MANAGEMENT OF AIRWAY

1. SIMPLE MEASURES

• Position the patient eg the recovery position (left side, head down) for the unconscious patient. This will keep both the airway patent and provide a degree of protection.
• Suction the airway to clear secretions, blood or other fluids Which helps the air entry
• Heimlich man oeuvre - where appropriate always

2. SIMPLE AIRWAY OPENING MAN OEUVRES - PERFORMED WITH THE PATIENT SUPINE

• Head tilt : This maneuver is performed behind or beside the patient's head. Placing the head in the sniffing position IE with the neck flexed and the head extended. This is contraindicated in cases of potential or actual cervical spine injury. Great care must be taken in small children to avoid hyper extension of the head as this itself may occlude the airway.
• Chin lift : This is performed from behind or beside the patient's head. Grip the chin from behind by placing your thumb below the lower lip, slightly retracting it, and your fingers on the underside of the chin. With this 'pistol grip' pull the mandible forwards and upwards. This lifts the tongue away from the posterior wall of the pharynx.
• Jaw thrust : This is performed from a position behind the patient's head. Place your hands on either side of the head with the little fingers behind the angles of the mandible. Then lift the mandible forward, which lifts the tongue away from the posterior wall of the pharynx. This is the method of choice in patients with cervical spine injury.

None of these simple airway opening techniques will provide airway protection.

3. SIMPLE ARTIFICIAL AIRWAY OPENERS

• Pharyngeal airway : This is easy to insert. The correct size is that where the length from the flange to posterior tip reaches from the incisors to the angle of the mandible. An average adult will take a size 3. In adults it is inserted into the mouth upside down and then rotated through 180 degrees on reaching the pharynx. In children it is inserted in the position of function (a tongue depressor may be used to hold the tongue clear) as the rotation may injure the soft palate.

Advantages

• cheap
• easy
• effective
• safe

Disadvantages

• does not protect the airway
• if the patient is conscious there may be gagging, coughing, straining and vomiting.

Complications

• field placement causing airway obstruction
• trauma
• vomiting and aspiration
• Pharyngeal airway

This is a softer artificial airway than the pharyngeal and it is passed along the floor of the nose into the pharynx. The correct size is that with a length from flange to tip adequate to reach from the nares to the angle of the mandible. It must be lubricated prior to insertion.

Advantages

• can be used in patient with clenched jaw
• does not cause as much gagging as an pharyngeal airway
• does not have to negotiate the tongue

Disadvantages

• more difficult to insert
• cannot use if possible fracture to base of skull, facial fractures
• does not protect the airway
• hemorrhage more likely

Complications

• as for pharyngeal airway with the addition of intracranial placement in the setting of fractured base of skull.

4. COMPLEX OR DEFINITIVE AIRWAY TECHNIQUES

• End o tracheal incubation
• Laryngeal mask airway
• Surgical airways

These are only for use by those skilled to do so. The timing of these interventions depends on whether the airway compromise (to potency and protection) is actual or potential. If it is actual and more simple man oeuvres have not been effective, then the need for the procedure is immediate and urgent. If the airway compromise is potential, then the procedure can be delayed until: 

• All appropriate staff and equipment are assembled
• The patient is fully assessed with regard to breathing and circulation and treatment of these is at least commenced, if not completed EG chemotherapeutic managed or excluded.
• Neurological status has been assessed.