Airway Management Protocol

ASSESSMENT

Each patient presents unique problems that cannot be fully outlined in any algorithm. As such, the provider must rely on thorough assessment techniques and consider each of the following:

Airway Patency:  Assess for airway obstruction or risk of impending obstruction due to facial injuries, mass, foreign body, swelling, etc. Assess for presence/absence of gag reflex.

Ventilatory Status: Assess for adequate respiratory effort and impending fatigue/failure/ apnea. Assess for accessory muscle use, tripod positioning, and the ability of the patient to speak in full sentences. If available, assess waveform capnography.

Oxygenation: Any oxygen saturation < 90% represents relatively severe hypoxia and should be considered an important warning sign. In addition to oxygen saturation, assess for cyanosis.

Airway Anatomy: Before attempting airway maneuvers or endotracheal intubation, especially with the use of RSI, assess patient anatomy to predict the probability of success and the need for a backup device or technique.

• First, assess for difficulty of the mask seal. Patients with facial hair, facial fractures, obesity, extremes of age, and pathologically stiff lungs (COPD, acute respiratory distress syndrome, etc.) may require special mask techniques or alternatives.
• Next assess for difficulty of intubation. Patients with a short neck, the inability to open their mouth at least three finger widths (or other oral issues such as a large tongue or high arched palate), less than three finger-widths of thyromental distance (or a receding jaw), reduced atlanto-occipital movement (such as in suspected c-spine injury), obesity or evidence of obstruction (such as drooling or stridor) may be difficult to intubate.

DEVISE A PLAN

• Each patient will present unique challenges to airway management. Therefore, before any intervention is attempted, the provider should contemplate a plan of action that addresses the needs of the patient and anticipates complications and how to manage them.
• Airway management is a continuum of interventions, not an “all or none” treatment. Frequently patients may only need airway positioning or a nasal or oral airway to achieve adequate ventilation and oxygenation. Others will require more invasive procedures. The provider should choose the least invasive method that can be employed to achieve adequate ventilation and oxygenation.
• Continually reassess the efficacy of the plan and change the plan of action as the patient’s needs dictate.
• In children, a graded approach to airway management is recommended. Basic airway maneuvers and basic adjuncts followed by bag-valve-mask (BVM) ventilation are usually effective.

BASIC SKILLS

Mastery of basic airway skills is paramount to the successful management of a patient with respiratory compromise. Ensure a patent airway with the use of:

• Chin-lift/jaw-thrust
• Nasal airway
• Oral airway
• Suction
• Removal of foreign body.

Provide ventilation with a bag-valve-mask (BVM). Using a PEEP valve set at 5 – 15 cmH2O is recommended. Proper use of the BVM includes appropriate mask selection and head positioning so sternal notch and ear are at the same level, to ensure a good seal. Elevate the stretcher to at least 30o when appropriate. If possible, utilization of the BVM is best accomplished with two people: one person uses both hands to seal the mask and position the airway, while the other person provides ventilation, until chest rise. If the patient has some respiratory effort; synchronize ventilations with the patient’s own inhalation effort.

ADVANCED AIRWAY SKILLS

Only after basic procedures are deemed inappropriate or have proven to be inadequate should more advanced methods be used. Procedures documenting the use of each device/technique listed below are found elsewhere in this manual.

ETT: The endotracheal tube was once considered the optimal method or “gold standard” for airway management. It is now clear, however, that the incidence of complications is unacceptably high when intubation is performed by inexperienced providers or monitoring of tube placement is inadequate. The optimal method for managing an airway will, therefore, vary based on provider experience, emergency medical services (EMS) or healthcare system characteristics, and the patient’s condition.

Supraglottic Airways: Utilization of supraglottic airways is an acceptable alternative to endotracheal intubation as both a primary device or a back-up device when previous attempt(s) at ETT placement have failed. Each device has its own set of advantages/ disadvantages and requires a unique insertion technique. Providers should have access to, and intimate knowledge of, at least one supraglottic airway. Examples include:

• Combitube.
• I-gel.
• LMA NIV.

Non-Invasive Ventilation (NIV) with continuous positive airway pressure (CPAP) or high-flow nasal cannula has been shown to be effective in reducing the need for intubation and in decreasing mortality in properly-selected patients with acute respiratory distress.

DOCUMENTATION

• All efforts toward airway management should be clearly documented and, at the minimum, should include the following:
• Pre/post intervention vital signs including oxygen saturation as well as capnography (if available).
• Procedures performed/attempted, including number of failed attempts and who performed each attempt/procedure.
• Size of device(s) placed, depth of placement (if applicable).
• Placement confirmation: methods should include auscultation, symmetrical chest wall rise, and waveform capnography, if available.

INDICATIONS

Sudden onset of respiratory distress often with coughing, wheezing, gagging or stridor due to a foreign-body obstruction of the upper airway.