Respiratory Arrest and Airway Management: Maintaining Airway Patency

Opening the Airway

There are a variety of airway adjuncts that can be used to maintain an open airway. The first step in opening the airway is to use one of two maneuvers to create a straight line from mouth to trachea. 

The head tilt-chin lift maneuver is used in patients with no known trauma, especially in the spine. The jaw thrust maneuver is used in patients with suspected cervical spine trauma.¹

If it is uncertain if the patient has experienced a trauma, it is best to err on the side of caution and use the jaw thrust to open the airway. The jaw thrust maneuver is a little more difficult to perform and requires practice.

Head tilt-chin lift maneuver

Airway Adjuncts

There are two main airway adjuncts that can be used to maintain an open airway.

Related Video – What are Ventilation Devices?

An oropharyngeal airway (OPA) is a rigid J-shaped airway used in unconscious patients with no gag reflex because it may induce vomiting in the conscious patient. Its purpose is to displace the tongue from the oropharyngeal space. The tongue is the most common source of airway obstruction.²

The OPA can be used for access to suction secretions, vomitus, or blood. OPAs should always be used in conjunction with a bag-mask device to ventilate a patient.

An oropharyngeal airway is a J-shaped device (in green).

OPAs come in a variety of sizes. It is important to choose the correct size. Using an OPA that is too small will not keep the tongue from obstructing the airway, and using an OPA that is too big can obstruct the airway or irritate the larynx and cause laryngospasm. 

To measure for the correct size, hold the OPA to the patient’s face: the tip of the OPA should be at the corner of the patient’s mouth, while the flange should reach the tip of the ear. Adjust up or down in size accordingly. Alternately, hold the OPA against the face with the flange of the OPA just anterior to the lateral incisors and the tip of the OPA at the angle of the mandible.

When inserting the OPA, use a tongue depressor to hold the tongue down and forward. Some practitioners choose to insert the OPA with the concave side facing toward the palate and then rotating the device 180°. However, if performed too roughly, this method can damage the palate, the teeth, or the oral mucosa. 

Oropharyngeal airways should never be used as bite blocks to prevent the patient from biting down on an endotracheal tube. The OPA is only meant to be used for a short time until the airway can be better secured.³

The nasopharyngeal airway (NPA) is a soft and flexible airway adjunct that provides airway patency via the nares and the pharynx. It can be used in semi-conscious and conscious patients with active gag reflexes. 

As with OPAs, choosing the correct size is important. To measure for correct size, hold the NPA against the side of the patient’s face: the tip should be at the patient’s nare and the flange should be at the corner of the ear. 

Lubrication should be used to facilitate passage of the tube. The NPA should be inserted gently along the normal curvature of the nasal passage. Introduction of the NPA should never be forced, as forcing insertion may cause bleeding. 

If insertion is difficult, attempt insertion in the other nare. In about 80% of individuals, the right nare is slightly larger, so it makes sense to try the right nare first. 

The NPA should never be used on individuals with trauma to the face, particularly midface trauma or a basilar skull fracture, as intubation into the soft tissue, skull, or even the brain could occur, although this is exceedingly rare. NPAs should not be used for patients with known bleeding issues.

Read: Respiratory Arrest and Airway Management: Ventilation Devices

Related Video – Tips for Bagging

Suctioning

Secretions, vomitus, and blood are common causes of airway obstructions that can be cleared by suctioning. Suctioning is used to clear secretions when the patient is unable to do so on their own.⁴

In the field, emergency medical services (EMS) uses a portable suction device that can create a vacuum force of 80–120 mm Hg. In-hospital wall-mounted suction devices can create a vacuum force of about 300 mm Hg.

Suctioning is not a benign procedure. It can lead to hypoxia, arrhythmias, and injury. Therefore, there should be a clear indication for suctioning. Prior to suctioning, the patient should be hyperoxygenated, as this will help to prevent hypoxia. Hyperoxygenation involves providing 100% oxygen for approximately 30 seconds before attempting suctioning.

There are numerous types of suction catheters commercially available. The type of suction catheter used is dependent on the area requiring secretion removal. Soft catheters can be used to suction the nasal passages, nasopharynx, and the mouth. A Yankauer catheter is a rigid suctioning tube that is capable of suctioning out very thick secretions from the mouth.

A nurse is preparing a suction machine to suction a patient’s mucus.

Suctioning should not be performed for longer than 10–15 seconds to avoid hypoxia. It is also important to remember that suction should only be applied as the catheter is being removed, never during insertion. 

Most suction tubes have a port that is covered and uncovered with the thumb to control when suction is being applied. At a minimum, oxygen saturation should be monitored during suctioning.

Maintaining an airway is essential to caring for a patient in respiratory distress. It is important for the clinician to know the maneuvers for opening the airway, inserting airway adjuncts, and providing suctioning.