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.