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Airway Establishment and Control

By

Vanessa Moll

, MD, DESA, Emory University School of Medicine, Department of Anesthesiology, Division of Critical Care Medicine

Last full review/revision Apr 2020| Content last modified Apr 2020
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Airway management consists of

  • Clearing the upper airway

  • Maintaining an open air passage with a mechanical device

  • Sometimes assisting respirations

Methods of establishing an airway include

Whatever airway management techniques are used, tidal volume should be 6 to 8 mL/kg (significantly less than previously recommended) and ventilatory rate should be 8 to 10 breaths/minute (significantly slower than previously recommended to avoid negative hemodynamic consequences). Slower rates are commonly used in patients with severe air trapping (eg, acute asthma Asthma Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea... read more , COPD Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more Chronic Obstructive Pulmonary Disease (COPD) [chronic obstructive pulmonary disease]), and passive oxygenation without positive pressure ventilation shows promise in the first minutes after cardiac arrest. Smaller volumes and slower respiratory rates are also desirable in any state of hemodynamic instability; however, it is important to keep in mind that positive pressure ventilation is the opposite of physiologically normal negative pressure ventilation. In cardiac arrest Cardiac Arrest Cardiac arrest is the cessation of cardiac mechanical activity resulting in the absence of circulating blood flow. Cardiac arrest stops blood from flowing to vital organs, depriving them of... read more , physiologic demands are significantly less, and in non-arrest, the benefits of hypoventilation in hemodynamic stability and lung protection often outweigh the negative effects of permissive hypercapnia and moderate hypoxia.

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Clearing and Opening the Upper Airway

To relieve airway obstruction caused by soft tissues of the upper airway and provide optimal position for bag-valve-mask ventilation Bag-Valve-Mask Devices If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more and laryngoscopy, the operator flexes the patient’s neck to elevate the head until the external auditory meatus is in the same plane as the sternum and positions the face roughly parallel to the ceiling (see figure Head and neck positioning to open the airway Head and neck positioning to open the airway Airway management consists of Clearing the upper airway Maintaining an open air passage with a mechanical device Sometimes assisting respirations (See also Overview of Respiratory Arrest.) read more ). This position is slightly different from the previously taught head tilt position. The mandible should be displaced upward by lifting the lower jaw and submandibular soft tissue or by pushing the rami of the mandible upward (see figure Jaw lift Jaw lift Airway management consists of Clearing the upper airway Maintaining an open air passage with a mechanical device Sometimes assisting respirations (See also Overview of Respiratory Arrest.) read more ).

Head and neck positioning to open the airway

Head and neck positioning to open the airway

A: The head is flat on the stretcher; the airway is constricted. B: The ear and sternal notch are aligned, with the face parallel to the ceiling, opening the airway. Adapted from Levitan RM, Kinkle WC: The Airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.

Jaw lift

Jaw lift

Anatomic restriction, various abnormalities, or considerations caused by trauma (eg, inadvisability of moving a possibly fractured neck) may obviate the operator’s ability to properly position the neck, but careful attention to optimal positioning when possible can maximize airway patency and improve bag-valve-mask ventilation and laryngoscopy.

Obstruction by dentures and oropharyngeal foreign material (eg, blood, secretions) may be removed by finger sweep of the oropharynx and suction, taking care not to push the material deeper (more likely in infants and young children, in whom a blind finger sweep is contraindicated). Deeper material can be removed with Magill forceps or by suction.

Heimlich maneuver (subdiaphragmatic abdominal thrusts)

The Heimlich maneuver (for more detailed instructions, see How To Do the Heimlich Maneuver How To Do the Heimlich Maneuver in the Conscious Adult or Child The Heimlich maneuver (abdominal thrusts) is a rapid first-aid procedure to treat choking due to upper airway obstruction by a foreign object, typically food or a toy. Chest thrusts and back... read more ) consists of manual thrusts to the upper abdomen or, in the case of pregnant or extremely obese patients, chest thrusts until the airway is clear or the patient becomes unconscious; it is the preferred initial method in the awake, choking patient.

In conscious adults, the rescuer stands behind the patient with arms encircling the patient’s midsection. One fist is clenched and placed midway between the umbilicus and xiphoid. The other hand grabs the fist, and a firm inward and upward thrust is delivered by pulling with both arms (see Figure Abdominal thrusts with victim standing or sitting Abdominal thrusts with victim standing or sitting (conscious) Airway management consists of Clearing the upper airway Maintaining an open air passage with a mechanical device Sometimes assisting respirations (See also Overview of Respiratory Arrest.) read more ).

An unconscious adult with an upper airway obstruction is initially managed with CPR Cardiopulmonary Resuscitation (CPR) in Adults Cardiopulmonary resuscitation (CPR) is an organized, sequential response to cardiac arrest, including Recognition of absent breathing and circulation Basic life support with chest compressions... read more (cardiopulmonary resuscitation). In such patients, chest compressions increase intrathoracic pressure in the same manner that abdominal thrusts do in conscious patients. Rescuers should examine the oropharynx before each set of breaths and use their fingers to remove any visible objects. Direct laryngoscopy with suction or Magill forceps can also be used to remove a foreign body in the proximal airway, but once an object has passed through the vocal cords positive pressure from below the obstruction is most likely to be successful.

Abdominal thrusts with victim standing or sitting (conscious)

Abdominal thrusts with victim standing or sitting (conscious)

In older children, the Heimlich maneuver How To Do the Heimlich Maneuver in the Conscious Adult or Child The Heimlich maneuver (abdominal thrusts) is a rapid first-aid procedure to treat choking due to upper airway obstruction by a foreign object, typically food or a toy. Chest thrusts and back... read more may be used. However, in children < 20 kg (typically < 5 years), very moderate pressure should be applied, and the rescuer should kneel at the child’s feet rather than astride.

Back blows—infant

Head-down position: Dislodgment of foreign bodies from the tracheobronchial tube. (Adapted from Standards and Guidelines for Cardiopulmonary Resuscitation [CPR] and Emergency Cardiac Care [ECC], in the Journal of the American Medical Association 25:2956 and 2959, June 6, 1986. Copyright 1986, American Medical Association.)

Back blows—infant

Chest thrusts—infant

Chest thrusts are delivered on the lower half of the sternum, just below the nipple level.

Chest thrusts—infant
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How To Do Bag-Valve-Mask (BVM) Ventilation
Bag-valve-mask (BVM) ventilation is the standard method of quickly providing rescue ventilation to patients with apnea or severe ventilatory failure. Which of the following is an important consideration when administering this type of ventilation?
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