Airway management and assisted ventilation in an emergency
Essentials
- Respiratory insufficiency is managed by ensuring a patent airway and assisting ventilation. The most common causes of loss of airway patency and/or respiratory insufficiency are cardiac arrest, impaired consciousness or critical respiratory distress.
- The simplest way to ensure airway patency and to assist ventilation is to open the airway manually and to start assisting ventilation using a bag-mask attached to oxygen.
- The airway must be kept patent and maintained using an airway device, such as an oropharyngeal (oral) or supraglottic airway, an endotracheal tube or by an emergency tracheotomy.
- An oral airway can be used initially for assisted ventilation with a bag-mask.
- A supraglottic device should be used as the primary airway device Dynamed.
- Intubation can be used as the primary method of airway management if there is an experienced intubator present with a high probability of success.
- For emergency tracheotomy i.e. cricothyrotomy, see videos Cricothyrotomy using an intubation tube (emergency tracheotomy) and Cricothyrotomy using a Mini-Trach cannula (emergency tracheotomy).
Primary measures
- In patients with cardiac arrest or impaired consciousness, assisted ventilation should primarily be started using a bag-mask attached to oxygen Dynamed.
- If in hospital, always ask for further assistance according to local guidelines.
- In a health care unit, act according to local guidelines and/or call the emergency number (112) to get support from emergency services for treatment and to have them take the patient for further treatment, as necessary.
- To facilitate bag-mask ventilation, an oral airway should be inserted, as necessary (Image (Insertion of an oral airway)).
- Choose a size 3–4 oral airway for an adult, a smaller one for a child. The correct length is the distance from the corner of the patient’s mouth to the earlobe.
Choice of airway device
- Laryngeal mask airway, LMA
- The correct size depends on the manufacturer and the model.
- Laryngeal tube, LT
- For choice of size, see Table T1.
- i-gel®
The most common problems
- Placement of the laryngeal mask airway (LMA) does not result in a good seal.
- Wrongly chosen size of device
- Device introduced obliquely into the pharynx
- Fix the problem by reinserting the device.
- The laryngeal tube (LT) does not produce a good seal.
- Make sure that the cuff is intact and the air volume correct.
- Check the correct depth (deflate slightly, as necessary, insert at correct depth, fix carefully).
Table 1. Choosing the size of laryngeal tube (LT-D)
Patient’s weight/height | LT-D colour* | LT-D no. | |
---|---|---|---|
Child | 12–25 kg | green | 2 |
125–150 cm | orange | 2.5 | |
Adult | < 155 cm | yellow | 3 |
155–180 cm | red | 4 | |
> 180 cm | purple | 5 | |
* The corresponding colour on the syringe shows the maximum cuff filling volume. |
Assisted ventilation
- After inserting the airway device, continue assisted ventilation using a bag attached to the airway device Dynamed.
- The tidal volume for an adult patient is approx. 500 ml and the respiratory rate 15 per minute.
- Make sure that the patient’s chest rises with each ventilation and that the ventilation is effective (Table T2).
Monitoring devices
- All patients should have
- 3-lead ECG monitoring
- expiratory carbon dioxide monitoring (etCO2, capnograph) with graph display.
- If the patient has a rhythm with pulse, a SpO2 sensor and automatic pneumatic noninvasive blood pressure (NIBP) monitoring should be used in addition to monitoring the rhythm.
Observation | Issues to be observed |
---|---|
Does the chest rise? | Does the mask sit tightly on the face? |
Is the mask of the right size? | |
Are the head position and the grip correct? | |
Is the oral airway of the right size? | The oral airway must be measured before insertion. The correct length is the distance from the corner of the patient’s mouth to the earlobe. |
If the oral airway is of the wrong size, it will obstruct rather than open the airway. | |
Is air going into the stomach? | Make sure that the airway is patent. |
Sufficiently long inspiration (approx. 1 s) synchronized with compression (in the case of cardiac arrest) | |
Is the airway device (supraglottic or endotracheal tube) in the correct position? | Correct positioning must be ensured immediately after insertion primarily based on the expiratory carbon dioxide flow curve. |
Auscultate breath sounds. |
Copyright © 2023 Duodecim Medical Publications Limited.
Citation
"Airway Management and Assisted Ventilation in an Emergency." Evidence-Based Medicine Guidelines, Duodecim Medical Publications Limited, 2019. Evidence Central, evidence.unboundmedicine.com/evidence/view/EBMG/451492/all/Airway_management_in_an_emergency.
Airway management and assisted ventilation in an emergency. Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. https://evidence.unboundmedicine.com/evidence/view/EBMG/451492/all/Airway_management_in_an_emergency. Accessed September 6, 2024.
Airway management and assisted ventilation in an emergency. (2019). In Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited. https://evidence.unboundmedicine.com/evidence/view/EBMG/451492/all/Airway_management_in_an_emergency
Airway Management and Assisted Ventilation in an Emergency [Internet]. In: Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. [cited 2024 September 06]. Available from: https://evidence.unboundmedicine.com/evidence/view/EBMG/451492/all/Airway_management_in_an_emergency.
* Article titles in AMA citation format should be in sentence-case
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