The importance of maintaining an open airway is common sense. If you want to try an experiment, just try holding your breath for as long as you can. After a minute or two, when your lungs are screaming for oxygen and you can no longer hold your breath, you will completely understand what an important topic this is.
Brain Damage begins approximately 5 minutes from the time the patient has stopped breathing oxygenation. Fortunately, though, it doesn’t take a whole to maintain an open airway in most patients. It is only in a small percentage of patients that advanced medical procedures are needed to adequately maintain and secure an airway.
Most airway occlusions occur because a patient has lost consciousness, and the tongue has relaxed enough that it falls back against the epiglottis and covers the trachea (wind pipe). If the epiglottis is sealed, no air will be able to enter the lungs.
What is the difference between an “open airway” and a “secure airway?”
An open airway simply means that air can pass from the nose/mouth, into the oropharynx, down the trachea and into the lungs. There is an open pathway for the air to travel without interruption. An open airway is not completely protected and can suffer from aspiration when the patient vomits and stomach contents come up the esophagus and enter the trachea and lungs. An open airway can also be compromised by blood, tissue trauma, and inflammation/swelling.
A secure airway is a protected airway. This normally involves placing a tube with a large bulb on it. The tube extends from the mouth/nose and goes all the way into the trachea, near the bronchi in the lungs. The bulb is then inflated and secures it from vomit, blood, and inflammation/swelling. It is an open airway that is also protected from compromise.
What causes a closed airway?
Upper airway obstructions can be caused by Infectious, medical, and trauma related issues. Below are a few of the more common ones:
► Blast Injury (overpressure can cause unconsciousness and tongue occlusion)
► Blunt force trauma (blow to head or face can cause fractures and/or unconsciousness)
► Foreign Body (large piece of meat that is blocking the airway, etc.)
► Burns (burned tissue swells and occludes the airway)
► Inflammatory conditions like asthma
► Peritonsillar abscess (super swollen infected tonsils that block the airway)
► And a host of other things.
Signs and Symptoms
► May be gasping for breath
► International sign of choking (hands on throat and turning blue)
► Chest with very little rise and fall, but muscles appear to be straining
Before we begin treatment, we must closely look at the mechanism of injury. In other words, how did the patient end up in this predicament? Did they suffer a fall from a great height, and have associated fractures? Were they sitting in a chair and suddenly slumped over? Were they shot and fell to the ground while running from one position to another? Knowing the mechanism of injury helps determine how much we can move the patient.
Studies from Iraq and Afghanistan showed us that neck injuries on the battlefield were fairly uncommon. We didn’t have to worry so much about the big neck fracture that could possibly paralyze a guy if we did a head tilt-chin lift maneuver. However, if the person was involved in a vehicle crash, the statistics showed the possibility of neck injury increased. Based on that sort of history, I am not likely to perform a head tilt-chin lift maneuver. I will have to reach into my aid bag for another device to open and secure the airway.
NOTE: None of the techniques mentioned below SECURE an airway. They only help maintain them in the open position.
► Head Tilt-Chin Lift
This is a very simple maneuver to perform and will quickly provide an open airway in most cases. You just have to make sure there the patient has not suffered a neck injury first. If the patient did not suffer a fall from a great height, a motor vehicle accident, and shows no signs of facial trauma….this is a good technique to use.
► Oropharyngeal Airway (aka, the J-Tube)
This has been around forever, but I rarely use it anymore. OK, I may use it as a bite block, but not to open an airway. The J-tube is inserted through the mouth and keeps the tongue lifted off the epiglottis, thereby keeping the airway open. It can only be used when the patient has no gag reflex, and therein lies its biggest drawback. Just because a trauma patient starts out unconscious doesn’t mean he is going to stay that way. Patients come in and out of consciousness all the time. Once they start waking up, you better get that J-tube out quickly or he will start gagging and possibly vomit. Then we have to worry about aspiration into the lungs.
► The Nasopharyngeal Airway (aka, the NPA)
I love the NPA. I’ve used it a lot and it works well. It keeps the airway open and the patient can come in and out of consciousness all they want. It inserts through the nose and the opening rests behind the tongue. It will not cause the gag reflex to activate and thus vomiting. I’ve had medics give conscious patients an NPA prior to evacuation, just in case they lose consciousness enroute to the hospital.
► The Recovery Position
By far, this is one of the simplest things that anyone can do to keep a patient from aspirating and try to maintain an open airway. It simply involves putting the patient into a position where he is no longer on his back and his tongue will not fall forward to occlude the airway. I take it a little further and will try to place his head in a downhill position with the mouth facing downhill. I always use an NPA when using the recovery position.
For a better understanding of these techniques and how they are properly utilized, please see some of our videos regarding each technique.
When to seek medical attention?
►If the patient is unconscious, then they cannot protect their airway and need medical attention.
►If they cannot swallow, then their airway is in danger of being compromised and they may aspirate stomach contents into their lungs. This is an extremely dangerous event
►If they have facial trauma and there may be fractures and bleeding to the mouth, jaw, and sinuses
►If you are not sure what you should do…..go to the ER and play it safe.
Patrick O'Neil, PA