Not So Basic Airway Maneuvers

Airway. Breathing. Circulation. Preservation and restoration of these three entities represent the core knowledge and values imparted to every EMS provider from the moment they begin medical training. Why do we spend so much time focused on these three words? Simply put, it is because none can exist without the others, and human life cannot exist without at least minimal function of all three. Thus, the initial management and stabilization of these three areas, especially the airway, have become the defining roles of emergency medicine and emergency medical systems worldwide.

Although educational curricula have emphasized the importance of airway patency and the maneuvers necessary to accomplish this task for almost 40 years, lack of a patent airway still represents one of the most frequent causes of death in traumatically injured (surgical critical care) and severely ill (medical critical care) patients. Although definitive airway control is considered to be tracheal intubation, EMT-Basics are unable to perform this procedure. Occasionally, EMT-Paramedics will be unable to intubate their patient. Unless the Combitube or other "intermediate" device or a rescue airway device is used, basic airway maneuvers will still be the fallback strategy necessary to preserve life. This article provides a brief overview of airway maneuvers that can be performed at the EMT-Basic level and common reasons why EMS providers do not properly perform them.

Opening the Airway

Partial or complete airway obstruction has many causes (Table I). Partial airway obstruction in a patient with altered mental status may be due solely to posterior displacement of the tongue, which can lead to complete airway obstruction if the patient becomes unconscious. The head-tilt, chin-lift maneuver is recommended for opening the airway if there is no chance of traumatic neck injury. Otherwise, the modified jaw thrust is performed by grasping the mandibular rami at each angle and pulling forward while simultaneously pushing down on both sides of the chin with the thumbs. Since the tongue is attached to the mandible, it is pulled anteriorly and inferiorly away from the glottis. If aspirated food or other foreign body is the cause of airway obstruction, the standard algorithm for foreign body airway obstruction should be followed. Complications of the Heimlich maneuver and abdominal thrusts are known but rare if the procedure is properly performed. Refer to any AHA or ARC manual for further information.

Patient Positioning

The patient who requires basic airway maneuvers to be performed should be placed supine on the flattest surface available at the beginning of resuscitation. Patients who require cervical spine immobilization and are placed on a backboard should be secured to this board tightly enough so they will not slide or fall if the board is turned on its side to allow gravity to affect the drainage of vomitus or secretions.

Suctioning

Any patient in whom blood, secretions, vomitus or foreign body are present in the upper airway requires suction. Large bore rigid or tonsil suction tips are specifically designed to handle a large load of debris and are the instrument of choice for use in emergency clearance of any airway obstructions. Suctioning should not exceed 15-second intervals before supplemental oxygen is reapplied in order to limit hypoxia, although it is also not desirable to push large amounts of unrecovered debris down the trachea and into the lower airways. Suctioning should be performed under direct visualization of the posterior pharynx.

Artificial Airways

Nasopharyngeal and oropharyngeal airways are intended to prevent the tongue from falling backward and occluding the upper airway. Oral airways may also decrease teeth-clenching. Their use should be considered mandatory if mask ventilation is planned for a prolonged period of time. Nasal airways may be tolerated by semi-conscious patients. After adequate lubrication, they are inserted with the bevel facing the septum and gently rotated into place. The patient must lack a gag reflex to accept an oral airway. In this event, when the patient is totally unconscious, every attempt should be made to have a qualified healthcare provider intubate the patient as soon as possible. The oral airway may be directly inserted into the mouth along the tongue, if the tongue is held down by a tongue blade. The most common complication of oral airways is gagging and intolerance in a patient who is regaining consciousness. Nasal airways should be avoided in patients who may have sustained facial or basilar skull fractures.

Artificial Ventilation

Once the airway has been reestablished and cleared of obstructions, an estimate must be made concerning the adequacy of oxygenation and ventilation. If the patient has inadequate ventilation or cannot maintain normal oxygen saturation despite high concentrations of supplemental oxygen, artificial ventilation must commence. All attempts should be made to avoid mouth-to-mouth ventilation, given the risk of infectious disease transmission, unless there is no alternative. Mouth-to-mask ventilation is the preferred method of artificial ventilation until a bag-valve-mask becomes available. Mouth-to-mask ventilation provides a barrier between rescuer and patient through incorporation of a unidirectional valve in the device. The unidirectional valve directs the patient's exhaled air away from the rescuer and isolates the two airways. The transparent plastic composition also provides an imper- vious barrier to blood and vomitus.

Bag-valve-mask (BVM) ventilation is a basic skill taught to all healthcare professionals, but it is a difficult skill to remain proficient with, especially if it is used infrequently. No scientific studies to date are able to show that EMS providers consistently deliver adequate tidal volumes with a BVM. The two-man BVM technique is preferred in order to assure proper mask seal and reduce leakage of air around the face (see the photograph on opposite page). One provider forms a seal with the appropriately sized mask, while a second provider uses two hands to ventilate the patient. Factors that lead to inadequate ventilation and complications of artificial ventilation can be found in Tables II and III.