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2/15/2014 Clinical Skills Resource Centre, University of Liverpool, UK 1

BASIC AIRWAY

MANAGEMENT


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AIRWAY OBSTRUCTION

Obstruction of the airways is a medicalemergency.

It may be partial or complete, and may occur

at any level of the respiratory tract.

If untreated, airway obstruction leads to a

lowered blood oxygen levels and risks

hypoxic damage to the brain, kidneys andheart, or even death.


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CAUSES OF AIRWAY

OBSTRUCTION Decreased muscle

tone

Vomit

Blood Regurgitation of

stomach contents

Trauma

Foreign Bodies

Oedema

Inflammation

Anaphylaxis

Excessive bronchial

secretions Mucosal Oedema

Bronchospasm

Pulmonary Oedema Aspiration of gastric

contents


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RECOGNITION OF OBSTRUCTION

1 Inspiratory StridorUpper airway problem

Expiratory WheezeLower airway problem

Complete obstructionparadoxicalmovement (see-saw respirations)

Central cyanosis is a late sign of airwayobstruction


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RECOGNITION OF AIRWAYS

OBSTRUCTION 2

Look- for chest and abdominal

movement

Listen- for air-flow at mouth andnose and absence of breath sounds

Feel- for airflow against cheek


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OBSTRUCTION 3 In complete upper airway obstruction, there are no

breath sounds at the mouth or nose. In partial

obstruction, air entry is diminished and often noisy.

Certain noises assist in localising the level of the

obstruction:

Gurgling suggests the presence of liquid in the

mouth or upper airways

Snoring occurs when the pharynx is partially

obstructed by the tongue


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OBSTRUCTION 4

Crowing occurs during laryngeal spasm

Inspiratory stridor is caused by obstruction

above or at the level of the larynx

Expiratory wheeze results from airway

narrowing or irregularities of the air passages

during expiration (e.g. asthma)


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MANAGEMENT OF AIRWAY

OBSTRUCTION

In the majority of cases, the use of simplemethods is all that is required to open the

airway, such as suction to remove

secretions, use of head tiltchin liftmanoeuvre or the insertion of an

oropharyngeal or nasopharyngeal airway.


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SUCTION

The patients airway must be kept clear of foreignmaterials, blood, vomitus, and other secretions.Materials that are allowed to remain in the airwaymay be forced into the trachea and eventually intothe lungs.

This causes complications ranging from severepneumonia to complete airway obstruction.

Suctioningis the method of using a vacuumdevice to remove such materials.

A patient needs to be suctioned immediatelywhenever a gurgling sound is heardwhetherbefore, during or after artificial ventilation.


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SUCTION

Each suction unit consists of a suction source, acollection container for materials you suction and asuction catheter.

The most popular type of suction catheter is therigid pharyngeal tip known as a Yankauer.

This rigid device allows you to suction the mouthand pharynx with excellent control over the distalend of the device.


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HOW TO USE SUCTION

Always use appropriate infection control practiceswhile suctioning.

Suction as much as you can before opening the

airway further Suction should not be used for longer than 15

seconds at a time.

Place the tip of the catheter where you want to

begin suctioning and suction on the way out only.

SUCTION ONLY WHERE YOU CAN SEE


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YANKAEURSUCKER

WALL MOUNTEDSUCTION UNIT


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Oxygen non re-breathing mask

This device is used when a patient needs additionaloxygen and is breathing independently, it can also

be used with simple airway adjuncts inserted

All acute medical / trauma emergencies, e.g

Asthma

Myocardial infarction (Heart attack)

Pre / post operative

Trauma Respiratory distress



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Oxygen non re-breathing mask

It is designed to function with an oxygen flowrate in excess of 10 L/min which will if used

correctly deliver 8090% oxygen.

It works by having a simple valve that permitsthe flow of oxygen, but during exhalation closes

to prevent dilution of oxygen in the reservoir

bag.

However, not all exhaled air is removed.

Therefore, there is an element of re-

breathing



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Preparing the mask

Turn the oxygen supply to at least a 10L flow rate.

Block the mask and allow the reservoir bag to fill.

Immediately apply the mask to the patients face.

To monitor effectiveness, Observe the rise & fall of the patients chest.

Observe the contraction & expansion of the

reservoir bag. Effective method at distance.

The mask fogging on exhalation & clearing on

inhalation.



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Preparing the mask 1

Turn the oxygen supplyto at least a 10L flow

rate.

Grasp the body of themask allowing the

reservoir bag to fill.

Then apply it to the

patients face



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Preparing the mask 2

Immediately apply themask to the patients face.

To monitor effectiveness,

Observe the rise & fall of

the patients chest. Observe the contraction

& expansion of the

reservoir bag. Effective

method at distance.

The mask fogging on

exhalation & clearing on

inhalation.



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Simple airway adjuncts

Simple airway adjuncts may assist maintenance ofan airway in either the spontaneously breathing or

ventilated patient

May be useful if prolonged resuscitation isundertaken without formal endotracheal intubation

They can be used in addition to head tilt-chin lift or

jaw thrust

The two commonest are the oropharyngeal(Guedal) and the nasopharyngeal airways


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Nasopharyngeal airway

Only airway device tolerated by the conscious patient.

May be lifesaving in people with clenched jaws, trismus orjaw injuries

Should NOTbe used where there is evidence of fracture of

the base of the skull Size to use = diameter of the nostril, length is

predetermined corresponding to the width selected inadults.

To prevent inhalation, or passing of the nasopharyngeal

airway too far into the nasal cavity, a safety pin if providedmust be inserted through the flange

This airway adjunct will protect the airway from obstructionof by the soft palate, but may not from obstruction by thetongue


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Nasopharyngeal airway

Most new models have a wide flange and nolonger require the insertion of pin

lubricate well with water based jelly to easeinsertion

Check nostril patency

Insert airway bevel end first, pass vertically alongfloor of the nose using slight rotation

If obstruction felt, try other nostril Tip should lie in the pharynx

Once in place look, listen, feel


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NASOPHARYNGEAL AIRWAY


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Oropharyngeal airways

Curved plastic tubes

Size = incisors to angle of the jaw

Incisors should be level with some part of the bite

block ( coloured section) Should only be used in the unconscious patient as

stimulation of the gag-reflex may result in vomiting

and stimulation of the laryngeal-reflex may result

in laryngospasm

Open mouth and ensure no foreign material


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Introduce into oral cavity inverted

Rotate through 180 as passes below palate

Any coughing or retching should prompt removal of

the airway

After insertion check airway with look, listen, feel

(insertion technique is different in children)

Oropharyngeal airways


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OROPHARYNGEAL AIRWAY


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Is the Patient breathing ?

YES. Give additional oxygen via a re-breathing mask

Set Oxygen flow rate at 10 -15 litres / minute

This should deliver approx 85% oxygen

NO. (but has a pulse)

If the patient stops breathing you need to ventilate

Methods of ventilation include :-

Mouth to mouth (as in BLS)

Pocket mask

Self inflating Bag Valve Mask (BVM)



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Using a Pocket-mask

A pocket face mask allowseasier ventilation with jaw thrust

and can be used with head tilt -

chin lift

Non-return valve prevents

rescuer from re-breathingvictims expired air

Removes need for mouth to

mouth ventilation, but

administers only 16% O2

concentration Adding high flow (10-15

litres/min) oxygen can improve

oxygenation markedly (45-50%

concentration)


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Technique of using pocket-mask

Apply mask to face using thumbsof both hands

Lift jaw using pressure applied to

angles of the jaw by fingers

Blow through inspiratory valve

Watch chest rise and fall

Any leaks can be reduced or

abolished by adjusting position

of mask, contact pressure,

position of digits or altering jaw

thrust

Apply oxygen via input nipple at

10-15 litres/min if available


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Self Inflating Bag-valve-mask

Mask applied to face Contact and jaw lift are maintained with two hands

The bag is squeezed by a second person, to deliverapprox 500mls of air per breath

Watch chest rise and fall

Delivers 21% oxygen

Attaching oxygen at a high flow (> 10 Litres/min) canraise concentration to 50-55%

Ideally there should be a filter in situ.

Preferably it should be once use only B.V.M.


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SELF INFLATING BAG-VALVE-MASK

TWO PERSON TECHNIQUE

ONE PERSON TECHNIQUE

TWO PERSON TECHNIQUE


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Bag-valve-mask-reservoir

The addition of areservoir to the

bag-valve-mask

arrangementraises oxygen

concentration to

approx.. 90% witha high-flow rate of

10 -15 litres


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Delivery of oxygen

Method O2concentration

Mouth to mouth 16%

Mouth to mask 16%

Mouth to mask with O2attached (10-15l/min)

45-50%

Mask and bag 21%

Mask and bag mask with

O2attached (10-15l/min)

50-55%

Mask and bag mask withreservoir and O2attached(10-15l/min)

90%


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Self inflating bag valve mask.

In cardiac or respiratory arrest it maybe desirable touse this device.

It has the advantage of delivering a higher

concentration of oxygen to the patient plus allowing

connectivity to more advanced airway devices.

The disadvantage is that it is not easy to use and it is

recommended that it is used as a two person

technique. However, if there is no alternative or the

individual is skilled it may be used by one person.

If necessary the person tasked to squeeze the bag may

also do the 30 chest compressions between squeezes.

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19 airways management dec2012

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