Airway

and
Ventilatory
Management
Initial Assessment and Management
 Chapter Statement

Prevention of hypoxemia requires a

protected, unobstructed airway and
adequate ventilation, which take
priority over management of all
other conditions.
 Case Scenario

● 34-year-old motorcyclist
lost control and crashed
into a fence
● Obvious facial trauma
● No helmet
● Smells of alcohol
● Belligerent at scene; now
not communicating
● Pulse oximeter 85%
 Objectives

1. Define definitive airway.

2. Recognize the signs and symptoms of
airway obstruction and ventilatory
compromise.
3. Describe the techniques for establishing
and maintaining a patent airway.
4. Describe techniques for confirming the
adequacy of ventilation and
oxygenation.
 Airway Assessment

How do I know the airway

is adequate?
 Airway Assessment

How do I know the airway

is adequate?
• Patient is alert and oriented.

• Patient is talking normally.

• There is no evidence of injury to the

head or neck.

• You have assessed and reassessed for

deterioration.
 Airway Assessment

Signs and symptoms of airway

compromise
• High index of suspicion
• Change in voice / sore throat
• Noisy breathing (snoring and stridor)
• Dyspnea and agitation
• Tachypnea
• Abnormal breathing pattern
• Low oxygen saturation (late sign)
 Airway Assessment

When to intervene in a
patient with a patent airway
• Impending airway compromise
(Airway problem)

• Need for ventilation

(Breathing problem)

• Inability to protect the airway

(Disability problem)
 Airway Management

How do I manage the airway

of a trauma patient?
 Airway Management

How do I manage the airway

of a trauma patient?
• Supplemental oxygen
• Basic techniques
• Basic adjuncts
• Definitive airway
• Cuffed tube in the trachea

• Difficult airway adjuncts

• Unexpected difficult airway
• Predicted difficult airway
 Airway Management

Protect the cervical spine during airway

management!
 Airway Management

Basic Techniques

Chin-lift Maneuver
 Airway Management

Basic Techniques

Jaw-thrust Maneuver
 Airway Management

Basic Adjuncts
Oropharyngeal airway
● Patients who can tolerate an oral airway will usually need
intubation

Nasopharyngeal airway
● Often well tolerated

Avoid in patients with

mid-face fractures
 Airway Management

How do I predict a potentially

difficult airway?
 Airway Management

How do I predict a potentially

difficult airway?
• Maxillofacial trauma and deformity
• Mouth opening
• Anatomy
• Beard
• Short, thick neck
• Receding jaw
• Protruding upper teeth
 Airway Management

Is this a difficult airway?

How would you manage this patient?
 Airway Management

A definitive airway is a tube placed

in the trachea with the cuff inflated
below the vocal cords, the tube
connected to some form of oxygen-
enriched assisted ventilation, and
the airway secured in place with
tape.
 Airway Management

Definitive Airway - Easy

• Oral intubation (medication assisted)
• BURP, suction back-up
• Maintain c-spine immobilization

Anticipate difficult airway

 Airway Management

Is this a difficult airway?

How would you manage this patient?
 Airway Management

Definitive Airway - Difficult

• Get help • Consider use of:

• Be prepared • Gum elastic
bougie
• Rapid sequence vs.
• Combitube
awake intubation
• (Intubating) LMA
• Maintain c-spine
immobilization • Surgical airway
• Other advanced
techniques
 Airway Management

Definitive Airway
Surgical airway
● Cricothyroidotomy

Needle Surgical
 Airway Confirmation

How do I know the tube is in

the right place?
 Airway Confirmation

How do I know the tube is in

the right place?
• Visualize it going through
the cords
• Watch the chest
• Auscultation
• CO2 detector / ETCO2
monitor
• Pulse oximeter
• X-ray
 Case Scenario

● 34-year-old motorcyclist
lost control and crashed
into a fence
● Obvious facial trauma
● No helmet
● Smells of alcohol
● Belligerent at scene;
now not communicating
● Pulse oximeter 85%
Questions?

?
 Summary

● Suspect airway compromise in all injured patients

and protect the cervical spine
● Be prepared for easy and difficult airway
● Consider adjuncts for establishing a patent airway
● Definitive airway is a cuffed tube in the trachea
● Quickly assess the patency and adequacy of
ventilation using a pulse oximeter and end-tidal
CO2