Ati Skills Module 3.0 Airway Management

Airway management is a critical skill for all healthcare providers, especially those working in acute care settings. The ATI Skills Module 3.0 focuses on providing a comprehensive understanding of the principles and techniques involved in maintaining a patent airway, ensuring adequate oxygenation, and preventing complications. This module aims to equip students and professionals with the knowledge and practical skills necessary to effectively manage airway emergencies and routine respiratory care.

Introduction to Airway Management

Airway management involves a series of interventions aimed at maintaining a clear and open passage for air to flow into and out of the lungs. This is essential for ensuring adequate gas exchange, which is vital for cellular function and overall survival. Effective airway management is a fundamental aspect of emergency medicine, critical care, and anesthesia.

A patent airway is necessary for:

• Oxygenation: Allowing oxygen to reach the lungs and subsequently the bloodstream.
• Ventilation: Facilitating the removal of carbon dioxide from the body.
• Prevention of Hypoxia: Avoiding a dangerous deficiency of oxygen in the tissues.
• Avoiding Hypercapnia: Preventing excessive carbon dioxide buildup in the bloodstream.

Airway compromise can occur due to various reasons, including:

• Obstruction: Foreign bodies, secretions, or anatomical abnormalities blocking the airway.
• Trauma: Injuries to the face, neck, or chest affecting airway patency.
• Medical Conditions: Allergic reactions, infections, or neurological disorders that impair respiratory function.

Key Components of Airway Assessment

Before initiating any airway management interventions, a thorough assessment of the patient's airway is crucial. This assessment involves evaluating several key indicators to determine the extent of airway compromise and guide appropriate interventions.

1. Level of Consciousness:

   • Assess the patient's alertness and responsiveness. A decreased level of consciousness may indicate inadequate oxygenation or perfusion to the brain.
   • Use standardized scales like the Glasgow Coma Scale (GCS) to quantify the level of consciousness.

2. Breathing Effort:

   • Observe the patient's respiratory rate, depth, and pattern. Look for signs of labored breathing, such as:
     • Tachypnea: Rapid breathing.
     • Bradypnea: Slow breathing.
     • Use of Accessory Muscles: Engagement of neck and chest muscles to assist breathing.
     • Nasal Flaring: Widening of the nostrils during inhalation.
     • Retractions: Sinking in of the skin between the ribs or above the sternum during inhalation.

3. Airway Sounds:

   • Listen for abnormal airway sounds that may indicate obstruction or other respiratory issues:
     • Stridor: A high-pitched, whistling sound usually indicating upper airway obstruction.
     • Gurgling: A wet, bubbling sound suggesting the presence of fluids or secretions in the airway.
     • Wheezing: A whistling sound usually indicating narrowing of the lower airways, such as in asthma or bronchiolitis.
     • Snoring: A low-pitched sound often caused by the tongue obstructing the airway.

4. Skin Color:

   • Observe the patient's skin color for signs of hypoxia:
     • Cyanosis: Bluish discoloration of the skin and mucous membranes, indicating low oxygen saturation.
     • Pallor: Paleness, which can suggest poor perfusion or anemia.

5. Oxygen Saturation:

   • Use a pulse oximeter to measure the patient's oxygen saturation (SpO2).
   • Normal SpO2 is typically between 95% and 100%. However, target SpO2 may vary based on the patient's underlying medical conditions.

Basic Airway Management Techniques

Basic airway management techniques are non-invasive methods used to open and maintain a patent airway. These techniques can be performed quickly and require minimal equipment.

1. Head-Tilt/Chin-Lift Maneuver:

   • This technique is used to open the airway by lifting the chin and tilting the head back.
   • Contraindication: Suspected cervical spine injury.
   • How to perform:
     • Place one hand on the patient's forehead and apply gentle pressure to tilt the head back.
     • Place the fingertips of the other hand under the bony part of the chin and lift the chin forward.

2. Jaw-Thrust Maneuver:

   • This technique is used to open the airway without extending the neck. It is the preferred method for patients with suspected cervical spine injury.
   • How to perform:
     • Place your fingers behind the angles of the patient's jaw.
     • Thrust the jaw forward while stabilizing the head.

3. Suctioning:

   • Suctioning is used to remove fluids, secretions, or foreign material from the airway.
   • Equipment:
     • Suction machine
     • Suction catheters (various sizes)
     • Personal protective equipment (PPE)
   • How to perform:
     • Select the appropriate size suction catheter.
     • Attach the catheter to the suction tubing.
     • Turn on the suction machine and adjust the pressure as needed.
     • Insert the catheter into the airway without applying suction.
     • Apply intermittent suction while withdrawing the catheter in a rotating motion.
     • Limit suctioning to 10-15 seconds to prevent hypoxia.

4. Oropharyngeal Airway (OPA):

   • An OPA is a curved plastic device inserted into the mouth to keep the tongue from obstructing the airway.
   • Indications: Unconscious patients with no gag reflex.
   • Contraindications: Conscious or semi-conscious patients, patients with a gag reflex.
   • How to insert:
     • Measure the OPA from the corner of the mouth to the angle of the jaw.
     • Insert the OPA upside down into the mouth.
     • Rotate the OPA 180 degrees as it passes the tongue, so that the curve follows the natural curvature of the tongue.
     • Ensure the flange rests against the lips.

5. Nasopharyngeal Airway (NPA):

   • An NPA is a flexible tube inserted through the nostril into the pharynx to maintain an open airway.
   • Indications: Conscious, semi-conscious, or unconscious patients; can be used in patients with a gag reflex.
   • Contraindications: Suspected basilar skull fracture, nasal trauma.
   • How to insert:
     • Measure the NPA from the tip of the nose to the earlobe.
     • Lubricate the NPA with a water-soluble lubricant.
     • Insert the NPA into the nostril, following the natural curvature of the nasal passage.
     • Advance the NPA gently until the flange rests against the nostril.

Advanced Airway Management Techniques

Advanced airway management techniques involve invasive procedures to secure and maintain a patent airway. These techniques require specialized training and equipment.

1. Endotracheal Intubation (ETI):

   • ETI involves inserting an endotracheal tube through the mouth or nose into the trachea to establish a secure airway.
   • Indications: Respiratory failure, airway obstruction, need for prolonged mechanical ventilation.
   • Equipment:
     • Laryngoscope with blades (various sizes)
     • Endotracheal tube (various sizes)
     • Stylet
     • 10 mL syringe
     • Suction equipment
     • Capnography
     • Personal protective equipment (PPE)
   • Procedure:
     • Prepare and check all equipment.
     • Preoxygenate the patient with 100% oxygen.
     • Position the patient in the sniffing position.
     • Insert the laryngoscope blade into the mouth to visualize the vocal cords.
     • Advance the endotracheal tube through the vocal cords.
     • Inflate the cuff with 5-10 mL of air.
     • Remove the stylet.
     • Confirm tube placement using capnography, auscultation, and chest X-ray.
     • Secure the tube with tape or a commercial tube holder.

2. Laryngeal Mask Airway (LMA):

   • An LMA is a supraglottic airway device inserted into the pharynx to provide ventilation.
   • Indications: Alternative to ETI for short-term ventilation, difficult airway management.
   • Contraindications: Patients at high risk for aspiration, morbid obesity, significant airway edema.
   • Procedure:
     • Select the appropriate size LMA.
     • Deflate the cuff completely.
     • Lubricate the LMA with a water-soluble lubricant.
     • Insert the LMA into the mouth and advance it along the hard palate until resistance is met.
     • Inflate the cuff with the appropriate volume of air.
     • Confirm placement with auscultation and capnography.

3. Cricothyrotomy:

   • Cricothyrotomy is an emergency surgical procedure to create an airway through an incision in the cricothyroid membrane.
   • Indications: Failure to intubate or ventilate, upper airway obstruction.
   • Procedure:
     • Identify the cricothyroid membrane between the thyroid and cricoid cartilages.
     • Cleanse the area with antiseptic solution.
     • Make a vertical incision through the skin and cricothyroid membrane.
     • Insert a tracheostomy tube or endotracheal tube into the trachea.
     • Confirm tube placement and secure the tube.

4. Needle Cricothyroidotomy:

   • Needle Cricothyroidotomy is similar to Cricothyrotomy, however it involves the insertion of a large-bore needle into the trachea.
   • Indications: Similar to Cricothyrotomy when ventilation is not possible. Often used as a temporizing measure until a formal Cricothyrotomy can be performed.
   • Procedure:
     • Identify the cricothyroid membrane between the thyroid and cricoid cartilages.
     • Cleanse the area with antiseptic solution.
     • Insert a large-bore needle into the trachea.
     • Confirm placement and attach to oxygen source.

Pharmacological Adjuncts to Airway Management

Certain medications can be used to facilitate airway management, particularly during intubation.

1. Sedatives:

   • Sedatives such as etomidate, propofol, or ketamine are used to induce relaxation and reduce anxiety during intubation.

2. Neuromuscular Blocking Agents (Paralytics):

   • Paralytics such as succinylcholine or rocuronium are used to provide muscle relaxation, which can improve intubation success rates.
   • Important Note: When using paralytics, always ensure that adequate sedation is provided, as the patient will be unable to move or breathe on their own.

3. Analgesics:

   • Analgesics such as fentanyl or morphine can be used to manage pain and discomfort during airway management procedures.

4. Vasopressors:

   • These medications such as epinephrine can be used to maintain blood pressure in hypotensive patients. Phenylephrine is also commonly used.
   • Important Note: When using vasopressors, blood pressure should be monitored.

Complications of Airway Management

Airway management procedures carry the risk of potential complications, which can be minimized with proper technique and monitoring.

1. Hypoxia:

   • Inadequate oxygenation during airway manipulation can lead to hypoxia, which can cause brain damage or death.
   • Prevention: Preoxygenate the patient before any airway intervention, limit suctioning time, and monitor oxygen saturation closely.

2. Aspiration:

   • Aspiration of gastric contents into the lungs can cause pneumonia or acute respiratory distress syndrome (ARDS).
   • Prevention: Use proper positioning, suctioning, and rapid sequence intubation techniques to minimize the risk of aspiration.

3. Trauma:

   • Airway management procedures can cause trauma to the teeth, lips, tongue, or airway structures.
   • Prevention: Use gentle technique, select appropriate-sized equipment, and visualize the airway structures carefully.

4. Esophageal Intubation:

   • Inadvertent placement of the endotracheal tube into the esophagus instead of the trachea.
   • Prevention: Use capnography to confirm tracheal placement, auscultate breath sounds, and observe chest rise.

5. Laryngospasm:

   • Spasmodic closure of the vocal cords, making ventilation difficult.
   • Management: Provide positive pressure ventilation, administer muscle relaxants if necessary.

6. Bronchospasm:

   • Constriction of the airways in the lungs, leading to wheezing and difficulty breathing.
   • Management: Administer bronchodilators such as albuterol, provide oxygen, and consider epinephrine if severe.

7. Infection:

   • Introduction of bacteria into the airway during intubation can lead to pneumonia or other respiratory infections.
   • Prevention: Use sterile equipment, maintain aseptic technique, and provide appropriate post-intubation care.

Special Considerations for Pediatric Airway Management

Airway management in pediatric patients requires special considerations due to anatomical and physiological differences compared to adults.

1. Anatomical Differences:

   • Children have a larger tongue relative to their mouth size, which can increase the risk of airway obstruction.
   • The epiglottis is longer and more U-shaped in children, making visualization of the vocal cords more challenging.
   • The trachea is narrower and shorter in children, increasing the risk of tube misplacement or obstruction.

2. Equipment Selection:

   • Use age- and weight-appropriate equipment, such as smaller laryngoscope blades and endotracheal tubes.
   • Cuffed endotracheal tubes are generally recommended for children older than 8 years to reduce the risk of air leak.

3. Ventilation:

   • Use lower tidal volumes and faster respiratory rates to match the child's physiological needs.
   • Avoid excessive pressure during ventilation to prevent lung injury.

4. Medication Dosing:

   • Calculate medication doses based on the child's weight.
   • Be aware of age-related differences in drug metabolism and clearance.

5. Monitoring:

   • Monitor vital signs closely, including heart rate, respiratory rate, oxygen saturation, and blood pressure.
   • Assess for signs of respiratory distress, such as nasal flaring, retractions, and grunting.

Airway Management in Specific Clinical Scenarios

1. Trauma Patients:

   • Prioritize cervical spine immobilization.
   • Use the jaw-thrust maneuver to open the airway.
   • Be prepared for difficult intubation due to facial or neck injuries.

2. Patients with Asthma or COPD:

   • Administer bronchodilators and corticosteroids to reduce airway inflammation and bronchospasm.
   • Use caution with positive pressure ventilation to avoid barotrauma.

3. Patients with Anaphylaxis:

   • Administer epinephrine to reverse airway swelling and bronchospasm.
   • Provide oxygen and monitor vital signs closely.

4. Obese Patients:

   • Position the patient in the ramped position to improve visualization of the vocal cords.
   • Use a larger laryngoscope blade and endotracheal tube.
   • Be prepared for rapid desaturation due to reduced functional residual capacity.

5. Patients with Covid-19:

   • Use proper PPE to prevent spread of infection.
   • Limit the number of attempts to intubate and use a viral filter during ventilation.

Conclusion

Airway management is a fundamental skill for healthcare providers, requiring a thorough understanding of anatomy, physiology, and various techniques. The ATI Skills Module 3.0 provides a comprehensive overview of airway management principles and practices, equipping students and professionals with the knowledge and skills necessary to effectively manage airway emergencies and routine respiratory care. By mastering these skills, healthcare providers can significantly improve patient outcomes and save lives. Continuous training and practice are essential to maintain proficiency and stay up-to-date with the latest advances in airway management.