Basic airway management in adults
- Kathleen A Wittels, MD
Kathleen A Wittels, MD
- Instructor of Emergency Medicine
- Harvard Medical School
Bag-mask ventilation is the cornerstone of basic airway management and is not a skill easily mastered . This procedure is most often needed because of inadequate ventilation, which can result from impaired respiratory effort or airway obstruction. Basic airway interventions may also be needed to manage the patient with inadequate oxygenation and during cardiopulmonary resuscitation.
This topic will review the essential techniques involved in basic airway management in adults. Airway management of children is discussed separately (see "Emergency endotracheal intubation in children"). Issues related to endotracheal intubation in adults and other advanced airway management techniques are discussed elsewhere.
CAUSES OF INADEQUATE VENTILATION
Respiratory effort — Inadequate respiratory effort can result from intrinsic (eg, intracranial hemorrhage) or extrinsic (eg, opioid overdose) factors. Poor respiratory effort causing inadequate ventilation can be difficult to discern: it is often silent, and detection depends on close observation of chest wall movement. Thorough evaluation requires that the patient be undressed and the clinician observe the rate, pattern, and depth of breathing, use of accessory muscles, abnormal sounds, and signs of injury. Both laymen and health care professionals often fail to accurately determine the adequacy of respiratory effort [2,3].
Airway obstruction — Soft tissue airway obstruction in the unconscious patient can occur by several mechanisms. These include prolapse of the tongue into the posterior pharynx and loss of muscular tone in the soft palate [4,5]. Simple airway maneuvers, such as the head-tilt chin-lift or jaw-thrust with or without a head tilt, often ameliorate this problem quickly (see 'Airway maneuvers' below). Obstruction by foreign bodies, injured tissue, blood, and secretions can also occur.
Noises produced by the obstructed upper airway often make such obstruction easier to detect than poor respiratory effort. As an example, snoring or gurgling noises may be heard when the upper airway becomes partially obstructed by soft tissue or liquid (eg, blood, emesis). Complete airway obstruction is silent but may manifest transiently as retractions of the accessory muscles of respiration (suprasternal, supraclavicular, intercostal, subcostal) or as cyanosis, until frank respiratory arrest supervenes.
- Komatsu R, Kasuya Y, Yogo H, et al. Learning curves for bag-and-mask ventilation and orotracheal intubation: an application of the cumulative sum method. Anesthesiology 2010; 112:1525.
- Ruppert M, Reith MW, Widmann JH, et al. Checking for breathing: evaluation of the diagnostic capability of emergency medical services personnel, physicians, medical students, and medical laypersons. Ann Emerg Med 1999; 34:720.
- Vargo JJ, Zuccaro G Jr, Dumot JA, et al. Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Gastrointest Endosc 2002; 55:826.
- Shorten GD, Opie NJ, Graziotti P, et al. Assessment of upper airway anatomy in awake, sedated and anaesthetised patients using magnetic resonance imaging. Anaesth Intensive Care 1994; 22:165.
- Mathru M, Esch O, Lang J, et al. Magnetic resonance imaging of the upper airway. Effects of propofol anesthesia and nasal continuous positive airway pressure in humans. Anesthesiology 1996; 84:273.
- Heimlich HJ. A life-saving maneuver to prevent food-choking. JAMA 1975; 234:398.
- Ingalls TH. Heimlich versus a slap on the back. N Engl J Med 1979; 300:990.
- Skulberg A. Chest compression--an alternative to the Heimlich manoeuver? Resuscitation 1992; 24:91.
- Redding JS. The choking controversy: critique of evidence on the Heimlich maneuver. Crit Care Med 1979; 7:475.
- Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S414.
- Travers AH, Rea TD, Bobrow BJ, et al. Part 4: CPR overview: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S676.
- Gallardo A, Rosado R, Ramírez D, et al. Rupture of the lesser gastric curvature after a Heimlich maneuver. Surg Endosc 2003; 17:1495.
- Majumdar A, Sedman PC. Gastric rupture secondary to successful Heimlich manoeuvre. Postgrad Med J 1998; 74:609.
- Dupre MW, Silva E, Brotman S. Traumatic rupture of the stomach secondary to Heimlich maneuver. Am J Emerg Med 1993; 11:611.
- Langhelle A, Sunde K, Wik L, Steen PA. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. Resuscitation 2000; 44:105.
- Guildner CW. Resuscitation--opening the airway. A comparative study of techniques for opening an airway obstructed by the tongue. JACEP 1976; 5:588.
- Uzun L, Ugur MB, Altunkaya H, et al. Effectiveness of the jaw-thrust maneuver in opening the airway: a flexible fiberoptic endoscopic study. ORL J Otorhinolaryngol Relat Spec 2005; 67:39.
- Donaldson WF 3rd, Heil BV, Donaldson VP, Silvaggio VJ. The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study. Spine (Phila Pa 1976) 1997; 22:1215.
- Brimacombe J, Keller C, Künzel KH, et al. Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers. Anesth Analg 2000; 91:1274.
- Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine fractures. J Trauma 1987; 27:980.
- Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Am J Emerg Med 1999; 17:135.
- Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial pressure after head injury. ANZ J Surg 2002; 72:389.
- Roberts K, Whalley H, Bleetman A. The nasopharyngeal airway: dispelling myths and establishing the facts. Emerg Med J 2005; 22:394.
- Stoneham MD. The nasopharyngeal airway. Assessment of position by fibreoptic laryngoscopy. Anaesthesia 1993; 48:575.
- Schneider, RE, Murphy, MF. Bag/mask ventilation and endotracheal intubation. In: Manual of Emergency Airway Management, Walls, RM (Eds), Lippincott, Williams and Wilkins, Philadelphia 2004. p.43.
- Gerstein NS, Carey MC, Braude DA, et al. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth 2013; 25:193.
- Joffe AM, Hetzel S, Liew EC. A two-handed jaw-thrust technique is superior to the one-handed "EC-clamp" technique for mask ventilation in the apneic unconscious person. Anesthesiology 2010; 113:873.
- Conlon NP, Sullivan RP, Herbison PG, et al. The effect of leaving dentures in place on bag-mask ventilation at induction of general anesthesia. Anesth Analg 2007; 105:370.
- Racine SX, Solis A, Hamou NA, et al. Face mask ventilation in edentulous patients: a comparison of mandibular groove and lower lip placement. Anesthesiology 2010; 112:1190.
- Paradis NA, Martin GB, Goetting MG, et al. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans. Insights into mechanisms. Circulation 1989; 80:361.
- Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation 2004; 109:1960.
- 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care With Treatment Recommendations. Circulation 2005; 112 (suppl I):III.
- Bowman FP, Menegazzi JJ, Check BD, Duckett TM. Lower esophageal sphincter pressure during prolonged cardiac arrest and resuscitation. Ann Emerg Med 1995; 26:216.
- Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med 2004; 32:S345.
- Yannopoulos D, Tang W, Roussos C, et al. Reducing ventilation frequency during cardiopulmonary resuscitation in a porcine model of cardiac arrest. Respir Care 2005; 50:628.
- CAUSES OF INADEQUATE VENTILATION
- Respiratory effort
- Airway obstruction
- AIRWAY MANEUVERS
- Head-tilt chin-lift
- Jaw-thrust maneuver
- Cervical spine immobilization
- AIRWAY ADJUNCTS
- Oropharyngeal airway
- Nasopharyngeal airway
- BAG-MASK VENTILATION
- Mask placement
- Single-hand technique for bag-mask ventilation
- Two-hand technique for bag-mask ventilation
- Trouble-shooting problems with bag-mask ventilation
- Ventilation volumes, rates, and cadence
- Cricoid pressure (Sellicks maneuver)
- SUMMARY AND RECOMMENDATIONS