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Airway Management

What Is It, When It Is Required, and More

Author: Ali Syed, PharmD

Editors: Ahaana Singh, Lisa Miklush, PhD, RN, CNS

Illustrator: Jillian Dunbar


What is airway management?

Airway management is the assessment, planning, and series of medical procedures required to maintain or restore an individual’s ventilation, or breathing. By maintaining an open airway, air can flow from the nose and mouth into the lungs. 

Airway management is an essential skill for clinicians in critical situations and is fundamental to the practice of emergency medicine.  Lack of airway management in situations where it may be required can lead to reduced blood oxygen levels in individuals and can be life-threatening. 

What are the different types of artificial airways?

The different types of medical devices used to maintain or open an individual’s airway include the oropharyngeal airway (OPA), nasopharyngeal airway (NPA), and endotracheal airway (ETA).

The OPA is a medical device that is used to maintain or open an individual’s airway by preventing the tongue from covering the epiglottis, a small flap in the throat. The OPA is typically used in unresponsive individuals. 

Meanwhile, the NPA is a tube that is passed through the nasal passageway to secure an open airway. NPAs are better tolerated than OPAs and may be considered when OPA use is difficult, such as when an individual’s jaw is clenched or the individual is responsive. 

Lastly, an ETA is a plastic tube that is inserted through the mouth and into the trachea or windpipe. The ETA is then connected to a ventilator, which mechanically delivers oxygen to the lungs.

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When is airway management required?

Airway management may be required for individuals in a variety of circumstances, ranging from simple choking to complicated airway obstruction. Airway obstruction most commonly occurs as a result of the tongue or foreign bodies blocking the airway. It can also be the result of injury to the airway, increased presence of blood and secretions (e.g., saliva and mucus), or inflammation of the airway. Specific clinical signs that may indicate the need for airway management include respiratory failure, reduced level of consciousness, rapid change in mental status, active choking, or penetrating trauma. Depending on the particular circumstance, various different types of airway management may be performed.

Basic airway management may be used alone for mild airway obstructions, such as choking, or in combination with other airway management techniques. Basic airway management involves the use of non-invasive techniques without the need for specialized medical equipment. Examples include chest compressions, abdominal thrusts, and back blows, all of which may be used independently or in combination to relieve foreign body airway obstruction. In some cases, if the individual is unresponsive to these techniques, they may require cardiopulmonary resuscitation (CPR), as chest compressions, when compared to abdominal thrusts, can produce higher airway pressures to resolve the obstruction.

The head-tilt/chin-lift and jaw-thrust are also basic airway management maneuvers. By preventing the tongue from obstructing the upper airway, these maneuvers are used to avoid airway obstruction in unconscious individuals. The head-tilt/chin-lift is not recommended in individuals for which cervical spine injury, or the injury of the upper spine in the neck, is a concern. On the other hand, the jaw-thrust maneuver is suitable when cervical spine injury is suspected. 

 

In cases involving inadequate ventilation, which can result from difficulty breathing or an airway obstruction, bag valve mask ventilation may be required. This intervention pushes air into the individual’s chest in a form known as positive pressure. Choosing to mask ventilate involves having an open airway, creating a tight seal with a mask over the individual’s mouth and nose, and maintaining appropriate ventilation (e.g., volume, rate, and pace) for the duration of the intervention. Careful monitoring of bag valve mask ventilation involves observing the individual to ensure there is chest rise with each cycle of ventilation.  

Once an open airway has been established using basic management techniques, advanced airway management techniques may be employed. Advanced airway management involves the use of specialized medical equipment and invasive procedures to open and maintain an airway in individuals who are critically ill or under sedation. The most commonly used device is the laryngeal mask airway (LMA) that is used as a temporary method to maintain an open airway during administration of anesthesia or as an immediate life-saving measure in a difficult airway situation. A difficult airway is when three or more attempts, of over 10 minutes each, are unsuccessful in securing the airway. 

Other advanced airway management techniques include the use of OPAs or NPAs, which may be used as supplementary techniques to maintain an open airway in deeply unconscious individuals. Both types of airway device will prevent the tongue from blocking the airway and provide adequate ventilation, but they will not protect the trachea from respiratory secretions or an uprise of stomach contents (i.e., regurgitation). 

In critical situations, such as with respiratory failure, airway injury, or reduced levels of consciousness, an ETA may be used as part of endotracheal intubation (ETI) to maintain an open airway and channel to administer medications if necessary. The ETA is passed through the mouth and vocal cords and into the trachea. Clinical signs -- such as mist in the ETA, chest rise with each breath, and breath sounds from air movement in both lungs -- indicate successful intubation. In emergency or critical situations, such as during cardiac arrest, rapid sequence induction (RSI) of anesthesia and intubation may be employed. RSI is performed by inducing unconsciousness and muscle relaxation with various medications.

Finally, if other methods of management have been unsuccessful or are not recommended in a particular situation, surgical intervention for airway management may be required. Cricothyrotomy is a surgical method in which an incision is made in the cricothyroid membrane, which connects the thyroid and cricoid cartilages of the larynx in critical situations. A tracheostomy tube is then inserted into the incision to achieve a functioning airway. This can be confirmed through breath sounds in the lungs as well as through observation of rise and fall of the chest.

Tracheotomy is another surgical procedure in which an incision in the neck is made to insert a breathing tube into the trachea, used in situations where mechanical ventilation may be required for extended periods of time.

What is the most effective method of airway management?

In emergency medicine, RSI, which involves ETI alongside the use of medications, has proven to be the fastest and most effective method of airway management. RSI is particularly useful in individuals with a functioning gag reflex, full stomach, or life-threatening conditions requiring immediate airway management. However, this approach may not be suitable for individuals with known or suspected adverse reactions to any of the drugs used in RSI. Additionally, RSI is not recommended for those with total airway obstruction requiring surgery or those with an anticipated difficult airway. Risk factors for a difficult airway may include a narrow oropharynx, certain airway and vocal cord conditions, as well as a history of difficulties with airway management.

What are the most important facts to know about airway management?

Airway management is an essential technique for clinicians taking care of individuals in critical situations and emergency medicine. Airway management involves a series of maneuvers and medical procedures used to maintain or restore airway functionality. Airway management may be required in situations of airway obstruction, respiratory distress, or when the individual is under sedation. Depending on the clinical presentation of an individual, basic or advanced forms of airway management may be used. Basic airway management techniques are non-invasive, whereas advanced airway management techniques are invasive and require specialized medical equipment, such as OPAs, NPAs and ETAs. Bag valve mask ventilation serves as another approach to prevent inadequate ventilation, which can result from impaired breathing or airway obstruction. The most effective and commonly used method of airway management involves the use of RSI, which involves ETI and medications to induce unconsciousness and muscle relaxation.

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Related links

Advanced cardiac life support (ACLS): Clinical practice
Airflow, pressure, and resistance
Respiratory system anatomy and physiology
Ventilation

Resources for research and reference

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