Overview of Airway Management
If a healthcare professional is to properly handle a person’s ability to breath (airway management), they need a deep understanding of the vital parts of the throat and lungs, how it works, and what can go wrong with it. They should also be well-versed in the various tools and techniques that can be used to manage the airway. These often come into play for something called endotracheal intubation, a process where a tube is inserted into your windpipe (trachea) through your mouth or nose.
Understanding when to do this procedure, when not to, and the potential risks involved is crucial. They also need to know how to make sure the tube is correctly placed in the windpipe. The differences in adult, child, and newborn airways and the ability to handle tricky situations are critically important for safety.
When dealing with airway management as part of a more advanced procedure called Advanced Cardiovascular Life Support, the healthcare professional should think about:
* Is the airway unblocked and functioning properly?
* Is there a need for advanced measures to open the airway?
* Is the device in the right place for effective ventilation?
* Is the tube secure, and do we check its position regularly?
Answering these questions can help guide the healthcare professional in making key decisions for safe and effective respiratory support.
Anatomy and Physiology of Airway Management
The throat in a grown-up is very narrow at the vocal cords, but in children, it is more narrow right underneath the vocal cords and is positioned more towards the front. Kids who are 12 years old or younger have a smaller vocal cord area, and their voice box is more flexible, cone-shaped, and located more towards the top. Because children often have larger sized heads with shorter necks, it can become harder for doctors to see inside their throat using a special instrument called a laryngoscope, and line up the mouth, voice box, and windpipe. This is why doctors sometimes have to put a rolled-up towel or a small bump under their shoulders to help them breathe better and do necessary medical procedures. It’s crucial to understand that kids’ throats are different from adults’ in order to perform a procedure called intubation, where a tube is placed into the throat for medical reasons.
The size of the windpipe can vary depending on a child’s age and gender. To figure out the right size for the intubation tube, doctors use various mathematical formulas, including the Cole formula for tubes without a cuff, the Motoyama formula for tubes with a cuff for kids two years or older, and the Khine formula for tubes with a cuff for children younger than two years. In some cases, using an ultrasound to measure the inside of the child’s throat can give more precise results, but this method may not be possible for emergency situations. Therefore, doctors should be very familiar with these calculations. Cuffed tubes, which can be inflated to create a seal, are often preferred to avoid air leaks and to prevent tissue damage in patients who are on a ventilator. However, these tubes are bigger and could induce temporary vocal cord spasms during the intubation process. One modern method doctors use to look inside the throat is called video-assisted laryngoscopy, which gives a better view of the airway.
Why do People Need Airway Management
Endotracheal intubation is a medical procedure required under certain circumstances. These often include the failure of a person’s respiratory system, which might result in low oxygen levels (hypoxic) or high carbon dioxide levels (hypercapnic) in the body. If someone begins to stop breathing (known as apnea), this treatment could become necessary.
In addition, if a person becomes unconscious or less responsive – sometimes measured by a score of 8 or less on the Glasgow Coma Scale (a scoring system used to describe the level of consciousness in a person following a traumatic brain injury) – they may also need this procedure. Rapid or sudden changes in mental status are more instances when the treatment could be useful.
Endotracheal intubation may also be required after an injury to the airway or if there’s a risk that airway might soon become compromised. Additionally, if there’s a high risk of aspiration (inhaling food, stomach acid, or saliva into the lungs), or the patient has suffered laryngeal trauma (an injury affecting the voice box), this course of action can be necessary. Laryngeal trauma includes any penetrating injuries – wounds that pierce the skin and underlying tissues – to the neck, abdomen, or chest.
When a Person Should Avoid Airway Management
There are certain conditions where a medical procedure called endotracheal intubation cannot be carried out. This procedure involves placing a tube in your windpipe (trachea) to help you breathe. When severe trauma or blockages in the airway make it impossible to insert this breathing tube safely, doctors must consider other options.
If this tube can’t be placed and your breathing needs to be secured, a surgical procedure to create an opening, known as a surgical airway, may be necessary. Approaches in this urgent situation could include a needle cricothyrotomy or cricothyrotomy, which are procedures that create a small opening in your neck to help you breathe.
However, these methods are always temporary, and they must be replaced with a more long-term solution, such as a tracheostomy, as soon as possible. A tracheostomy is a surgery to make a hole in your windpipe that you can breathe through for a longer period of time.
Cricothyrotomy, in particular, is rarely done in children who can’t be intubated using a breathing tube. Instead, an emergent tracheostomy is usually preferred. The deciding factor that makes cricothyrotomy not possible in kids is their age, though the exact age limit for safely carrying out a surgical cricothyrotomy is a point of debate and includes factors like body size and build. Various professionals believe that this age limit can range anywhere from 5 to 12 years old. But, the Pediatric Advanced Life Support guidelines state that for children aged between 1 to 8, their airway comes under the pediatric label.
On the otherhand, a needle cricothyrotomy with a procedure called transtracheal ventilation should be used in kids instead of an incision-based surgical cricothyrotomy. This needle procedure should then be changed to a formal tracheostomy later on.
Equipment used for Airway Management
If someone has difficulty breathing because their airway is blocked, methods like gently tilting their head, lifting their chin, or thrusting their jaw forward can help. For babies and children, a simple method to clear the airway involves using a bulb syringe or a mechanical suction device to remove mucus or other blockages. When using the bulb syringe on a baby, it’s crucial to suction the mouth before the nose to avoid any potential choking risks. However, suctioning should not last more than 10 seconds because babies can have a negative reaction that may slow their heart rate.
There are other tools that can also assist with airway obstructions. Oropharyngeal airways are devices that are useful for patients who are breathing on their own but need help keeping their airways open, like people who have sleep apnea. However, these devices should not be used on patients who have a severe gag reflex or oral trauma because they can induce gagging and the potential choking on stomach contents. Another helpful tool, called a nasopharyngeal airway, is used for patients who have a strong gag reflex, muscle spasms in the jaw, oral trauma, or have had recent oral surgery. The size of the nasopharyngeal airway that is used depends on the patient’s nostril size and their height.
Bag-mask ventilation is a common technique for managing airways. A person can use one or two hands to administer this technique, but one hand is usually enough for newborns. Bag-mask ventilation effectively provides continuous positive airway pressure and is often used in preparation for intubation, which is the process of placing a flexible plastic tube into the windpipe to maintain an open airway.
The use of advanced airway devices, known as supraglottic devices, has recently become more common. These devices go above the voice box and include the laryngeal mask airway, laryngeal tube, and esophageal-tracheal device. These devices are favored because of their safety, effectiveness, and ease of use, especially in emergencies or when less experienced healthcare professionals are managing children’s airways. However, children with a recent upper respiratory infection may have a greater risk of complications with these devices than healthy children.
The esophageal-tracheal tube and endotracheal tube are additional advanced airway devices. These are designed to provide ventilation and are favored for their ease of use, although they are not often used in pediatric airway management. They come in different sizes and are typically used by emergency medical personnel.
Oxygen is a critical element of airway management. There are various methods of delivering oxygen before intubation, such as through a nasal cannula, a two-valve mask, high-flow oxygen, or bilevel-positive airway pressure (BiPAP).
Last but not least, a device named bougie – a long, semi-rigid plastic device – can be used to facilitate endotracheal tube placement, especially in situations where it’s challenging to see the vocal cords clearly.
Who is needed to perform Airway Management?
For the best patient care, it’s important to have at least 2 more people helping the main doctor when they place a breathing tube. These extra team members can give medication, help with breathing assistance and watch over the patient’s condition. The team usually includes a doctor, a respiratory therapist (a specialist in breathing treatment), a nurse, a nursing technician, a paramedic, and an advanced practice provider (a specially trained healthcare provider).
Preparing for Airway Management
Patients who need help to breathe may require a procedure called intubation. This involves placing a tube into the windpipe to ensure oxygen can reach the lungs. This begins with preparation of the patient’s airway. The doctors closely supervise and control the patient’s breathing while ensuring the neck is kept stable to prevent any unnecessary movements. This leads to a smooth and safe process of placing the tube.
There are four key factors doctors consider when doing this procedure. They call them the ‘4Ds’ and they include:
* Distortion: abnormal shaping of the throat
* Disproportion: size issues between the throat and mouth opening
* Dysmobility: restriction or lack of movement in the throat or neck
* Dentition: the state of the patient’s teeth which could obstruct the procedure
The doctors look for specific parts of the throat to guide the tube placement. One such place is the vallecula. The vallecula is important because identifying it correctly ensures the tube would reach the windpipe and not the esophagus (food tube). There are a couple tools the doctor uses to guide them, they are including the Macintosh and Miller. Depending on which tool is used, the approach towards the vallecula differs. However, in both cases, the end goal is to ensure the vocal cords are in sight, which allows for proper placement of the breathing tube in the windpipe.
There’s also a method called video laryngoscopy, where the doctor uses a camera to see the vocal cords which guide them to place the tube. The camera is a curve-shaped blade, which is placed near the vallecula. A clear sight of the vocal cords gives the doctor a green signal to put the breathing tube in place. If they don’t see the required parts of the throat on the first try, they slowly pull back the blade until the required parts come into view. This method gives doctors a second chance to correct their placement.
Several pieces of equipment assist the doctors during this process:
* Laryngoscope: A tool with a light to help visualize throat structures
* Carbon dioxide detectors: Devices to ensure the tube is in the right place
* Continuous waveform capnography: A device for monitoring the level of carbon dioxide in the patient’s breath
* Material to secure the tube to the patient’s mouth
* Chest x-ray: An imaging tool to confirm the tube’s placement after the procedure
In addition to equipment, the doctors also administer medications to aid the procedure:
* Sedatives, such as Etomidate, Fentanyl, Midazolam, Propofol, and Thiopental help the patient relax and become less aware of the surroundings.
* Paralytic agents like Succinylcholine, Rocuronium, and Vecuronium help to relax the muscles, which makes introducing the tube into the windpipe easier.
All these medications are carefully measured based on the patient’s body weight to ensure safety and effectiveness.
How is Airway Management performed
: Intubation is a technique doctors use to help you breathe. There are several steps involved:
* They give you oxygen first.
* They then administer medications to make you sleepy and relaxed.
* They apply pressure to an area in your neck called the cricoid.
* They stabilize your neck and use a tool to see your windpipe.
This technique is the safest and best way to help you breathe if you need it.
The best way to make sure the breathing tube is in the right place is to look directly with a special tool called a laryngoscope. Other methods include measuring the carbon dioxide you’re breathing out, analyzing the pattern of your breathing, looking at an x-ray, using an ultrasound, and checking your overall condition. The American Heart Association recommends using continuous capnography (measurement of carbon dioxide) along with a general check-up to confirm that the tube is in the right place.
Some of the complications that can occur include the tube going into your esophagus (the tube that carries food from the mouth to the stomach) or the tube going too far into the right side of your lungs. If it’s not in the right place, you might need it to be repositioned. Doctors can tell if it’s the wrong place by checking your x-ray, looking at the pattern of your breathing, or listening to your breathing sounds.
If you’re not breathing properly or your oxygen levels are low, it means the tube placement might be incorrect. Once the tube is confirmed to be in the right place, it’s secured so it doesn’t move. Your breathing and oxygen levels are then kept under continuous check.
Breathing tubes with cuffs (small balloons around the tube) are used in kids to prevent air from leaking out.
When someone is injured, it’s one of the main reasons they might not survive, especially for people between 15 to 50 years old. In fact, injuries are the second most common cause of death, causing 8% of all deaths globally. The World Health Organization estimates that injuries from things like car crashes, drowning, poisoning, falls, burns, and violence cause over 5 million deaths every year worldwide.
If you’re severely injured, getting to a trauma center quickly can really help improve your chances of survival. However, there’s some debate about whether intubation (getting a breathing tube) should be done before getting to the hospital. The medical director of the emergency medical service decides when this is allowed. The emergency medical service is responsible for getting patients to the nearest trauma center quickly and safely.
In some cases, a surgical airway might be needed. This means making a hole in the neck to help with breathing. This is usually safe for kids but the exact age at which it can be done is debated. Different sources say it’s safe for kids between the ages of 5 to 12. The Pediatric Advanced Life Support guidelines apply to kids aged 1 to 8.
Possible Complications of Airway Management
Intubation, which is when a tube is inserted into a person’s throat to help them breathe, can sometimes lead to complications. Some of these problems can include difficulties in keeping the airway open, inserting the tube into the food pipe instead of the windpipe, and experiencing respiratory failure that can lead to an emergency situation. There could also be risks of injuries to the throat or voice box, which can cause bleeding, swelling of softer tissues, and damage to vocal cords.
It’s important to mention that extra complications may occur when intubating patients with chest injuries. These issues can include tension pneumothorax (a condition where air gets trapped in the chest) and air leaks from bronchial injuries (damage to the tubes that carry air to your lungs). If a patient has a pneumothorax, a tube should be inserted into the chest before the intubation to help manage the condition. In situations where a bronchial injury has occurred, intubation can cause a significant air leak. This leak can be managed by using a bronchial blocker, a device that can block the damaged part of the lung to prevent more air from escaping.
What Else Should I Know About Airway Management?
When caring for a patient’s airway (the path that air follows to get into and out of the lungs), doctors consider several factors:
* The differences between the airways of children and adults: Children’s airways are smaller and shaped differently, which can affect the treatment approach.
* The best way to manage the airway: Depending on the patient’s condition, the approach can vary and may include procedures to clear, open, or bypass the airway.
* When and how to use rapid-sequence induction: This quick and effective method of putting a tube down the windpipe is used to help a patient breathe. Doctors consider the patient’s health, the drugs to be used, and the techniques to make it as safe and effective as possible.
* How to evaluate a difficult airway: Some patients may be more challenging than others to manage their breathing, and doctors utilize special techniques in these cases.
* Alternate techniques to achieve a good airway: If the usual method for airway management fails, doctors can use other techniques.
* Various helpers in airway management: These can be equipment or substances used to aid in the management of the airway.
* Special situations like penetrating trauma: Certain situations like severe injuries require unique approaches to airway management.
* The role of training and practice for non-hospital medical staff in managing children’s airways: Since children’s airways are uniquely different, special training for pre-hospital staff like paramedics is essential.
* When to use, when not to use, and possible complications of endotracheal intubation: This operation involves inserting a tube into a patient’s windpipe. It requires careful consideration of the patient’s condition and potential risks.
* Confirming that the endotracheal tube (EET) is in the right place: It’s crucial to ensure that the tube is correctly positioned, as misplacement can harm the patient.
