A Guide to Identifying and Managing Lower Airway Issues


Often when we think of the airway, we consider the entire respiratory system, forgetting that the upper and lower airway structures have different anatomies and, thus, are affected by different respiratory issues.


It’s critical that EMS providers understand common issues affecting patients’ lower airways so they can offer distinct interventions and tactics, such as modes of ventilation and suctioning and appropriate devices and strategies for airway management, as well as to prevent lower airway issues from escalating or affecting other regions of the airway.


We’ve outlined some common lower airway issues and appropriate suctioning and treatment responses to help providers better differentiate between upper and lower airway structures and prepare for a variety of patient respiratory concerns.


Lower airway structures


The lower respiratory tract begins after the larynx, or voice box, of the upper respiratory tract.

Located in the lower throat and thoracic cavity, the lower airway is made up of the trachea and lungs, which are divided into three lobes on the right and two lobes on the left, with the bronchi branching off into smaller bronchioles and ending at the alveolar ducts.


The correct path for air to travel through the lower airway is from the upper respiratory tract, through the trachea and primary bronchi, secondary bronchi, tertiary bronchi, bronchioles and tertiary bronchioles to reach the alveoli. Gas exchange then occurs within the alveoli.


Lower airway issues


One of the most common lower airway diseases, asthma, is characterized by lower airway swelling, hyperreactivity and increased mucus production, and often results in lower airway obstructions, causing hyperinflation and ventilation perfusion mismatch. The physiological changes asthma patients experience lead to coughing, wheezing, shortness of breath and chest tightness.


Bronchiolitis is another lower airway disease that primarily affects young children and is infectious in nature. This condition often leads to airway edema and obstructed airflow, resulting in wheezing and ongoing respiratory distress.


Some other common lower airway issues are tracheal rupture and tracheal stenosis. Tracheal stenosis is the narrowing of the trachea caused by an injury or birth defect. There are two types of stenosis:


  • Acquired tracheal stenosis, resulting from a reaction to repeated irritation or injury.
  • Congenital tracheal stenosis, resulting from a rare condition in which the cartilage support structure of the trachea causes a narrowing of the airway.


Suctioning the lower airway


Depending on the severity of the lower airway issue, patients may need airway suctioning or more intensive intervention methods, such as balloon dilation, tracheal resection and primary anastomosis, or slide tracheoplasty for tracheal stenosis.


There are specific steps providers must follow, and specific factors to be aware of when suctioning the lower airway. Steps for suctioning the lower airway include:


  • Preparing and assembling equipment (if the patient has an advanced airway in place, providers may need to use a small, flexible catheter that can be inserted into the ET tube or stoma) 
  • Using a sterile technique when handling the catheter
  • Lubricating the suction catheter
  • Preoxygenating the patient
  • Inserting the catheter into the tube or stoma until the patient coughs
  • Applying suction while rotating the catheter and slowly withdrawing the catheter from the airway
  • Monitoring the patient’s vital signs, especially the cardiac monitor
  • Reattaching the bag-valve mask and continuing with ventilation


Making the right treatment choices


Lower airway issues can be just as challenging as upper airway issues, but they require distinct airway management strategies, tactics and devices, depending on the areas being treated, as well as specific patient needs and concerns.


With the right knowledge and understanding of appropriate airway management methods and how lower and upper airway structures differ, providers will be better equipped to ensure optimal outcomes when treating airway challenges in a variety of patient scenarios.jjj


Read this blog to learn more about airway stenosis and selecting the right device and methods for treatment.