Airway Care Study Guide

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Anatomy and Physiology Review

• Upper and lower airway
• Alveoli and pulmonary capillaries

Key Concepts: Respiratory Physiology

• Perfusion: Adequate blood flow to the body cells that allows the proper delivery of oxygen and nutrients and the adequate removal of waste products
  • Oxygen is transported on the red blood cell by the hemoglobin molecule
• Minute volume: Tidal volume × Rate
• Alveolar ventilation: The amount of air that reaches the alveoli during ventilation
• External respiration: The exchange of oxygen and carbon dioxide from air to blood at the level of the alveoli
  • Requires adequate alveolar ventilation
  • Requires adequate blood flow to pulmonary capillaries
• Internal respiration: The exchange of oxygen and carbon dioxide from blood to the cells of the body
  • Requires adequate external respiration
  • Requires adequate blood flow to the cells (perfusion)

Pathophysiology of the Airway

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• Upper airway obstruction
  • Mental status: Decreasing mental status can cause structures of the airway (such as the tongue and epiglottis) to relax and obstruct air flow. Remember, this is a dynamic condition that can change rapidly.
  • Foreign body airway obstruction from liquids (such as blood, vomit) and/or objects (foreign bodies, as in choking)
  • Swelling of airway structures, as in anaphylaxis or trauma
• Disruption of alveolar ventilation
  • Obstruction of air flow in the lower airways—example: bronchoconstriction
  • Changes in the alveoli and small airways—example: pulmonary edema
    

    Click for larger image

• Inadequate breathing
  • Rate problems leading to inadequate minute volume—example: very slow breathing as with narcotic overdose
  • Volume problems leading to inadequate breathing—example: collapsed lung (pneumothorax)
• Disordered control of breathing
  • Conditions such as seizures or brain injury that challenge the ability to keep an airway open or maintain adequate breathing
• Respiratory decompensation after prolonged compensation for a respiratory challenge
  • Failure of the muscles of respiration as increased demand and overall respiratory challenge outpace the ability to supply oxygen to them
  • Exhaustion

Recognizing Airway Problems

• Airway trauma
• Obvious airway obstruction (foreign bodies or liquid)
• Altered mental status
  • Can cause airway failure
  • Can be caused by hypoxia and high levels of carbon dioxide (consider a broad spectrum of mental status changes, from agitation/anxiety to lethargy and unconsciousness)
• Dyspnea and respiratory distress
• Inability to speak/move air
• Hoarse or raspy voice
• Accessory muscle use
• Stridor: the sound of restricted air movement in the upper airway
• Cyanosis
• Signs of compensation: tachypnea, tachycardia
• Lung sounds
  • The sounds of diminished air movement
  • The sound of no air movement (silent chest)
  • Adventitious sounds: stridor, wheezing, rales and rhonchi
• Pulse oximetry less than 94%
• Capnography: increased exhaled carbon dioxide (readings greater than 45 mmHg)

Key Airway Interventions: Opening the Airway

• Head-tilt, chin-lift: Create the “sniffing” position
  • Beware excessive neck movement in trauma
• Jaw-thrust: Move mandible forward to adjust soft tissues of the airway and clear the pathway for air
  • Used for trauma patients
• Oral pharyngeal airways
  • Used to maintain an airway
  • Indicated in unconscious patients without gag reflex (beware stimulating gag reflex on insertion—have suction ready)
  • Measure from corner of mouth to earlobe
  • In adults, insert upside down and rotate 180 degrees following natural curvature of the airway
  • In pediatric patients, insert following the natural curvature of the airway (rotation is unnecessary)
• Nasal pharyngeal airways
  • Used to maintain an airway
  • Indicated in situations where oral airways are contraindicated—can be used on patients who have intact gag reflex (although may still cause gag reflex)
  • Use caution in patients with head/facial trauma and possible basilar skull fractures
  • Measure from tip of the nose to earlobe
  • Lubrication is necessary
  • Insert in a backwards/downward direction using gentle twisting motion to pass nasal turbinates; DO NOT force insertion

Key Airway Interventions: Clearing the Airway

• In situations of obstruction by a liquid (blood/vomit), use position to clear the airway—roll patient onto side, allowing gravity to aid removal (always consider the need for spinal motion restriction)
  • The recovery position (patient in lateral recumbent position) is designed to prevent obstruction
• Portable Suction (can be mechanical or manual) and Onboard Suction (uses power from ambulance)
  • Beware power failures and have a manual backup
  • Must be capable of generating 300 mmHg pressure when occluded
• Suction catheters
  • Rigid (Yankauer)
    • Insert only as far as is visible
    • Avoid posterior hypopharynx—can cause bradycardia and decreased blood pressure
  • Soft (French)
    • Used when rigid tip is inappropriate
    • Insert only as far as is visible
    • Avoid posterior hypopharynx—can cause bradycardia and decreased blood pressure

Important Concepts: Airway Care

• Recognition of an airway problem is a critical concept that anchors the primary assessment. Always look for signs and symptoms (both dramatic and subtle) of airway problems.
• Remember that airway problems are dynamic and often develop over time. A patent airway now is no guarantee that it will remain patent.
• Airway problems often will require advanced capabilities to resolve. Consider the early activation of ALS and rapid transport to an appropriate destination hospital.
• Study Tip: Consider each of the pathophysiologies listed here. How would you recognize each one, and what steps would be necessary to treat it?
• Study Tip: Consider each skill and intervention in context. How would you use the device or intervention in a real person? In what type of situation would you use the device/intervention?

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