As a paramedic, the most critical treatment you provide is airway management. Whether intubating the patient in cardiac arrest, dislodging an obstruction, or simply assisting respirations, the speed and effectiveness of your treatment can mean the difference between life and death for your patients. So, let’s review three critical airway management steps you can’t afford to miss: assessment, equipment, and intervention.
ASSESSMENT
Nothing takes the place of a good patient assessment. How are you going to know what to treat if you don’t take the time to thoroughly assess your patient? The key is to be systematic so that nothing is missed. Yes, some critical patients will demand immediate intervention, but a good assessment need not be time-consuming. It basically comes down to look, listen, and feel.
Look
- Is your patient in obvious distress?
- Is he or she conscious and alert?
- What is the respiratory rate?
- Is his or her breathing labored?
- Is the respiratory pattern normal or abnormal?
- What is the respiratory depth?
These simple questions can help you determine if your patient is in respiratory distress or imminent failure.
Listen
Auscultation of the lungs can be enhanced by these simple techniques:
- If possible, have the patient sit up and take slow, deep breaths.
- Place the stethoscope against bare skin.
- Do not rush your patient—it can lead to hyperventilation or exacerbate his or her dyspnea.
- Auscultate over six sites both anteriorly and posteriorly—bilaterally at the second, third, and (peripherally) fifth ribs.
Feel
Palpate the chest by placing your hands directly on the chest wall. Be on the lookout for:
- Equal/unequal chest rise
- Crepitus with suspected rib fractures
- Subcutaneous emphysema
A thorough assessment will indicate the types of airway intervention required. But you had better have the right equipment on hand for treatment.
EQUIPMENT
Once you’ve determined that a respiratory emergency exists, you must have the appropriate equipment available to initiate treatment. This includes:
Basic Airway Adjuncts
- OPA
- For use in unconscious patients lacking a gag reflex
- Size the OPA by measuring from the central incisors to the angle of the jaw
- Must be used in conjunction with manual airway maneuvers
- NPA
- Placed within the nares and extends down into the oropharynx
- Better tolerated than the OPA in semi-conscious patients
- The appropriately sized NPA will measure from the tip of the nose to the tragus of the ear
- Use the largest size possible but do not force into place
- Contraindicated in facial fractures or head trauma with evidence of basilar skull fracture
Suction
Nothing takes the place of a good portable suction unit. Here are a few reminders:
- Make sure the unit is charged and operable—check at the beginning of each shift.
- Make sure the unit is clean; disinfect after each use.
- Have an assortment of catheters on hand to handle any type of obstruction.
- Keep your suction unit with you on every call!
Advanced Airway Interventions
For the unstable airway, you may have to rely on advanced interventions, which can include:
- Orotracheal intubation
- Nasotracheal intubation
- LMA
- Combitube
- Surgical airways
- Needle cricothyrotomy
- Surgical cricothyrotomy
INTERVENTION
You’ve completed your assessment, your equipment is at your side and ready to go, and now comes the intervention. Start with the basics and work your way up to the advanced interventions, based on your patient’s status and response. Sometimes the simplest treatments are most effective. Here is a quick list:
Positioning
Some airway emergencies can be remedied by simple repositioning. Options include:
- Head tilt–chin lift – for use in non-trauma emergencies
- Tongue–jaw lift – used for visualizing foreign-body obstructions
- Jaw thrust – provides a patent airway in patients with suspected spinal trauma
Supplemental Oxygen
When respirations are insufficient, supplemental oxygen may be called for and can be delivered via:
- Mouth-to-mouth ventilation
- Barrier device/resuscitation mask
- Bag-mask ventilation
- Cannulas and non-rebreathing masks
Airway Adjuncts
If positioning and supplemental oxygen are not enough to ensure a patent airway, then adjuncts must be considered. The use of basic versus advanced will depend on your patient’s status, your skill and proficiency, and your transport time to a facility. If you can provide adequate ventilations using a bag-mask device (with good O2 sats) and the receiving facility is nearby, it may be more beneficial to simply transport than to remain on scene to intubate. Use good judgment and always consider your patient’s best interest when making critical airway decisions.
2011, Pollak, A., Ed.
Critical Care Transport, American College of Emergency Physicians, Jones and Bartlett.
