Basic Airway Maintenance
Even though the new guidelines for the American Heart Association are not focusing on compressions, that doesn’t mean that airway and breathing should be ignored. In fact, if two rescuers are present, then it makes sense that one works on maintaining an airway while compressions are delivered hard and fast. When more experienced providers are present, then the management of the airway becomes even more important. This usually means that the patient has been down a long time, and the tissues are in need of fresh oxygen.
Intubation is a great technique, but it isn’t always possible. For this reason, it is important to learn how to secure airways and deliver breaths without the use of an intubation tube. It is generally more difficult to manage a basic airway, although intubation has its own problems with initiation. All BLS certified medical professionals should know the basics of how to establish and maintain an airway – provided that another professional is already working on compressions. In one rescuer CPR, only compressions are recommended, but when you have the extra hands, getting that airway, even a basic one, is an important component in rescuing the patient from the arrest.
The most basic form of airway management is the head tilt-chin lift. This essentially puts the patient’s head into a sniffing position. It is achieved by pushing back on the forehead and pulling up on the chin. In this position, the airway is easier to maintain because the tongue and other soft tissue are pulled out of the central airway. However, this is not a complete removal of the tissue, and intubation is the preferred method for maintaining an airway.
In cases where neck injuries are suspected or the chin lift isn’t feasible, the jaw thrust is a positioning system that performs the same function. Bracing your palms against the cheekbones, you grasp behind the jaw and lift up. Once again, this clears the tongue from the airway and allows rescue breaths to enter the lungs. While administering breaths, either of these techniques needs to be employed to keep the airway open. The jaw thrust is often used in conjunction with bag-valve-mask techniques. However, it is difficult to apply the pressure to the jaw and work the bag. In these cases, it is important to maintain good form and get the patient to more definitive care as soon as possible.
Most paramedics and crash carts have plastic airways that can be inserted into the mouth or nose to keep the airway patent. The most common type is the mouth airway that is shaped rather like a question mark. The hooked end goes into the patient’s airway and mechanically keeps the tongue out of the way. There are two ways to insert this sort of airway. One is to simply slide the hook along the patient’s tongue and into the back of the throat. However, the most accepted way is to insert the hook portion toward the patient’s nose, then twist when it is entirely within the mouth.
Nasal airways are not used as often because they don’t have the same ability to clear the tongue out of the airway. It travels down the nasopharynx, though, beyond the tongue, and this makes nasal airways useful when the mouth or neck is injured. These are simply rubber tubes that are inserted into a nostril. Often, you will need to thoroughly lubricate the airway to get it to drop into position. In many cases, it takes less time to get a patient intubated than to get a nasal airway. If you have no other choice, though, this can help to get the rescue breaths into the lungs.
The bag-valve-mask is an important skill to learn, and it helps to practice on a mannequin to get the feel for this often unwieldy piece of equipment. It is comprised of a stiff rubber bag that acts to force air into the lungs, a valve that regulates pressure, and a mask that keeps a seal over the patient’s mouth. When intubated, the mask is removed and the valve is attached directly to the tube, but most emergent situations require the use of the mask. You should keep several thoughts in mind when giving breaths with this device.
First, you need to keep the mask sealed on the patient’s face. You can do this by circling the valve with your finger and thumb, then using the rest of your fingers to grasp the jaw. Usually, this is done with the off hand, and by pulling up, you can maintain a jaw thrust. Second, you don’t want to overinflate the lungs. When you depress the bag, you should not give more air than it takes to simply raise the chest. You should also give breaths every eight to ten seconds while compressions are ongoing. Using this device is sometimes difficult, but it is vital to giving breaths to patients who lose consciousness in the field.