Airway management skills are essential tools in the emergency
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.
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.
See Chapter 29, Pediatric Airway Management,
for a detailed discussion of airway anatomy in children.
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.
Respiratory process at alveoli and tissue levels.
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.
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.
Signs of airway obstruction include extreme anxiety, audible
wheezing or stridor, and coughing. If obstruction is complete, no
audible breath sounds ...