Basic Airway Management

So there I was....

"Look at me! Keep breathing!" I said, as I lowered Mr. [Redacted] to the ground. I could tell he was losing consciousness, each breath getting progressively more difficult. I knew I didn't have much time, other methods weren't working to correct his airway issue. He was turning purple (cyanotic), was unable to speak and tell me what was happening. I was racing against time, fumbling through my gear in the middle of a large dining room in the middle of a nursing home.

Ok lets see here.... I have a dying geriatric in a nursing home dining room. I was putting the pieces together as I was getting my equipment ready. There was a large, half eaten steak sitting on his plate. We had zero compliance with our Bag Valve Mask. The air just wasn't going in. They teach us in medic school "when you see hoof prints look for horses not zebras." I never really understood what that meant until this moment. After what felt like an eternity, but was more like a minute or so IRL, I solved the mystery.

My man was choking.

I pulled out my laryngscope blade and magills foreceps. The laryngscope is to open the jaw and displace the tongue so I can get a good look of the upper airway to see whats obstructing it. The forceps are to grab whatever is blocking said upper airway.

I place his head in what's called the "sniffing position" where I hyperextend his neck so I can get a straight, clear view of the airway. I take a look.

I'm pretty sure I snort laughed right in my dying friends face when I saw this giant, triumphant, half chewed piece of steak blocking his airway. I reached down, grabbed with my forceps, dislodged it and held it up triumphantly.

For some reason I thought I was going to get a standing ovation, but alas, I forgot I was in the dementia ward and nobody was paying attention.

Airway Management

This post was originally going to be on basic airway care and rescue breathing, but it was going to be entirely too long, so I will be splitting this topic into 2 posts. This first post covers basic airway anatomy and two basic ways to open an airway. Part 2 will go over rescue breathing and how to clear an airway if a victim has a foreign body airway obstruction.

But before we dive in, we must further understand basic airway anatomy and review the major structures of the upper respiratory system before we practice these skills. Understanding the functions of these structures will give you the base knowledge to become proficient in these skills.

In humans, the basic life sustaining substances are food, water, and oxygen.

A person can live several weeks without food because it can use its stored nutrients, and can live several days without water. However, just a few minutes without oxygen can result in irreversible damage and death.

The most sensitive cells in the body are found in the brain. . If brain cells are deprived of oxygen for 4-6 minutes they begin to die. Once the brain cells have been destroyed, they cannot be replaced. Womp Womp.

Ok so onto the respiratory system. It provides the body's tissues with oxygen and removes carbon dioxide from the red blood cells as they pass through the lungs. This forms the basis for CPR, but that will be covered later.

People in medicine love to use fancy terms to describe simple concepts. If you look at the chart above you see terms like Oropharynx and Nasopharynx. These are just fancy terms for the nose and mouth. The Trachea is your windpipe and Esophagus is where the food goes down.

Air enters the body through the nose and mouth. If a victim is unconscious and laying on their back, their airway may be blocked by the tongue. When a person loses consciousness, the jaw relaxes and the tongue falls back into the rear of the mouth, which in effect blocks air from passing through the nose and mouth to the lungs. A partially blocked airway usually produces a snoring sound.

Yes yes I know, "My significant other haas a partially blocked airway every night!" But seriously sleep apnea is no joke, you should really get that checked out. Remember earlier about the brain cells dying and not coming back? Yeah, thats happening with sleep apnea.

Anyways, let's look at the back of the throat. Theres two passages: the esophagus, which is the tube through which food passes, and the trachea. We also have this thin flappy piece of skin called the epiglottis that allows air to enter the trachea but helps prevent food from entering the airway. Ever have the ol' "it went down the wrong pipe!"? Yep, your epiglottis malfunctioned.

As air passes through the trachea the airway eventually divides into whats called the bronchi, which are basically two large tubes supported by cartilage. The bronchi branch into smaller and smaller airways in the lungs (known as the bronchioles). The bronchioles end as tiny air sacs called alveoli. They are surrounded by very small blood vessels, capillaries.

This is where the actual exchange of gases takes place.

The incoming oxygen passes from the alveoli into the blood, while the outgoing CO2 passes from the blood into the alveoli. Higher concentration to lower concentration and vice versa, you get the point.

When a victim isn't breathing, artificial ventilation is necessary to supply oxygen to the heart and the rest of the body.

Now, the lungs are whats know as a negative pressure system. That is, when you take a deep breath, the diaphragm and the muscles between your ribcage contract, creating a vacuum, or negative pressure. The negative pressure draws the are you breath into your lungs.

Alright enough science, let's put this into practice.

With an injured or seriously ill person may not be able to to protect the airway and so it may become blocked. If a victim is unable to their airway, you must take certain steps to check the condition of the airway and correct the problem to keep the victim alive.

Check For Responsiveness

When you first approach a victim, you can immediately determine if a victim is conscious or unconscious. Basically are they responsive or unresponsive?

"Hey! Are you okay? Can you hear me?"

If you get a response you can safely assume the victim is conscious and has an open airway.

If you do not get a response grab the victims shoulder and gently shake them unless they have a traumatic injury. In my response area we have a lot of "unhoused" individuals that have substance and mental issues so I will not grab them. Instead I use my foot and give them a gentle shake. NO I am not saying kick them!

If you still do not get a response then you can assume you have an unconscious victim and you need to call 911 immediately.

An unconscious victims airway is usually blocked because the tongue has dropped back and is obstructing it. In this scenario, a head tilt-chin lift or jaw-thrust maneuver may help the victim breath spontaneously.

Head Tilt-Chin Lift

1. Place the victim on their back and kneel beside.

2. Place one hand on the victim's forehead and apply firm pressure backward with you palm. Move the victims head back as far as possible.

3. Place tips of the fingers of your free hand under the bony part of the jaw near the chin.

4. Lift the chin forward to help tit back the head.

Jaw-Thrust Maneuver

The Jaw-Thrust is used for a unconscious victim who was was injured in some sort of traumatic fashion where cervical spinal injury is a concern. Think fall, diving mishap, motor-vehicle crash. Tilting the head in this situation may cause permanent paralysis.

1. While maintaining cervical spinal immobilization, place the victim on their back and kneel at the top of the head. Place your fingers behind the angles of the lower jaw and move the jaw up towards the ceiling with firm pressure.

2. Now use your thumbs to pull down the jaw (towards feet) opening the mouth enough to allow breathing through the mouth and nose.

If you are unable to open the victims airway using the jaw-thrust maneuver, you may use the head tilt-chin lift as a secondary attempt to open the airway.

Check for Fluids, Foreign Bodies, or Dentures.

Oh man, dentures. Gross. Anyway.....

Once you have opened the airway, and hopefully you have some sort of eye protection on, check for any foreign bodies in the airway. Candy, food, dirt, whatever. If you find anything try removing it by using a finger sweep, and I would advise to only stick your fingers in a strangers mouth if they are confirmed unconscious and you have a pair of medical gloves on. However do whatever is comfortable to you.

Finger Sweep

A finger sweep can be done quickly and requires no special equipment except medical gloves (see above).

1. Open mouth

2. Insert gloved finger into mouth, sliding down the side of the cheek, until you hit the base of the tongue

3. Curve your finger into a C-shape, or a 'hook' and sweep from one side of the mouth to another.

4. Scoop out nastiness.

5. Repeat until you have removed all the foreign material.

You must be able to see the foreign body before performing the finger sweep.

These techniques are for adults only. Pediatric respiratory emergencies are a whole other ballgame.

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