AIRWAY

Airway  management

Airway management should follow a stepwise assessment, followed by: 

• Basic interventions are recommended if it addresses the airway obstruction/respiratory insufficiency: Nasopharyngeal airway, oropharyngeal airway, BVM with PEEP valve (if available), patient positioning if not contraindicated.
• If the patient continues to decompensate, perform intermediate interventions: Supraglottic airway.
• If the patient requires emergent surgical intervention due to severe obstruction/respiratory insufficiency despite interventions above, obtain an advanced airway: oral endotracheal tube or via a surgical airway.

Positioning of the patient to help clear airway obstruction should be considered first, when possible.  The simple option of placing the patient in a sitting position, placing the patient in the lateral “recovery” position, or head tilt-chin lift/jaw thrust maneuver may be enough to ensure adequate respirations.  While beneficial, a jaw thrust or chin lift maneuver is difficult to maintain as it dedicates one individual solely to opening the airway. Likely more practical is placing a patient with their chin away from chest (whether its supine or recovery), when possible and not contraindicated. Simple adjuncts such as a nasal or oropharyngeal airway (NPA/OPA) may be utilized in addition to proper positioning to help ensure a clear airway.⁴  Of note, there are multiple sizing challenges with an NPA that can actually cause further obstruction if not measured precisely, therefore, remain vigilant. Oropharyngeal airway insertion can present a considerable noxious stimulus and may not be tolerated by conscious or even some semiconscious patients.  BVM ventilation is the next step. 

For those patients requiring prolonged active respiratory support or airway protection, a definitive airway is preferred.  A definitive airway requires control of the patient’s airway with an inflated cuff in the trachea. Definitive airway placement requires considerable skill and sustainment training. If not current and practiced, or if encountering difficulty securing a definitive airway consider other airway adjuncts such as supraglottic airways.

Furthermore, intubation and providing mechanical ventilation are not without risk.  The benefits should outweigh the attributable cost and risk of managing the mechanically ventilated patient, especially within the austere/battlefield setting.  Pathology associated with failure to oxygenate and failure to ventilate will most often require definitive airway interventions and appropriate mechanical ventilator support.  At times, it may only serve as a temporizing measure while seeking definitive critical care.  Initiation of mechanical ventilation must be guided by clinical suspicion of underlying pathophysiology and clear criteria.  A definitive airway is required for effective mechanical ventilation and these patients require sedation – both mechanical ventilation and sedation may make a hypotensive patient more hypotensive and could result in hemodynamic instability.  Thoughtful consideration for whether the patient requires mechanical ventilation must occur.  In patients with hemorrhagic shock requiring intubation and mechanical ventilation, remember the general principle of “resuscitation before intubation.” Utilize airway adjuncts if the patient’s airway can be maintained adequately during initial resuscitation efforts with blood products. In an under-resuscitated patient, cardiac arrest can occur when induction and paralytic medications are given during rapid sequence intubation.