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Airway management skills are essential tools in the emergency physician’s armamentarium.

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The goals of airway management are oxygenation and ventilation. Achieving these goals may be as simple as repositioning a patient’s head or as complicated as creating a surgical airway. The most difficult task for the ED physician is choosing which airway technique to utilize. Successful airway management requires expert airway knowledge and proficient procedural skills. Figure 28-1 summarizes airway management decision making in the ED.

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Figure 28-1.
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Airway management decision making. *See Chapter 30, Tracheal Intubation and Mechanical Ventilation. CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; NPPV = noninvasive positive pressure ventilation; RSI = rapid-sequence intubation.

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The anatomic airway (Figure 28-2) begins at the oral/nasal cavities and continues posteriorly to the tongue/turbinates, the tonsils/adenoids; past the palate; through the oropharynx; across the epiglottis, which protects the glottis (the narrowest portion of the airway); past the false and true vocal cords; and into the larynx. Surrounding the larynx is the thyroid cartilage, cricoid cartilage, and thyroid gland. The upper airway ends here. The lower airway then continues to the trachea and into the lungs. Obstruction may develop anywhere along this route.

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Figure 28-2.
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The anatomic airway.

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See Chapter 29, Pediatric Airway Management, for a detailed discussion of airway anatomy in children.

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Details of the physiology of oxygenation and ventilation are discussed in Chapter 20, Blood Gases. Figure 28-2.1 provides an illustration of process of oxygen and co2 exchange.

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Figure 28-2.1.
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Respiratory process at alveoli and tissue levels.

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Airway management begins by assessing for a patent airway and adequate oxygenation and ventilation. The decision to institute airway support is usually made quickly, based on clinical signs and symptoms of inadequate oxygenation and ventilation, and usually without laboratory results.

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Maintain Patent Airway

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Aspiration risk is increased if the patient is not able to protect the airway. The role of the gag reflex in airway protection is unclear. Up to 37% of healthy volunteers do not demonstrate a gag reflex. Do not initiate a gag reflex if the airway may not be protected, as vomiting and aspiration may result. Current evaluation of airway protection is to note spontaneous swallowing. Patients who do not spontaneously swallow are at risk for airway compromise and aspiration and may require emergent intervention.1 Initiate airway management whenever there is concern about airway patency, oxygenation, or ventilation.

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Relieve Airway Obstruction

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Signs of airway obstruction include extreme anxiety, audible wheezing or stridor, and coughing. If obstruction is complete, no audible breath sounds ...

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