Chapter 07. Airway management and ventilation

Importance of Airway Management in ALS

• Airway obstruction is a common cause of cardiorespiratory arrest.
• Effective airway management is essential for oxygen delivery and to prevent secondary brain damage.
• A structured, stepwise approach should be used for airway interventions during CPR.
• Avoid prolonged interruptions in chest compressions when securing the airway.

 Stepwise Approach to Airway Management

Airway interventions should be performed in a stepwise manner during CPR:

 Basic Airway Opening Techniques

• Head tilt–chin lift: Used in unconscious patients without suspected cervical spine injury.
• Jaw thrust: Used if cervical spine injury is suspected.
• Look, listen, and feel for chest movements, breath sounds, and airflow to assess airway patency.

 Basic Airway Adjuncts

• Oropharyngeal airway (OPA): Prevents tongue obstruction, used only in unconscious patients.
• Nasopharyngeal airway (NPA): Used in semi-conscious patients with a risk of airway obstruction.

 Advanced Airway Techniques

• Bag-mask ventilation (BMV): First-line airway management for non-intubated patients.
• Supraglottic airway (SGA): Devices like laryngeal mask airway (LMA) provide better airway control than BMV.
• Tracheal intubation: Provides definitive airway control but requires high skill levels.
• Cricothyroidotomy: Emergency airway procedure for complete upper airway obstruction.

 Airway Management During CPR

1. Basic Techniques First: Start with head tilt–chin lift or jaw thrust and use simple airway adjuncts.
2. Ventilation Techniques:
   • Provide 2 ventilations every 30 chest compressions (if no advanced airway).
   • Once an advanced airway is placed, ventilate at 10 breaths/min without stopping compressions.
3. Use of Oxygen:
   • Provide 100% oxygen during CPR.
   • Adjust oxygen levels post-ROSC to maintain SpO₂ at 94-98%.
4. Avoid Hyperventilation:
   • Excessive ventilation increases intrathoracic pressure, reducing cardiac output.

 Advanced Airway Management

1. Supraglottic Airways (SGAs)

• Includes LMA, i-gel, and laryngeal tube.
• Easier to insert than tracheal tubes and can be placed without stopping compressions.
• Reduces the risk of gastric inflation compared to BMV.
• Some SGAs include a gastric drain tube to reduce aspiration risk.

2. Tracheal Intubation

• Gold standard for airway protection but requires high skill levels.
• No proven survival benefit over SGAs in out-of-hospital cardiac arrest.
• Waveform capnography must be used to confirm correct placement.
• Unrecognised oesophageal intubation is fatal – proper technique and confirmation are critical.

3. Emergency Airway Techniques

• Cricothyroidotomy: Used when intubation and ventilation fail.
• Needle cricothyroidotomy is a temporary measure, while surgical cricothyroidotomy provides a more stable airway.

 Special Airway Considerations

1. Airway Obstruction Causes

• Soft tissue collapse (tongue, epiglottis, palate).
• Foreign body airway obstruction (FBAO) – choking requires immediate intervention.
• Swelling (burns, anaphylaxis, trauma, infections).
• Blood or vomit in the airway – requires suctioning.

2. Choking (Foreign Body Airway Obstruction)

• Mild obstruction: Encourage coughing, do not interfere.
• Severe obstruction (silent, no air movement):
  • 5 back blows → 5 abdominal thrusts.
  • If unconscious: start CPR immediately.

3. Airway Management in Trauma Patients

• Use jaw thrust instead of head tilt–chin lift.
• Avoid cricoid pressure during intubation.
• Secure the cervical spine while managing the airway.

4. Post-Resuscitation Airway Management

• Continue oxygen therapy while maintaining SpO₂ at 94-98%.
• Confirm correct tube placement using waveform capnography.
• Consider ICU admission for prolonged ventilatory support if required.