‘Initial Examination of Airway’ - steps
Danger Response - AVPU Airway Look for and remove obvious obstructions Aspirate if necessary Ensure patient airway
what are the ‘Signs of normal breathing’
Even, bilateral rise and fall of the chest
Sound of air entering and leaving the nose and/or mouth
Feeling of air movement on your cheek
Normal skin colouration
Rate and depth of breathing adequate to sustain life
(Upper airway obstruction) Foreign body airway obstruction (FBAO) - cause
Tongue - most common cause in an unconscious patient
Foreign bodies - most common cause in a conscious patient: Blood, Saliva, Vomit, Displaced dentures, Food, Chewing gum, Extraneous small objects
Lower airway obstruction - cause
Excessive bronchial secretions
Pulmonary haemorrhage
Aspiration of regurgitated gastric contents
Partial Airway Obstruction - signs
Their is usually reduced air movement, the noise produced depends upon the nature and site.
Upper airway is more noticeable during inhalation whilst an obstruction of the lower airway is usually more apparent during exhalation.
Other airway noises: Gurgling
May indicate liquid or semi-solid material in the airway
Other airway noises: Snoring
May indicate a partial occlusion by the tongue
Other airway noises: Complete obstruction
No air movement will be heard or felt. But there may still be abdominal and chest movement
opening airway: head tilt/ chin lift
brings the tongue forward and upwards and so ensuring an open airway.
opening airway: Triple airway manoeuvre
Similar to jaw thrust manoeuvre except you maintain traction of the head using the heels of your hands
opening airway: Jaw thrust
For trauma patients.
Hold mouth open by downward movement of the chin with thumbs.
Using index fingers apply steady pressure upwards and forwards at the angles of the jaw to lift it.
Finger sweep
Open and inspect the mouth, carefully sweep two fingers from the side to the back, and hook out any foreign matter found, remove also any loose or broken dentures ONLY when clearly visible and very near to the lips.
Suction
Remove any blood/liquids/light solids by aspirating with appropriate catheter.
Mild airway obstruction
in response to “are you choking?”
patient answers “yes”
other signs - can speak, cough, breathe
Severe airway obstruction
in response to “are you choking?”
patient is unable to speak and may respond by nodding.
other signs - Unable to breathe, wheezy, attempts at coughing are silent, may be unconscious.
universal sign of choking
clutching the neck
management for: Mild airway obstruction - Adults
Encourage to cough and do nothing else.
Monitor carefully
Rapid transport to hospital
management for: Severe airway obstruction - Adults
Back Blows
Abdominal Thrusts
How to do: Back Blows
Stand to the side and slightly behind.
Support the chest (hold shoulder) and with one hand lean the patient forwards.
Give up to five sharp back blows between the scapulae.
How to do: Abdominal Thrusts
Stand behind the patient and place both arms around the upper part of the abdomen, clench your fist and grasp with the other hand.
Pull sharply & upwards with the aim of producing sudden expulsion of air and foreign body form the airway.
Airway obstruction: adult unconscious
if a patient is or becomes unconscious begin basic life support.
During CPR check the mouth for any foreign body that has been partly expelled.
Airway obstruction: children and infants.
Suspect that a child may be choking if there is:
Sudden respiratory compromise with associated coughing, gagging or stridor (creaking or grating noise).
No other signs of illness.
Other clues - eating, playing with small toys immediately prior
DO NOT PERFORM BLIND FINGER SWEEPS. airway obstruction may also occur with acute epiglottis or croup
General signs of airway obstruction:
witnessed episode
coughing or choking
sudden onset
recent history of playing with, or eating, small objects
Signs of ineffective cough
unable to vocalise quiet or silent cough unable to breath cyanosis decreasing level of consciousness
Signs of effective cough
Crying or verbal response to questions
loud cough
able to breath before coughing
fully responsive
Airway obstruction: back blows for infant and child
Position in the prone position with the head lower then the chest.
Deliver up to 5 back blows to the middle of the back between the scapulae.
With an infant hold them across your forearm and a child across your thigh whilst sitting.
Airway obstruction: chest thrusts for infant or child
Turn the child into a supine position again with head lower than the chest and the airway in an open position.
Give up to five chest thrusts to the sternum - the technique for chest thrusts is similar to that for chest compression.
Chest thrusts should be sharper and more vigorous than compressions and carried out at a rate.
FBAO
foreign body airway obstruction
FBAO child - effective coughing
encourage to cough. do nothing else
monitor continuously
rapid transport to hospital
FBAO child - ineffective coughing or cough becomes ineffective
Summon help if appropriate.
Determine child’s conscious level
IF CONSCIOUS: give back blows. if they do not relieve FBAO chest thrusts for infants. abdo thrusts for children
alternate until obstruction is relieved or patient loses consciousness.
FBAO child - unconscious STEP 1
place them on a firm flat surface
OPEN THE AIRWAY
check the mouth for any obvious object. if on can be seen and easily grasped make an attempt to remove with a single finger sweep.
DO NOT ATTEMPT BLIND OR REPEATED FINGER SWEEPS
FBAO child - unconscious STEP 2
Attempt Ventilations:
Open the airway and make 5 attempts to ventilate the lungs.
Assess the effectiveness of each ventilation.
If the chest does not rise, reposition the head before next attempt.
FBAO child - unconscious STEP 3
Commence CPR:
CPR for 1 minute - start with compressions.
When ventilating check for foreign body.
If seen attempt a single finger sweep
If obstruction is relieved open and check mouth.
Ventilate if not breathing.
If child regains consciousness and effective breathing place in recovery position.
Monitor breathing and LOC and transport to hospital.
Abdominal thrusts and infants
NOT RECOMMENDED in infants because they may rupture the abdominal viscera.
Perform cycles of 5 back blows and 5 chest thrusts only.
Repeat the cycles until the airway is cleared or the infant breathes spontaneously.
Clearing the airway in neck breathers
Check the neck:
Lie patient on their back.
Remove clothing form around the neck, including the stoma cove, but DO NOT remove any tube that is in place.
Clear the neck:
Wipe any mucus from the stoma or tube, aspirate with appropriate size catheter if necessary.
Make sure that the stoma or tube is clear.
Check for breathing:
Listen and feel for air from the stoma.
Watch for movement of the chest and abdomen.
Purpose & Limitation of OP airways
Every unconscious patient is in danger of death by asphyxia. This is because the tongue may fall back and obstruct the entrance to the trachea.
OP airway helps to control the lips, teeth and tongue and should be used in most unconscious patients - manual control must also be used.
An OP airway enables breathing to continue for those who are breathing, allows easier oro-pharyngeal suction and can reduce the risk of asphyxia.
An OP airway will only prevent obstruction by the relaxed tongue. It will not prevent stomach contents, saliva or blood form obstruction the patients airway.
OP airway Sizing.
Measure form the middle of the patients lips to the angle of their jaw.
- large adults
- adults
- small adults
- children (para only)
- infants (para only)
OP airway method of insertion
They are curved to follow the contour of the upper surface of the tongue.
Hold the flanged end and then turn the airway upside down so that the curved surface is facing upwards towards to roof of the mouth.
When you have inserted approximately half the length rotate 180 degrees
Purpose and Limitations of Naso-Pharyngeal airways
The NP airway, once in situ, is often better tolerated then the OP airway particularly by patients in the following circumstances: Fitting or Seizures Suspected cervical spine injury Awake or semi conscious state Active gag reflex
NP airway indications
Patients aged 12yrs or over
Upper airway obstruction due to backward displacement of the tongue in patients with clenched jaws, seizures, jaw fractures or awkward/loose teeth.
NP airway Contra-indications
Bilaterally obstructed or deformed nasal passages.
Severe mid-face fractures, in particular maxillary fractures.
CAUTION: suspicion of base skull fracture
NP airway sizing
The lumen should approximate to the size of the patients little finger. The length is measured from the nares to the angle of the jaw.
Size 7. Adult male
Size 6. Adult female
NP airway method of insertion
Ensure airway is clear.
Lubricate the airway.
Insert gently into largest nostril (usually the right).
Do not force the airway, rotating slightly may ease insertion.
Slide the airway into the nostril until the flange rests against the nasal opening.
Ensure air can pass through airway.