CLINICAL practical procedures

Resuscitation skills – part three Basic airway management

Author Phil Jevon, PGCE, BSc, The oropharyngeal airway RN, is resuscitation officer/ should only be used if the patient clinical skills lead, Manor is unconscious because if Hospital, Walsall. glossopharyngeal and laryngeal reflexes are present it may induce Airway obstruction is a common vomiting and laryngospasm. problem encountered during resuscitation. Basic airway adjuncts Nasopharyngeal airway are often helpful, and sometimes The nasopharyngeal airway is less essential, to maintain a patent likely to induce gagging than an airway – particularly during oropharyngeal airway and can be prolonged resuscitation. This article, used in a semi-conscious or Fig 1. Insertion of oropharyngeal airway: estimate correct size – equal to the third of a six-part series, conscious patient when the the vertical distance between the angle of the jaw and the incisors describes the use of oropharyngeal airway is at risk of compromise and nasopharyngeal airways. (for example in the post- resuscitation period) (Jevon, Background 2002). It can be life-saving in a The simple oropharyngeal patient with a clenched jaw, (Guedel) airway is commonly trismus or maxillofacial injuries. used to help maintain a clear A correctly sized airway should airway during the initial stages of be used – if it is too short it will resuscitation. The nasopharyngeal be ineffective and if it is too long airway is sometimes used in the it may enter the oesophagus post-resuscitation phase if the causing distension and patient is semi-conscious. Both hypoventilation or stimulate the provide an artificial passage for laryngeal or glossopharyngeal airflow by separating the posterior reflexes causing laryngospasm pharyngeal wall from the tongue. and vomiting (Resuscitation Although the position of the Council (UK), 2000). patient’s head and neck must also Fig 2. Open the mouth, insert the airway into the mouth in the be maintained to keep the airway Procedure for insertion inverted position aligned, simultaneous head tilt of oropharyngeal airway and jaw thrust may also be l Don gloves (if available). required (Nolan et al, 2005). l Clear the patient’s airway, apply suction if necessary. Oropharyngeal airway l Estimate the correct size of The oropharyngeal airway is the airway by placing it against available in a variety of sizes. An the patient’s face and measuring appropriately sized airway holds it from the angle of the jaw to the the tongue in the normal incisors (Fig 1). The correct size is position and follows its natural one that equates to the vertical curvature. If it is too big it may distance between the incisors occlude the patient’s airway by and the angle of the jaw (Nolan displacing the epiglottis, hinder et al, 2005). the use of a face mask and l If possible, lubricate the airway damage laryngeal structures; if before insertion (practically, in the it is too small it may occlude the emergency situation, this is rarely airway by pushing the tongue done). back (Jevon, 2002). In small, l Open the patient’s mouth, clear Fig 3. As it passes over the soft palate, rotate the airway through 180° medium and large adults airway the airway, using suction if sizes 2, 3 and 4 respectively are necessary, and insert the airway

used (Nolan et al, 2005). in the inverted position (Fig 2) SPL

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(the curved part of the airway will References help press the tongue down and prevent it from being pushed Jevon, P. (2002) Advanced Cardiac posteriorly). Life Support. Oxford: Butterworth l As it passes over the soft Heinemann. palate, rotate the airway through 180° (Fig 3). Marsh, A. et al (1991) Airway obstruction associated with the use l Following insertion, confirm that of the Guedel airway. British Journal the airway is in the correct of Anaesthesia; 67: 517–523. position – the patient’s airway should be improved and the Nolan, J. et al (2005) European flattened reinforced section should Resuscitation Council guidelines for be positioned in between the resuscitation 2005. Section 4. patient’s teeth or gums if there Advanced Life Support are no teeth (Resuscitation Council Resuscitation; 67S1: S39–S86. (UK), 2000). l Closely monitor the patency Resuscitation Council (UK) (2000) Fig 4. Insertion of nasopharyngeal airway – lubricate the airway using and position of the airway; it can Advanced Life Support Provider a water-soluble jelly become blocked by the tongue or Manual. London: Resuscitation epiglottis and can become Council (UK). wedged into the vallecula (Marsh et al, 1991). Vomit, secretions and blood can also compromise its patency.

Procedure for insertion of nasopharyngeal airway l Don gloves. l Select an appropriately sized airway. Sizes 6–7 are suitable for adults (Nolan et al, 2005). Some devices require a safety pin to be inserted through the flange (a precautionary measure to prevent inhalation of the airway). l Check the right nostril for patency. Fig 5. Insert the airway into the right nostril, bevelled end first l Thoroughly lubricate the airway using water-soluble jelly (Fig 4). l Insert the airway into the nostril, bevelled end first (Fig 5). Professional l Pass the airway vertically along responsibilities the floor of the nose, using a slight twisting action, into the All nurses who carry out clinical posterior pharynx (Fig 6) procedures must have received (Resuscitation Council (UK), 2000). approved training, undertaken If there is resistance remove the supervised practice and airway and try the left nostril demonstrated competence in (Jevon, 2002). Once inserted the the clinical area. The onus is flange should be at the level of also on the individual to ensure the nostril. that knowledge and skills are l Secure the airway with tape. maintained from both a l Reassess the airway and check theoretical and a practical for patency and adequacy of perspective. Nurses should also ventilation. Continue to maintain undertake this role in Fig 6. Pass the airway vertically along the floor of the nose, using a slight correct alignment of the airway accordance with an twisting action, into the posterior pharynx and chin lift as necessary and organisation’s protocols, monitor the patency of the policies and guidelines. airway. n

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