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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 4 – Practical procedures > Chapter 61 – Airway management Chapter 61 Airway management P.660
Call for anaesthetic help early. Patients may require support of their airway and ventilation/oxygenation in situations when they are unable to adequately maintain these. Such situations may be related to a Glasgow Coma Score of <8, which can cause difficulties with airway maintenance, or related to respiratory compromise or arrest in the critically ill patient. Simple airway adjuncts are used to overcome backward tongue displacement in an unconscious patient. Oropharyngeal airway (Guedel) A curved plastic tube with a flanged end that is inserted into the mouth. Size is estimated by holding it at the side of the patient’s face and estimating required length from angle of the mouth to angle of the jaw. Ensure the mouth is clear, then insert the airway ‘upside down’, with the curved side towards the tongue. When it is in as far as the soft palate, turn it around by 180 degrees and push it in further, so the flange is at the patient’s mouth. If the patient has a gag reflex, remove the airway. Suction can be performed through the airway and oxygen administered via a mask. Nasopharyngeal airway A soft plastic tube with a bevelled end and a flange at the other end. Better tolerated in the semi-conscious, and should not be used in those with base of skull fractures. Choose a tube size similar to the size of the patient’s little finger, and insert a safety pin through the flange. Lubricate it with water-soluble jelly and insert the bevelled end into a nostril and gently push back with a twisting action. Do not force if obstruction is encountered, but remove and try in the other nostril. Nasal bleeding can be caused if the mucosa is damaged. The safety pin ensures the airway is not dislodged into lung. Oxygen can be administered through a mask. Intubation Endotracheal tube The optimal method of managing a patient’s airway and providing airway protection from aspiration of gastric contents. Requires training in tube insertion. The tube is bevelled at one end with an inflatable cuff and has a connector at the other end. The connector can be removed if the tube needs to be cut, but can be replaced.

  • Patient lies flat, with neck flexed and head extended (the ‘sniffing the morning air’ position). A pillow is placed under the head, not the neck to aid this
  • Pre-oxygenate with bag and mask ventilation
  • Using the laryngoscope in left hand and standing behind the head, the mouth is opened and the laryngoscope placed over the right side of the tongue and advanced
  • It may be necessary to apply suction to clear the mouth of secretions
  • When the epiglottis is seen, the laryngoscope is advanced into the vallecula, between the root of the epiglottis and the base of the tongue. Upward pressure in the direction of the laryngoscope handle is applied to lift the jaw slightly and the cords should come into view, taking care not to damage the teeth
  • Slide the tube through the cords and then withdraw the laryngoscope
  • Inflate the cuff
  • Confirm adequate tube position by auscultating for breath sounds over the chest bilaterally
  • End tidal CO2 measurement should be used if available; 5 breaths showing CO2 confirm an adequate tube position
  • P.661

  • If the tube is not in position, usually because it has been passed into the oesophagus or the right main bronchus, deflate the cuff, remove the tube, and reoxygenate with the bag and mask, before trying again. Pull the tube back slightly if the breath sounds are only on the right as this suggests the tube is in the right main bronchus
  • Secure the tube
  • Administer oxygen with a self-inflating bag with oxygen and reservoir bag
  • CXR to confirm correct tube position 2–3 cm above the carina
  • Suction can be performed through the tube.

Laryngeal mask airway An alternative to formal intubation. A wide-bore tube with an inflated cuff at one end, which is positioned over the larynx and inflated, hence forming a seal; thus aspiration of gastric contents and gastric inflation are minimized. It is easy to insert and is used in anaesthetic practice and also used in emergencies. Requires minimal head tilt, so is ideal for use in patients with possible cervical spine injuries. Not suitable for patients with high airway resistance, such as pulmonary oedema, bronchospasm, or COPD. Select a size 4 or 5 tube and, after ensuring the cuff works, deflate it. Put water-soluble lubricating jelly over the cuff. The patient should be lying flat, with head extension if possible. Hold the tube like a pen and insert from behind the patient’s head, with the point of the cuff positioned to the back of the mouth. Advance along the roof of the mouth and then press it downwards and backwards until resistance is felt. Inflate the cuff, which will cause the tube to lift out of the mouth a little. Confirm adequate airway position by auscultating for breath sounds over the chest bilaterally. Secure the tube.

Line diagram of laryngeal mask insertion.

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