Manualmaneuversfacilitatetheopeningofanairway.Airwayadjuncts,suchaspharyngealairways,aredevices that assist in keeping the airway open by keeping the tongue away from the posterior wall of the pharynx.
Oral Airway [Objective 6]
An oral airway, also called an oropharyngeal airway or OPA, is a J-shaped plastic device that is used to create an air passage between the patient ’s mouth and the posterior wall of the pharynx. Because oral airway insertion may provoke vomiting and thus increase the risk of aspiration in a patient with an intact gag reflex, indications for insertion include patients who are unresponsive and have no gag reflex. An oral airway may be used as a bite block after the insertion of a tracheal tube or an orogastric tube.
Oral airways are available in a variety of sizes that range from 0 for neonates up to 6 for large adults.
The size of the airway is based on the distance, in millimeters, from the flange to the distal tip.
Thereare two main oral airwaydesigns.The Guedelairwayhas a tubulardesign with a single centerchan-nelthat allowsfor ventilation and thepassageof a suction catheter (Fig.2.15A). TheBerman airway has two
BOX 2.6 Suctioning
—
Possible Complications• Arrhythmias
• Bradycardia and hypotension from vagal stimulation
• Bronchospasm
• Hemorrhage
• Hypertension
• Hypoxia
• Increased intracranial pressure
• Local swelling
• Tachycardia
• Tracheal infection
• Tracheal trauma
Fig. 2.14 A soft suction catheter is used to remove secretions from the lower airway. (From Perry, Potter: Clinical nursing skills & techniques , ed 8, St. Louis, 2013, Mosby.)
airway channelsalong each sideof thedevice through which a suctioncatheter canbe passed to removesecre-tionsfromthebackofthethroat(Fig.2.15B).Whencorrectlypositioned,theflangeofthedevicerestsonthe patient ’s lips or teeth. The distal tip lies between the base of the tongue and the back of the throat, thereby preventing the tongue from blocking the airway (Fig. 2.15C). Air passes around and through the device.
Proper oral airway size is determined by holding the device against the side of the patient ’s face and selecting an airway that extends from the corner of the mouth to the tip of the earlobe or to the angle of the jaw (Fig. 2.16). To prevent inaccurate measurements for patients who experience facial drooping after a stroke, some experts recommend measuring from the first incisor or from the center of the lips to the tip of the earlobe or to the angle of the jaw. If an oral airway is too long, it may press the epiglottis against the entrance of the larynx, which may result in a complete airway obstruction (Fig. 2.17). If the airway is too short, it will not displace the tongue, and it may advance out of the mouth ( Fig. 2.18).
When inserting an oral airway into a patient ’s mouth, hold the device at its flange end and insert it with the tip pointing toward the roof of the mouth (Fig. 2.19). As the distal end nears the back of the
throat, rotate the airway 180 degrees so that it is positioned over the tongue. Alternatively, the airway can be inserted sideways and rotated 90 degrees into position. When the oral airway is inserted properly, the flange should rest comfortably on the patient ’s lips or teeth. The proper placement of the device is con-firmed by ventilating the patient. If the airway is placed correctly, chest rise should be visible and breath sounds should be present on auscultation of the lungs during ventilation. If the patient is not breathing or if his or her breathing is inadequate, begin positive pressure ventilation.
Another method of oral airway insertion requires the use of a tongue blade to depress the tongue. If this method is used, the airway is inserted with its tip facing the floor of the patient ’s mouth (ie, curved side down). With the use of the tongue blade to depress the tongue, the oral airway is advanced gently into place over the tongue.
If the patient ’s gag reflex returns or if he or she spontaneously attempts to displace the airway, remove the airway to minimize the risk of aspiration.
Flange (1)
A
C B
Channel (3) Body (2)
Flange (1)
Body (2)
Channel (3)
Oropharyngeal tube in place
Fig. 2.15 A, Guedel oral airway. B, Berman oral airway. C, Oral airway in place. (From Kacmarek, Stoller, Heuer: Egan's fundamentals of respiratory care , ed 10, St. Louis, 2013, Mosby.)
Fig. 2.16 Select an oral airway of appropriate size. (From Roberts J: Roberts and Hedges ’ clinical procedures in emergency medicine , ed 6, Philadelphia, 2014, Saunders.)
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CHAPTER 2 Airway Management
Nasal Airway [Objective 6]
A nasal airway (also called a nasopharyngeal airway, NPA, or nasal trumpet ) is a soft, uncuffed tube made from rubber or plastic polymers that is designed to keep the tongue away from the back of the throat.
Indications for the use of a nasal airway include unresponsive patients or those with an altered level of consciousness who continue to have an intact gag reflex but who need assistance with maintaining an Fig. 2.17 An oral airway that is too long may press the epiglottis against the entrance of the larynx, which may result in a complete airway obstruction. (From McSwain N, Paturas J: The basic EMT , ed 2, 2003, Mosby.)
Fig. 2.18 An oral airway that is too short will not displace the tongue, and it may advance out of the mouth. (From McSwain N, Paturas J: The basic EMT , ed 2, 2003, Mosby.)
Fig. 2.19 Open the patient ’s mouth and insert the oral airway with the tip pointing toward the roof of the mouth. (From Roberts J: Roberts and Hedges ’ clinical procedures in emergency medicine , ed 6, Philadelphia, 2014, Saunders.)
open airway. A nasal airway should not be used with patients who have sustained trauma to the nasal area or when space-occupying lesions or foreign objects block the nasal passages ( Barnes, 2013).
Nasal airways are available in many sizes varying in length and internal diameter (Fig. 2.20). Proper airway size is determined by holding the device against the side of the patient ’s face and selecting an airway that extends from the tip of the nose to the angle of the jaw or to the earlobe ( Fig. 2.21). A nasal airway that is too long may stimulate the gag reflex; one that is too short may not be inserted far enough to keep the tongue away from the back of the throat.
Before inserting a nasal airway, lubricate the distal tip of the device liberally with a water-soluble lubri-cant to minimize resistance and to decrease the irritation of the nasal passage. Hold the nasal airway at its flange end like a pencil, and slowly insert it into the larger of the patient ’s two nares, with the bevel facing the nasal septum (Fig. 2.22). During insertion, do not force the airway, because it may cut or scrape the nasal mucosa; this may result in significant bleeding, which increases the risk of aspiration. Bleeding can occur in up to 30% of patients after nasal airway insertion (Link, et al., 2015). If resistance is encountered, a gentle back-and-forth rotation of the device between your fingers may ease insertion. If resistance con-tinues, withdraw the nasal airway, reapply lubricant, and attempt insertion in the patient ’s other nostril.
Advance the airway along the floor of the nostril, following the natural curvature of the nasal passage until the flange is flush with the nostril. If blanching of the nostril is observed after placement of the Fig. 2.20 Nasal airways. (From Harkreader, Hogan, Thobaben: Fundamentals of nursing: caring and clinical judgment , ed 3, St. Louis, 2007, Saunders.)
Fig. 2.21 A nasal airway of proper size extends from the tip of the patient ’s nose to the angle of the jaw or to the earlobe.
(From Roberts J: Roberts and Hedges ’ clinical procedures in emergency medicine , ed 6, Philadelphia, 2014, Saunders.)
Fig. 2.22 Nasal airway insertion. (From Roberts J: Roberts and Hedges ’ clinical procedures in emergency medicine , ed 6, Philadelphia, 2014, Saunders.)
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CHAPTER 2 Airway Management
adjunct, the diameter of the nasal airway is too big. The nasal airway should be removed and a smaller airway should be inserted.
The proper placement of the device is confirmed by ventilating the patient. If the nasal airway is cor-rectly placed, chest rise should be visible, and breath sounds should be present on auscultation of the lungs during ventilation. If the patient is not breathing or if breathing is inadequate, begin positive pres-sure ventilation. Indications, contraindications, advantages, and disadvantages of oral and nasal airways are shown in Table 2.3.