Basic Airway Management in EMS
For Submission to Dr. Hector Carabello
August 15th, 2021
Jennie Helmer, ACP, M.Ed.
By its very definition, “basic airway management” is anything but basic. As a paramedic, you instinctively know that the most critical task you will be called on to perform, is managing the airway. Strikingly, the most basic airway decisions you make, whether your patient is struggling to breathe through infected lungs, or for those trauma patients drowning in their blood-clogged airways, might determine whether your patient lives or dies.
One of the best ways for paramedics to perform consistently and to make good critical decisions around basic airway management is to never stop learning and reading. Airway “best practices” tend to change over time, so read-up and connect in with your local Emergency Medical Service (EMS) educator. As well, practicing challenging skills in a wide variety of patient situations will make the job easier when that inevitable difficult airway arises. Practicing high-quality basic skills is the foundation of good EMS care.
Airway Management-Taking Action
Skillful airway management is often the first step in the successful resuscitation of a compromised patient. In order to get the job done as a paramedic, basic airway management skills are key to improving oxygenation and ventilation to your patient, airway management always beings with a thorough airway assessment.
Basic airway management begins with assessing the airway for:
- Foreign body obstructions
- Adequacy of respiratory rate and volume
- Level of consciousness
Do not rush this step. While educators impress the teaching of assessment techniques, it is more difficult to teach the critical thinking that goes along with it. Slow down, take your time and use the information from your assessment to inform your treatment decisions. Once you have assessed your patient and determined that you will need to manage their airway, it’s time to take action.
Starting with basic airway maneuvers are essential. Many, if not most, patients can be managed with simple maneuvers alone. Doing this, prevents what might be, an unnecessary tracheal tube. As well, starting with basic airway maneuver helps stabilize the patient, calms the scene, and it declares that you are competent, confident and in charge. Lastly, it also gives you precious time to assess the patient, gather information, determine your resuscitation plan, and to pre-oxygenate your patient.
Respiratory distress that requires airway management, may be the result of infectious disease such as COVID-19. Ensure you are using proper PPE and practice safe airway techniques at all times.
Any patient being resuscitated should be position in such a way that their airway is as open as possible. This generally means supporting the patient in their position of comfort for awake patients, or lifting the head of the stretcher slightly for those who are obtunded (depressed level of consciousness) or unresponsive.
In order to maximize the patency of the upper airway, perform a head-tilt chin lift, this is the most common means of opening the airway in the non-trauma patient. This is achieved by flexing the neck and extending the head (the face remains parallel with the stretcher). Another option, the simple jaw thrust, is an essential airway maneuver and must be mastered. The jaw thrust can be used to open the airway in suspected trauma. To do this, place your fingers behind the angle of the mandible and apply a forward force, elevating the mandible, and with it the tongue. (Russo 2013).
Next insert an oropharyngeal (OPA) or a nasopharyngeal (NPA) airway. These can be used along with manual airway maneuvers to provide a patent airway in the unresponsive patient. OPAs will relieve soft tissue obstruction of the posterior airway by displacement of the tongue and soft tissue anteriorly. Make sure the patient does not have a gag reflex when using the OPA, as vomiting, aspiration and laryngospasm may otherwise occur. Frequently, more than one of the OPA and NPA is required. In order to maintain an open airway, it is not unreasonable to place 2 nasopharyngeal airways and an oropharyngeal airway at the same time to facilitate bag mask ventilation.
Oropharyngeal airway insertion:
- Ensure that the OPA is sized appropriately for your patient (to choose the correct size, place one end at the tip of the chin, and the other end should reach the angle of the mandible
- The patient should be unresponsive without a gag reflex
- Open the patient’s mouth with your non-dominant hand, using a scissors action
- Insert the oral airway with the curve upside-down, sliding the tip along the hard palate
- When the tip of the airway reaches the back of the mouth, rotate it 180 degrees (Russo, 2018)
Nasopharyngeal airway insertion:
- To choose the correct sized tube, place one end at the tip of the patient’s nose and the opposite end should reach their external auditory canal
- Apply lubricant
- With the longer, beveled tip against the septum, insert the tube into the nare. It should enter at a 90-degree angle to the face. Insert completely until the flared end is against the patient’s nare (Russo, 2013)
- If required, repeat with a second tube in the opposite site
Provide supplemental oxygen as per your local guidelines, using either nasal prongs/cannula or a non-rebreather mask.
Suction is key to rescuing many an airway, and paramedics should not hesitate to use it. Suction will remove clotted blood, saliva or even chunky vomit. Basic airway management will not protect against aspiration of gastric contents should vomiting occur. As such, always have your suction equipment on during any airway procedure.
The Yankauer suction is the most common, and if the Yankauer tip is not adequate for the job at hand, consider removing the Yankauer and inserting the suction tubing directly into the patient’s mouth. As an alternative, paramedics can consider using an endotracheal tube attached to a meconium aspirator (Kei, 2016).
In order to get the job done properly and safely, EMS educators recommend always having your suction ready to get to work.
Ask any airway educator what the most-important skill is in airway management, and you might be surprised at the answer. Despite some assuming it to be laryngoscopy, educators tend to agree that the most important skill is effective bag value mask ventilation. If you can oxygenate and ventilate your patient with a BVM, an OPA and an NPA, you may not need to introduce more invasive tools that are associated with poor patient outcomes, such as intubation.
Therefore, ventilating the patient after the airway has been established is the next technique to master. Make sure you have an appropriately sized mask. The best fit is the smallest mask that will provide a good seal around the mouth and nose. It should cover the nose, mouth and chin, but not cover the eyes. (Russo, 2013). When ventilating, educators teach the standard one hand “CE” bag valve mask, as well as the two-person, 2-hand grip, with an assistant squeezing the bag. The American Heart Association’s opinion on bag-mask ventilation is that, when possible, it should be a two-person job. The two-hand grip is achieved by placing the thenar eminences of both hands along the sides of the mask, and gripping the ramus of the mandible with the fingertips (Gerstein 2013). Remember, the goal is to pull the face up into the mask, not push the mask into the face as downward pressure will cause airway misalignment.
When performing bag valve mask ventilation, in addition to sizing the mask and how you choose to hold it on the patients face, how you squeeze the bag to deliver a volume of air is critical. High pressures will inflate the stomach, and increase intrathoracic pressures. Both these scenarios are very bad for your patient. Paramedics should deliver 6-8 breaths a minute and gently squeeze the bag so that only 500 ml (6-7 mL/kg) of air is delivered over 1-2 seconds. An important consideration that all educators work to impress, is that “adult” bags for BVM hold 2 litres of air, and therefore to optimally deliver 500 ml of air, one should squeeze about 25% of the bag.
There are some patients who are predictably difficult to bag valve mask ventilate. The classic mnemonic for these patients is MOANS:
- M: Mask seal (beard, facial trauma can impede seal)
- O: Obesity or obstruction
- A: Age (generally >55)
- N: No teeth
- S: Stiff lungs
BVM use in EMS usually means a sick patient in an uncontrolled situation. Make it easier on yourself by ensuring you have an NPA or OPA, or both in place. If you started without these adjuncts and are having trouble, put them in. Similarly, if you didn’t start by using a two-hand grip, switch to that.
Supraglottic Airway Adjuncts
Supraglottic and endotracheal devices can be used if within scope and if the patient requires this intervention. Introducing unnecessary advanced airway managements to patients who don’t require it, can cause more harm than good.
Supraglottic airways such as the LMA are less invasive than tracheal intubation, and can be used as the primary means to support ventilation. (Braude 2007). The LMA can only be placed in deeply unconscious patients, and therefore without any airway reflexes. Although there are different supraglottic devices available, each with their own insertion technique, the following is a high-level approach to insertion of the LMA:
- Check the cuff for leaks
- Lubricate the posterior aspect of the LMA
- Place 2 fingers in the front of the LMA, open the mouth, and slide the LMA along the palate into the pharynx.
- Inflate the cuff to the appropriate volume of air
- Check for adequate ventilation using quantitative, waveform capnography.
- Secure the LMA
If you cannot easily ventilate the LMA, try pulling it back until it sits on the tongue, keep it fully inflated, perform a jaw thrust, and then push it back in. You can also try elevating the head or extending the neck.
Skillful prehospital airway management is often the first step in the successful resuscitation of a compromised patient and is a fundamental skill-set of all emergency responders and paramedics. For the EMS educator, the focus is far beyond simply developing the student’s airway placement psychomotor skills. Instead, it is about developing the critical thinking skills to support paramedic decision-making in the field. Likewise for the paramedic, you will get the job done right when you apply the appropriate amount of skill, knowledge and critical thought. Your patients will thank you.