Author: Gavin Lloyd / Editor: Gavin Lloyd / Reviewer: Grace McKay / Codes: C3AP6, RC1, RC2, RP1, RP8, SLO3, SLO6 / Published: 21/02/2020
Patients with airway compromise need prompt recognition and correction using basic airway techniques. These are essential skills for emergency physicians.
This session involves:
- Clinically identifying patients with airway compromise
- Responding to these with simple airway manoeuvres
- Selecting and introducing airway adjuncts appropriately
- Recognising the need for ventilation and delivering this effectively
The image shows a sagittal view of the adult airway. Partial or complete obstruction can occur at any point.
Patients with a reduced conscious level are vulnerable to airway obstruction through relaxation of their smooth muscle. Relaxed smooth muscle causes: occlusion of the nasopharynx by the soft palate, occlusion of the oropharynx by the tongue and occlusion of the laryngopharynx by the epiglottis.
Airway obstruction can also occur through other mechanisms (see table below)
Table 1: Causes of airway obstruction
|In the lumen||In the wall||From outside the airway|
– Peritonsillar abscess
– Retropharyngeal abscess
– Floor of the mouth infection
|Penetrating neck injury|
|Secretions||Trauma to larynx (blunt and penetrating)||Tumour|
|Blood||Tumour||Oesophageal foreign body|
Conscious patients with airway compromise will typically sit upright and look distressed. Make sure to examine for:
- Swollen tongue (angioedema or anaphylaxis)
- Sooty sputum (following a thermal injury)
- Neck haematomas (following blunt or penetrating trauma)
- Rashes (anaphylaxis or poisoning)
- Laboured breathing and wheeze (asthma)
- Facial fractures
- Crepitus and surgical emphysema (laryngeal injury)
In unconscious patients examine for:
- Snoring or added airway noises (indicative of partial airway obstruction)
- Abnormal chest and abdominal wall movement (suggestive of airway obstruction)
- Lack of fogging of the oxygen mask
|Fig 1: Lack of fogging of the oxygen face mask during normal inspiration||Fig 2: Fogging of the oxygen face mask due to normal expiration|
Unconscious patients are vulnerable to aspiration:
- Foreign bodies
Use a wide bore rigid sucker and gentle suction under direct vision to remove potential aspirates (see image)
If the patient is actively vomiting or if there is a significant amount of blood in the airway, turn the patient on their side and tip the trolley head down to avoid aspiration. (Not an option in c-spine injury)
If there are thick secretions or undigested food, remove the suction catheter and just use the tube to avoid blockage.
Unconscious patients lying supine are vulnerable to airway obstruction because the oral axis (OA), pharyngeal axis (PA) and laryngeal axis (LA) are misaligned (Fig 3).
Placement of a pillow or folded blanket beneath the head flexes the neck in relation to the torso (Fig 4).
A chin-lift manoeuvre extends the head in relation to the neck and achieves the sniffing position (Fig 5).
Both manoeuvres in combination improve axes alignment. If the patient is breathing adequately, a high-flow oxygen mask can be applied.
Malalignment of the oral, pharyngeal and laryngeal axes in a patient in the supine position.
Malalignment of the oral, pharyngeal and laryngeal axes in a patient in the supine position, and modification of alignment of axes, following placement of a pillow or folded blanket beneath the head.
Beware hyperextension of the neck with the chin-lift manoeuvre because it can further compromise the airway.
Gentle movement is advised in patients with fixed neck deformities.
The chin-lift manoeuvre – obese patients
In obese patients, standard pillow placement may compromise the airway further by causing flexion of the head in relation to the neck.
To optimise an obese patients airway, place a pillow under their shoulders and a number of pillows under their head to elevate the chin above the chest (See Figure 6 & 7).
|Fig 6: Chin-lift manoeuvre. Neutral position, malalignment of the axes. Obese patient||Fig 7: Chin-lift manoeuvre. ‘Sniffing’ position, improved alignment of the axes. Obese patient|
The jaw thrust
The jaw thrust lifts the mandible forwards and lifts the tongue off the posterior pharynx. The manoeuvre is used for patients who require bag-mask ventilation (see image).
The jaw thrust technique should be practiced in the clinical environment. It is achieved by hooking the little fingers underneath the angle of the jaw. Using the ring and middle fingers to secure grip under the mandible. Using the index finger and thumb to secure a tight seal between a mask and the face. Holding this position may become tiring.
In trauma patients with suspected cervical spine injury, the jaw-thrust should be used instead of the chin-lift because movement of the head and neck is contraindicated.
Oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) adjuncts are designed to address airway obstruction and free the airway practitioner. Both adjuncts are generally only tolerated in unconscious patients. If a patient is tolerating an OPA or NPA consider the need for an advanced airway practitioner and intubation.
Tolerating an OPA is an indicator of a vulnerable unprotected airway.
The Oropharyngeal airway
An OPA produces the same result as a jaw thrust.
Measure between the patients incisors to the angle of the jaw (See image)
|Fig 8: Oropharyngeal airway should reach from the patient’s incisors to the angle of the jaw||Fig 9: The flanged front end of the oropharyngeal airway should sit just in front of the teeth|
- Insert OPA ‘upside down’
- Twist 180 once inserted halfway (behind the tongue)
- The flanged front end should sit just in front of the teeth (See image)
An OPA may precipitate vomiting or laryngospasm. In both situations, remove the OPA promptly.
A NPA can be used for patients whose mouths are difficult to open, such as during a seizure.
The internal diameter of the NPA tube is marked on the side of the tube. Use a 6 mm size for women and 7 mm for men.
- Lubricate the tube with gel
- Insert into the nostril gently curved side down
- Aim towards the occiput
- Use a twisting motion if necessary
- Change to a smaller airway if there is firm resistance
NPA are unlikely to stimulate the oropharynx and are better tolerated in lightly unconscious patients.
NPA can cause nasal haemorrhage so always check the oropharynx post-insertion for blood.
Base of skull fracture is a relative contraindication to NPA insertion. Avoid using NPAs if patients have obvious mid-face injury.
After securing a patent airway, you must decide whether the patient needs:
- An oxygen mask for ‘Passive Ventilation’
- Assisted Ventilation
Determine the adequacy of the patients spontaneous ventilation by looking at:
- the depth of chest wall movement
- the rate of chest wall movement
- the coordination of breaths
- the oxygen saturations
- the end tidal c02 or pCO2 by arterial blood gas analysis.
If ventilation is required you will need:
- The correct size facemask (one that fits snugly from the bridge of the nose to just above the chin) (Fig 10)
- A self-inflating bag (Fig 11)
|Fig 10: Facemask fitting snugly from the bridge of the nose to just above the chin||Fig 11: Self-inflating bag|
Check the airway does not need suctioning first, then:
- Apply the mask firmly to the patients face using the index finger and thumb in a capital C shape
- Hook the little finger under the angle of the mandible and grip more mandible with the ring and middle fingers
- Raise the spread fingers to effect the jaw thrust
- Squeeze the bag firmly with the right hand, release, pause and repeat at a rate of 10 breaths per minute
Single operator bag-mask ventilation is not an easy skill and sometimes two-person ventilation will be required. Ask someone to squeeze the bag while you attempt to provide better airway patency and mask seal using both hands.
|Fig 12: Applying the self-inflating mask to the patients face||Fig 13: The bag of the face mask. Squeeze firmly|
Adequate ventilation can be confirmed by looking for chest wall movement and improvement in oxygen saturation.
Table 2 gives examples of difficulties in securing an adequate seal or ventilating with practical solutions.
|Poor mask seal||Solution|
|Blood and vomit creating a slippery surface||Clear the airway with suction; use a towel to dry the patient’s face|
|Edentulous patient||Replace the dentures or pack the cheeks with gauze if dentures missing|
|Unstable facial fractures||
|Beard||Apply gel to improve the seal|
|Facial asymmetry||Use a two-person technique??|
|History of snoring||Attention to correct head/neck positioning +/-adjuncts +/- two-person technique|
|Abdominal distension including obesity, third trimester and ascites||Consider elevating the head end in non-traumatic patients|
|Stiff or immobilised neck||No options available. Do not force elderly patients necks|
|COPD/asthma||Aggressive medical therapy|
|??Big tongue||Consider oropharyngeal airway|
Difficulty in Ventilation
After troubleshooting, you may find that ventilation is still difficult.
*Call for senior help * and in the interim:
- Optimise patient positioning
- Try 2 NPAs with a OPA
- Try a laryngeal mask airway
- If there is still no improvement you need an advanced airway practitioner and this patient may need intubation
- The sniffing position can be achieved in most patients with a pillow and chin-lift
- Turning the unconscious patient on their side and tipping the trolley head down may be the best way of avoiding aspiration
- In trauma patients, apply the jaw-thrust not the chin-lift manoeuvre
- Toleration of an oropharyngeal airway is one of the best indicators of an unprotected airway
- Use the nasopharyngeal airway in patients with airway compromise whose mouths are difficult to open
- Single operator bag-mask ventilation is not an easy skill. Practice on a manikin
- Difficult Airway Society. UK Training in Emergency Airway Management (TEAM) Course. View website
- Royal College of Anaesthetists. UK Training in Emergency Airway Management (TEAM). View website.
- Difficult Airway Society. DAS Guidelines. View here.
- Resuscitation Council (UK). The ABCDE approach. View here.
- Nickson, Chris. Airway Assessment. Life in the Fastlane. 2019.
- Bradley, Pierre. et al. Airway Assessment. ANZCA. 2016.