient's airway in the most effective way possible. When it's done in an organized manner, quickly, properly and effectively, considering all options of care, both patient and provider will be able to take a deep breath of relief.

CEU Review Form Airway MANAGEMENT (PDF)Valid until March 6, 2007

Bibliography

American Heart Association. Part 7.1: Adjuncts for Airway Control and Ventilation. Circulation 112:51-57, 2005. Retrieved October 10, 2006 from https://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-51. American Heart Association. BLS for Health Care Providers, p. 69. South Deerfield, MA: Channing Bete Company, 2006.
Halliday K. Body piercing: Issues and challenges for nurses. J Forens Nurs 1(2): 47-56, 2005.
Margolis GS. Paramedic: Airway Management. Sudbury, MA: Jones & Bartlett Publishers, 2004.

Marc Minkler, NREMT-P, CCEMT-P, is a paramedic/firefighter with the Portland (ME) Fire Department, faculty at Southern Maine Community College, and author of several instructor guides and PowerPoint programs. Contact him at mam@portlandmaine.gov.

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME, and EMS Program Coordinator at York County Community College in Wells, ME. He is the author of several EMS textbooks and a nationally recognized lecturer. Joseph J. Mistovich, Med, NREMT-P, is a professor and the chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, Ohio, and a nationally recognized lecturer.