Basic airway management | |
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Other names | Basic airway maneuvers |
Specialty | Emergency Medicine, Prehospital Medicine, Anesthesia, Critical Care Medicine, Nursing, First-Aid |
Uses | Clearing airway obstructions, preventing airway obstructions, ventilation |
Basic airway management is a concept and set of medical procedures performed to prevent and treat airway obstruction and allow for adequate ventilation to a patient's lungs. [1] This is accomplished by clearing or preventing obstructions of airways. Airway obstructions can occur in both conscious and unconscious individuals. They can also be partial or complete. Airway obstruction is commonly caused by the tongue, the airways itself, foreign bodies or materials from the body itself, such as blood or vomit. [2] Contrary to advanced airway management, basic airway management technique do not rely on the use of invasive medical equipment and can be performed with less training. Medical equipment commonly used includes oropharyngeal airway, nasopharyngeal airway, bag valve mask, and pocket mask. [2] Airway management is a primary consideration in cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.
If the patient is conscious symptoms of airway obstructions may include: [3]
Treatment includes several procedures aiming at removing foreign bodies from the airways. Most modern protocols, including those of the American Heart Association, American Red Cross and the European Resuscitation Council, [4] recommend several stages, designed to apply more pressure increasingly. Basic treatment includes several procedures aiming at removing foreign bodies from the airways. Most protocols recommend encouraging the victim to cough, followed by hard back slaps, and if none of these things work; abdominal thrusts (Heimlich maneuver) or chest thrusts. [5] Some guidelines recommend alternating between abdominal thrusts and back slaps. [4]
This stage was introduced in many protocols as it was found that many people were too quick to undertake potentially dangerous interventions, such as abdominal thrusts, for items that could have been dislodged without intervention. Also, if the choking is caused by an irritating substance rather than an obstructing one, and if conscious, the patient should be allowed to drink water on their own to try to clear the throat. Since the airway is already closed, there is very little danger of water entering the lungs. Coughing is normal after most of the irritants have cleared, and at this point, the patient will probably refuse any additional water for a short time.
Most protocols recommend encouraging the victim to cough, followed by hard back slaps with the heel of the hand on the victim's upper back. The number to be used varies by training organization but is usually between five and twenty. For example, the European Resuscitation Council and the Mayo Clinic recommend five blows between the shoulder blades. [4] [5] The back slap uses percussion to create pressure behind the blockage, assisting the patient in dislodging the article. Other recommendations only use back blows for patients less than one-year-old, alternating between five back blows and five chest thrusts. [6]
Performing abdominal thrusts involves a rescuer standing behind a patient and using his or her hands to exert pressure on the bottom of the diaphragm. This compresses the lungs and exerts pressure on any object lodged in the trachea, hopefully expelling it. The European Resuscitation Council and the Mayo Clinic recommend alternating between 5 back slaps and 5 abdominal thrusts in severe airway obstructions. [4] [5] While UpToDate recommends only using abdominal thrusts in adults and children more than one-year-old. [6] In some areas, such as Australia, authorities believe there is not enough scientific evidence to support the use of abdominal thrusts, and their use is not recommended in first aid. Instead, chest thrusts are recommended. [7] A person may also perform abdominal thrusts on himself by using a fixed object such as a railing or the back of a chair to apply pressure where a rescuer's hands would normally do so. As with other forms of the procedure, internal injuries may result.
If the patient can not receive pressure on the abdomen, the abdominal thrusts are replaced by chest thrusts. [8] This is the case of pregnant women, obese people, and others. Chest thrusts are applied in the same manner as abdominal thrusts, but pressing inwards on the lower half of the sternum (the chest bone). As a reference, the zone of pressure of the chest thrusts in women would be normally higher than the level of the breasts. The pressure is not focused against the endpoint of the chest bone (which is named the xiphoid process), to avoid breaking it.
The finger sweep should only be used if a foreign body is easily identified, a blind finger sweep should never be used. [2] [9] In the unresponsive patient receiving CPR, if a solid foreign body becomes visible it should be removed. [2]
In modern times, some commercial anti-choking devices (LifeVac, Dechoker, Lifewand) [10] [11] [12] have been developed and released to the market. They do not require electricity to work. The devices use a mechanical vacuum effect instead. Some choking cases where anti-choking devices were employed have appeared in the media. [13] [14]
Evaluation of an unconscious patient's breathing is often performed by the look, listen, and feel method. The ear is placed over the person's mouth so breathing can be heard and felt while looking for rising chest or abdomen. The procedure should not take longer than 10 seconds. As in conscious patients stridor can be heard if there is a partial airway obstruction. The tongue may also partially obstruct the airway resulting in a snoring sound. If the airway is obstructed by liquid it may produce a gurgling sound. Complete airway obstruction may not have any noise. In the unconscious patient agonal breathing is often mistaken for airway obstructions. If there is respiratory arrest or agonal breathing CPR is indicated. [15]
Treatment of unconscious patients focuses on preventing or treating obstructions of the airway, such as head-tilt/chin-lift and jaw-thrust maneuvers, while the use of the recovery position mainly prevents aspiration of things like stomach content or blood.
The head-tilt/chin-lift is the primary maneuver used in any patient in whom cervical spine injury is not a concern. The maneuver is performed by tilting the head backward in unconscious patients, often by applying pressure to the forehead and the chin. Head-tilt/chin-lift is taught in most first aid courses as the standard way of clearing an airway. [16] [17]
The jaw-thrust maneuver is an effective airway technique, particularly in patients in whom cervical spine injury is a concern. The jaw thrust is a technique used on patients with a suspected or possible cervical spinal cord injury and is used on a supine patient. The practitioner uses their index and middle fingers to physically pull the posterior (back) of the mandible towards the ceiling, while their thumbs open the mouth. [16] [17]
The recovery position refers to one of a series of variations on a lateral recumbent or three-quarters prone position of the body, in which an unconscious but breathing patient can be placed. The use of the recovery position helps to prevent aspiration.
Most airway maneuvers are associated with some movement of the cervical spine. [18] [19] Cervical collars for reducing cervical spine movement can cause problems maintaining an airway. It is recommended that manual stabilization of the cervical spine is held if the cervical collar must be removed to maintain the patient's airway.
There are some pieces of medical equipment that are used in basic airway management. When used correctly some help maintain an open airway, like an oropharyngeal airway. Other devices help ventilate the patient so oxygen can be delivered to the lungs and circulated through the body.
First aid is the first and immediate assistance given to any person with either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery until medical services arrive. First aid is generally performed by someone with basic medical training. Mental health first aid is an extension of the concept of first aid to cover mental health, while psychological first aid is used as early treatment of people who are at risk for developing PTSD. Conflict first aid, focused on preservation and recovery of an individual's social or relationship well-being, is being piloted in Canada.
Mouth-to-mouth resuscitation, a form of artificial ventilation, is the act of assisting or stimulating respiration in which a rescuer presses their mouth against that of the victim and blows air into the person's lungs. Artificial respiration takes many forms, but generally entails providing air for a person who is not breathing or is not making sufficient respiratory effort on their own. It is used on a patient with a beating heart or as part of cardiopulmonary resuscitation (CPR) to achieve the internal respiration.
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.
Choking, also known as foreign body airway obstruction (FBAO), is a phenomenon that occurs when breathing is impeded by a blockage inside of the respiratory tract. An obstruction that prevents oxygen from entering the lungs results in oxygen deprivation. Although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, choking often leads to death.
Abdominal thrusts, also known as the Heimlich maneuver or Heimlich manoeuvre, is a first-aid procedure used to treat upper-airway obstructions by foreign objects. American doctor Henry Heimlich is often credited for its discovery. To perform abdominal thrusts, a rescuer stands behind a choking victim and using the hands to exert pressure on the bottom of the diaphragm. This compresses the lungs and exerts pressure on the object lodged in the trachea in an effort to expel it.
Mechanical ventilation or assisted ventilation is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air into and out of the lungs, with the main goal of helping the delivery of oxygen and removal of carbon dioxide. Mechanical ventilation is used for many reasons, including to protect the airway due to mechanical or neurologic cause, to ensure adequate oxygenation, or to remove excess carbon dioxide from the lungs. Various healthcare providers are involved with the use of mechanical ventilation and people who require ventilators are typically monitored in an intensive care unit.
In first aid, the recovery position is one of a series of variations on a lateral recumbent or three-quarters prone position of the body, often used for unconscious but breathing casualties.
Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers. It can be provided by trained medical personnel, such as emergency medical technicians, and by qualified bystanders.
Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration).
Respiratory arrest is a serious medical condition caused by apnea or respiratory dysfunction severe enough that it will not sustain the body. Prolonged apnea refers to a patient who has stopped breathing for a long period of time. If the heart muscle contraction is intact, the condition is known as respiratory arrest. An abrupt stop of pulmonary gas exchange lasting for more than five minutes may permanently damage vital organs, especially the brain. Lack of oxygen to the brain causes loss of consciousness. Brain injury is likely if respiratory arrest goes untreated for more than three minutes, and death is almost certain if more than five minutes.
A resuscitator is a device using positive pressure to inflate the lungs of an unconscious person who is not breathing, in order to keep them oxygenated and alive. There are three basic types: a manual version consisting of a mask and a large hand-squeezed plastic bulb using ambient air, or with supplemental oxygen from a high-pressure tank. The second type is the expired air or breath powered resuscitator. The third type is an oxygen powered resuscitator. These are driven by pressurized gas delivered by a regulator, and can either be automatic or manually controlled. The most popular type of gas powered resuscitator are time cycled, volume constant ventilators. In the early days of pre-hospital emergency services, pressure cycled devices like the Pulmotor were popular but yielded less than satisfactory results. Most modern resuscitators are designed to allow the patient to breathe on his own should he recover the ability to do so. All resuscitation devices should be able to deliver more than 85% oxygen when a gas source is available.
A bag valve mask (BVM), sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately. The device is a required part of resuscitation kits for trained professionals in out-of-hospital settings (such as ambulance crews) and is also frequently used in hospitals as part of standard equipment found on a crash cart, in emergency rooms or other critical care settings. Underscoring the frequency and prominence of BVM use in the United States, the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care recommend that "all healthcare providers should be familiar with the use of the bag-mask device." Manual resuscitators are also used within the hospital for temporary ventilation of patients dependent on mechanical ventilators when the mechanical ventilator needs to be examined for possible malfunction or when ventilator-dependent patients are transported within the hospital. Two principal types of manual resuscitators exist; one version is self-filling with air, although additional oxygen (O2) can be added but is not necessary for the device to function. The other principal type of manual resuscitator (flow-inflation) is heavily used in non-emergency applications in the operating room to ventilate patients during anesthesia induction and recovery.
Outdoor emergency care (OEC) was first developed by the National Ski Patrol in the 1980s for certification in first aid, and other pre-hospital care and treatment for possible injuries in non-urban settings. Outdoor emergency care technicians provide care at ski resorts, wilderness settings, white-water excursions, mountain bike events, and in many other outdoor environments.
ABC and its variations are initialism mnemonics for essential steps used by both medical professionals and lay persons when dealing with a patient. In its original form it stands for Airway, Breathing, and Circulation. The protocol was originally developed as a memory aid for rescuers performing cardiopulmonary resuscitation, and the most widely known use of the initialism is in the care of the unconscious or unresponsive patient, although it is also used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations, from first-aid to hospital medical treatment. Airway, breathing, and circulation are all vital for life, and each is required, in that order, for the next to be effective: a viable Airway is necessary for Breathing to provide oxygenated blood for Circulation. Since its development, the mnemonic has been extended and modified to fit the different areas in which it is used, with different versions changing the meaning of letters or adding other letters.
A pocket mask, pocket face mask, or CPR mask is a device used to safely deliver rescue breaths during a cardiac arrest or respiratory arrest. The specific term "Pocket Mask" is the trademarked name for the product manufactured by Laerdal Medical AS. It is not to be confused with a bag valve mask (BVM).
Henry Judah Heimlich was an American thoracic surgeon and medical researcher. He is widely credited for the discovery of the Heimlich maneuver, a technique of abdominal thrusts for stopping choking, first described in 1974. He also invented the Micro Trach portable oxygen system for ambulatory patients and the Heimlich Chest Drain Valve, or "flutter valve", which drains blood and air out of the chest cavity.
Foreign body aspiration occurs when a foreign body enters the airway which can cause difficulty breathing or choking. Objects may reach the respiratory tract and the digestive tract from the mouth and nose, but when an object enters the respiratory tract it is termed aspiration. The foreign body can then become lodged in the trachea or further down the respiratory tract such as in a bronchus. Regardless of the type of object, any aspiration can be a life-threatening situation and requires timely recognition and action to minimize risk of complications. While advances have been made in management of this condition leading to significantly improved clinical outcomes, there were still 2,700 deaths resulting from foreign body aspiration in 2018. Approximately one child dies every five days due to choking on food in the United States, highlighting the need for improvements in education and prevention.
The head-tilt/chin-lift is a procedure used to prevent the tongue obstructing the upper airways. The maneuver is performed by tilting the head backwards in unconscious patients, often by applying pressure to the forehead and the chin. The maneuver is used on any patient where cervical spine injury is not a concern and is taught on most first aid courses as the standard way of clearing an airway. This maneuver and the jaw-thrust maneuver are two of the main tools of basic airway management.
The jaw-thrust maneuver is a first aid and medical procedure used to prevent the tongue from obstructing the upper airways. This maneuver and the head-tilt/chin-lift maneuver are two of the main tools of basic airway management, and they are often used in conjunction with other basic airway techniques including bag-valve-mask ventilation. The jaw-thrust maneuver is often used on patients with cervical neck problems or suspected cervical spine injury.
The Act+Fast Anti Choking Trainer, also known as the “Choking Rescue Training Vest”, is a simulation device manufactured by Act+Fast LLC, a company based in California. It helps practice choking rescue techniques and is mainly used in basic airway management to teach choking rescue protocols, abdominal thrusts and the back slap method. The Anti Choking Trainer was exhibited at the 2008 EMS Expo in Las Vegas, Nevada.
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