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Airway management

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Airway management

Airway management

Airway management is the medical process of ensuring there is an open pathway between a patient’s lungs and the outside world, as well as reducing the risk of aspiration. Airway management is a primary consideration in cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.

Airway maneuvers

Head-tilt chin-lift

The head-tilt chin-lift is the most reliable method of opening the airway.
Head-tilt chin-lift — The head-tilt chin-lift is the primary maneuver used in any patient in whom cervical spine injury is not a concern. The simplest way of ensuring an open airway in an unconscious patient is to use a head tilt chin lift technique, thereby lifting the tongue from the back of the throat. This is taught on most first aid courses as the standard way of clearing an airway.

Jaw-thrust maneuver

Jaw-thrust maneuver — The jaw-thrust maneuver is an effective airway technique, particularly in the patient in whom cervical spine injury is a concern. The jaw thrust is a technique used on patients with a suspected spinal injury and is used on a supine patient. The practitioner uses their index and middle fingers to physically push the posterior (back) aspects of the mandible upwards while their thumbs push down on the chin to open the mouth. When the mandible is displaced forward, it pulls the tongue forward and prevents it from occluding (blocking) the entrance to the trachea, helping to ensure a patent (secure) airway.

The International Liaison Committee on Resuscitation no longer advocates use of the jaw thrust by lay rescuers,[1] even for spinal-injured victims, although health care professionals still maintain the technique for specific applications. Instead, lay rescuers are advised to use the same head-tilt for all victims.

Cervical spine immobilization

Cervical spine immobilization — Most airway maneuvers are associated with some movement of the cervical spine (c-spine).[2][3] Even though collars for holding the head in-line can cause problems maintaining an airway and maintaining a blood pressure,[4] it is unrecommended to remove the collar without adequate personnel to manually hold the head in place.[5]

Invasive airway management

In roughly increasing order of invasiveness:

Supraglottic tubes

A tube is introduced into the pharynx, ensuring the upper respiratory tract remains open, without passing through the glottis.

Oropharyngeal airway

Oropharyngeal airways in a range of sizes

Oropharyngeal airways (OPA) (also known as Guedel airways)[6] are rigid plastic curved devices used to maintain an open airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.[7] An OPA should only be used in a deeply unresponsive patient because in a responsive patient they can cause vomiting and aspiration by stimulating the gag reflex.[8]

Nasopharyngeal airway

Learning to insert a nasopharyngeal airway

The nasopharyngeal airway (NPA) (also known as a nasal trumpet) is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx. Patients tolerate NPAs more easily than OPAs, so NPAs can be used when the use of an OPA is difficult, such as when the patient's jaw is clenched or the patient is semiconscious and cannot tolerate an OPA.[9] NPAs are generally not recommended if there is suspicion of a fracture to the base of the skull, due to the possibility of the tube entering the cranium.[10] However, the actual risks of this complication occurring compared to the risks of damage from hypoxia if an airway is not used are debatable.[10][11]

Supraglottic airway

ProSeal Laryngeal Mask Airway inflated 001

Supraglottic airways (also called extraglottic[12]) are a family of devices that are inserted through the mouth to sit on top of the larynx. Supraglottic airways are used in the majority of operations performed under general anaesthesia.[13] Compared to a cuffed tracheal tube (see below), they give less protection against aspiration but are easier to insert and cause less laryngeal trauma.[12]

The best-known example is the Laryngeal Mask Airway (LMA). A laryngeal mask airway is an airway placed into the mouth and set over the glottis and inflated.[14] This tube does not enter the trachea.[14]

Other variations include devices with oesophageal access ports, so that a separate tube can be inserted from the mouth to the stomach to decompress accumulated gases and drain liquid contents.[12] Some devices can have an endotracheal tube passed through them into the trachea (intubating LMA).[12]

Tracheal intubation

A cuffed endotracheal tube used in tracheal intubation

Tracheal intubation, often simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction. The most widely used route is orotracheal, in which an endotracheal tube is passed through the mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea.

Surgical methods

A surgical incision is made below the glottis in order to achieve direct access, bypassing the upper respiratory tract.


In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage
In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage

A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma.[15] A cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications.[16]]


A cuffed tracheostomy tube used in tracheal intubation through a tracheostoma

A tracheotomy is a surgically created opening from the skin of the neck down to the trachea (windpipe).[17] A tracheotomy may be considered where a person will need to be on a mechanical ventilator for a long time.[17] The advantages of a tracheotomy include less risk of infection and damage to the trachea such as tracheal stenosis.[17]

Removal of vomit and regurgitation

In the case of a patient who vomits or has other secretions in the airway, these techniques will not be enough. Suitably trained clinicians may elect to use suction to clean out the airway, although this may not always be possible. An unconscious patient who is regurgitating stomach contents should be turned into the recovery position when there is no suction equipment available, as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea.

Airway management in specific situations

Cardiopulmonary resuscitation

The best method of airway management during CPR is controversial.[18] There has been less emphasis on airway management (including simple mouth-to-mouth or invasive methods) during CPR, since it was shown that people receiving initial chest-compression-only CPR were more likely to survive than those who had standard CPR.[18] People who are resuscitated with basic bag-mask ventilation may also be more likely to survive than those who are intubated or have a supraglottic airway inserted.[18] However, in children, or where the cause of the arrest was an airway or breathing problem, or where the arrest is prolonged, airway management is still important.[18]

In basic life support, many people can be reluctant to start mouth-to-mouth resuscitation.[19] The American Heart Association now supports "Hands-only"™ CPR, which advocates chest compressions without any airway management for teens or adults.[19] Bystanders who see an adult suddenly collapse should call for help and move to chest compressions straight away.[19] It is likely that later in resuscitation care by trained professionals, simple methods as well as supraglottic and tracheal airways each have a role, depending on the skills of the person performing them and the equipment or environment they are working in.[12][18]


In prehospital environments, airway management is controversial, with intubation and supraglottic airways each having advantages and disadvantages. Trauma victims are often not fasting so there is an increased risk of aspiration, but blood and other material may make it difficult to see the larynx to intubate.[12]

See also


  1. ^ Part 2: Adult Basic Life Support - 112 (22 Supplement): III-5 - Circulation
  2. ^ Donaldson WF, Heil BV, Donaldson VP, Silvaggio VJ (1997). "The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study.". Spine (Phila Pa 1976) 22 (11): 1215–8.  
  3. ^ Brimacombe J, Keller C, Künzel KH, Gaber O, Boehler M, Pühringer F (2000). "Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers". Anesth Analg 91 (5): 1274–8.  
  4. ^ Kolb JC, Summers RL, Galli RL (1999). "Cervical collar-induced changes in intracranial pressure". Am J Emerg Med 17 (2): 135–7.  
  5. ^ Mobbs RJ, Stoodley MA, Fuller J (2002). "Effect of cervical hard collar on intracranial pressure after head injury". ANZ J Surg 72 (6): 389–91.  
  6. ^ Guedel A. E. J. Am. Med. Assoc. 1933, 100, 1862 (reprinted in “Classical File”, Survey of Anesthesiology 1966,10, 515)
  7. ^ Ed Dickinson; Dan Limmer; O'Keefe, Michael F.; Grant, Harvey D.; Bob Murray (2008). Emergency Care (11th Edition). Englewood Cliffs, N.J: Prentice Hall. pp. 157–9.  
  8. ^ "Guedel airway". AnaesthesiaUK. 14 May 2010. Retrieved 23 May 2013. 
  9. ^ Roberts K, Whalley H, Bleetman A (2005). "The nasopharyngeal airway: dispelling myths and establishing the facts". Emerg Med J 22 (6): 394–6.  
  10. ^ a b Ellis, D. Y. (2006). "Intracranial placement of nasopharyngeal airways: Is it all that rare?". Emergency Medicine Journal 23 (8): 661–661.  
  11. ^ Roberts, K.; Whalley, H.; Bleetman, A. (2005). "The nasopharyngeal airway: Dispelling myths and establishing the facts". Emergency Medicine Journal 22 (6): 394–396.  
  12. ^ a b c d e f Hernandez, MR; Klock, A; Ovassapian, A (2011). "Evolution of the Extraglottic Airway: A Review of Its History, Applications, and Practical Tips for Success". Anesthesia and Analgesia 114 (2): 349–68.  
  13. ^ Cook, T; Howes, B. (2010). "Supraglottic airway devices: recent advances".  
  14. ^ a b Davies PRF, Tighe SQM, Greenslade GL, Evans GH (1990). "Laryngeal mask airway and tracheal tube insertion by unskilled personnel".  
  15. ^ Mohan, R; Iyer, R; Thaller, S (2009). "Airway management in patients with facial trauma". Journal of Craniofacial Surgery 20 (1): 21–3.  
  16. ^ Katos, MG; Goldenberg, D (2007). "Emergency cricothyrotomy". Operative Techniques in Otolaryngology 18 (2): 110–4.  
  17. ^ a b c Gomes Silva, B. N.; Andriolo, R. G. B.; Saconato, H.; Atallah, Á. N.; Valente, O. (2012). Gomes Silva, Brenda Nazaré, ed. "Cochrane Database of Systematic Reviews".  
  18. ^ a b c d e Soar, J.; Nolan, J. P. (2013). "Airway management in cardiopulmonary resuscitation". Current Opinion in Critical Care 19 (3): 181–187.  
  19. ^ a b c Sayre, M. R.; Berg, R. A.; Cave, D. M.; Page, R. L.; Potts, J.; White, R. D.; American Heart Association Emergency Cardiovascular Care Committee (2008). "Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest: A Science Advisory for the Public from the American Heart Association Emergency Cardiovascular Care Committee". Circulation 117 (16): 2162–2167.  

Further reading

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