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Advancing Airway Management: Opening and Maintaining the Airway
“Open the airway,” “head-tilt chin lift,” “jaw thrust and modified jaw thrust.” All terms we’ve both heard and used many times, either in education or while engaged in patient care. But do we actually understand the physical dynamics of how to open an airway and keep it open for artificial ventilation?
More often than not I think we don’t actually understand how to open the airway properly. I wish I had hard scientific evidence to support my belief, but unfortunately I only have 30 years of personal experience to rely on. I can recall far too many cases where I arrived to hear the dreaded sound of air blowing out around the mask of the bag-valve device. Buurrrrrbbbbbb, buurrrrrrrbbbbbb—every three or four seconds—buurrrrrbbbbb. Notice I say every three to four seconds; that’s because we know hyperventilation is a problem, but it’s a topic better left for another article.
I must confess, I’ve been one of the many providers who just went through the motions and “bagged” the life right out of my patients. Ignorance is bliss. Luckily for me and all of my subsequent patients, a phenomenal physician named Dr. Michael Murphy and a wonderful CRNA named Judy Leftwich brought reality crashing down on me. “Open the airway and hold it open,” I was told. Easier said than done, I learned very quickly.
This article will address the most basic of our airway maneuvers: opening and maintaining the airway. Please, for the good of our profession and the patients we serve, read it carefully and then begin employing the techniques we teach in The Difficult Airway Course: EMS.
The Problem is the Tongue!
Providers are really good at trying to ensure the head is hyperextended in obtunded patients, but simply tilting the head back often does not remove the tongue from the post-oral pharynx. That’s where the “chin-lift” comes in. The tongue is securely fastened to the mandible and by moving the mandible anteriorly, the tongue will follow and prevent obstruction of the pharynx. The problem becomes applying enough force under the chin to adequately move the mandible, and thus the tongue, anteriorly. The often-performed one-man BVM with C&E technique is very hard to perform, and even harder to master. Even if we’re able to move the mandible with one-hand, maintaining that forward position is a daunting task, especially during prolonged artificial ventilation. For these reasons, we at The Difficult Airway Course: EMS, strongly encourage all agencies to dedicate two providers to airway management when providing bag-mask ventilations.
With the two-person approach, the provider responsible for opening and maintaining the airway has the distinct advantage of using both hands to exert enough pressure to move the mandible and tongue anteriorly. To perform this action well, the first step is to open the mouth fully, then place the thenar pad (the area of the hand where your thumb attaches to the hand) on the zygoma (cheek). This allows your fingers to naturally fall into place behind the angle of the mandible. Now, apply significant anterior pressure to ensure you move the head of the mandibular condylar process out of the temporomandibular joint (TMJ). In other words, nearly dislocate the jaw, which is called ‘translating’ the mandible anteriorly. This procedure, although it sounds dramatic, will ensure the mandible and tongue are sufficiently moved forward to make certain the pharynx is unobstructed.
Once this has been achieved, you have to maintain that position throughout the time you are providing bag-mask ventilations. If sufficient pressure is not maintained to ensure the condylar process is kept forward of the TMJ, in the absence of some mitigating TMJ disorder, the mandible will move posteriorly back into place, reintroducing the tongue into the pharynx.
Of course, it’s important to use airway adjuncts (oropharyngeal or nasopharyngeal) to assist with maintaining the tongue’s anterior placement. But adjuncts alone are not enough. The most important aspect of maintaining the open airway is ensuring the mandible and tongue are pulled forward.
I realize most EMS textbooks don’t go to this extent to describe this procedure, but I think they should. We’ve done a poor job teaching a very basic, but critically important procedure. Most providers do not understand the extent and force it takes to move the tongue and maintain the open airway. I don’t want you to take my word for it. I want you to watch the following two videos to see how a well-placed jaw thrust will ensure your patient’s airway is open.
The first video is a lateral fluoroscope of an airway being manipulated. At first you’ll see a jaw lift. Watch as the jaw is pulled forward and you’ll see the tongue move forward out of the pharynx, and the bright backlight will shine through showing what we hope to achieve. The next action is a hyperextended head tilt without a jaw lift. Unfortunately, even though we teach the jaw lift with the head tilt, more often than not patients are only afforded the hyperextension. What do you notice about the tongue in the post-oropharynx? Obstruction is what you are viewing. Despite an exaggerated head tilt, the tongue is firmly occluding the pharynx. Now, at about 10 seconds into the video, watch very carefully as a proper jaw thrust is performed. Pay particular attention to the incisors of the mandible as they are pushed anteriorly. Watch for the little “pop” as the condylar process moves out of the TMJ. Did you see it? Now look at all the white light passing through the post-oral pharynx. That airway is now open. See AW techniques x-ray rotate video.
In the second video, you are viewing the pharynx through a nasoscope. Note the epiglottis has the post-oral pharynx occluded and the airway closed. A well-executed jaw thrust moves the mandible, tongue and, by association, the epiglottis anterior and opens the airway.
Once you open the airway and are ready to hold it open, use the following Difficult Airway Course: EMS-recommended hand positioning on the mask to ensure you maintain an open airway and mask seal at the same time. Do not allow your thumbs to come across the bridge of the nose, as with the “double C & E” technique. This is not comfortable and does not help facilitate pulling the jaw into the mask. Instead, run your thumbs down the mask and allow your fingers to fall into position to pull the jaw anteriorly into the mask. It is critically important to pull the jaw up into the mask, not push the mask down onto the jaw. This position allows for a much more secure and comfortable position for prolonged ventilations.
Although opening and maintaining an airway is taught in the earliest days of any EMT class, the importance of this critical skill is often not conveyed well, nor is the importance of this skill carried into daily practice. Please consider the ideas and procedures of this article very closely and begin employing these concepts into your daily practice. As a profession, we need to do a better job of maintaining airways and appropriately ventilating the pulmonary fields, while minimizing gastric inflation.
Michael Keller is a curriculum faculty member at Gaston College, Department for EMS Education. He brings more than 25 years of experience in prehospital medicine to the teaching arena. Mike has worked in both urban and suburban/rural EMS environments and has experience with critical care transport, as well. He is a founding faculty member and the southeast regional course director for The Difficult Airway Course: EMS.
Comments
Thank you for this article. I realize this article is over 10 years old but unfortunately the links to the videos no longer work. I would love to see the videos if these links could be reestablished!
—Ruth Stewart