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Doctors: airways?

Whenever I assess patients I use the A to E approach and always in my experience airway has been patent- therefore I am not quite sure how quickly I would respond and what to do with a compromised airway, any useful suggestions?

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Original post by BreatheDeep
Whenever I assess patients I use the A to E approach and always in my experience airway has been patent- therefore I am not quite sure how quickly I would respond and what to do with a compromised airway, any useful suggestions?


Anything visible in the mouth? Take it out.
Head tilt, chin lift.
Jaw thrust.
OPA/NPA.
Call for help.
LMA.
Anaesthetist.

My experience is limited to steps 1-4, thankfully not yet had anything an NPA didn't improve.
Reply 2
Avatar for Helenia
Helenia
20
Original post by Becca-Sarah
Anything visible in the mouth? Take it out.
Head tilt, chin lift.
Jaw thrust.
OPA/NPA.
Call for help.
LMA.
Anaesthetist.

My experience is limited to steps 1-4, thankfully not yet had anything an NPA didn't improve.


This, plus suction to the oropharynx +/or with a fine bore catheter down the NPA. Though I would suggest that if you're thinking about putting in an LMA (which a lot of people are not very good at) you should be calling the anaesthetist already.
Original post by Helenia
This, plus suction to the oropharynx +/or with a fine bore catheter down the NPA. Though I would suggest that if you're thinking about putting in an LMA (which a lot of people are not very good at) you should be calling the anaesthetist already.


I thought the whole point of LMAs (or iGels at least) is their ease of use without training?
Original post by Becca-Sarah
I thought the whole point of LMAs (or iGels at least) is their ease of use without training?


They're fairly straight forward to put in but, if your patient has become so unresponsive that they are tolerating an LMA, you probably need some kind of help. They might also require a definitive airway +/- mechanical ventilation unless you want to stand there squeezing the bag indefinitely ;-)

It might be a little different if you are confident, surrounded by an experienced team, and in an appropriate setting, e.g. theatres, ED resus, or ITU. I was always taught that, as a rule of thumb, "if you ever find yourself managing an airway, there should already be a medical assistance team on the way".
Reply 5
Avatar for Helenia
Helenia
20
Original post by Becca-Sarah
I thought the whole point of LMAs (or iGels at least) is their ease of use without training?


Theoretically, and they're certainly easier than intubating. But having seen them used by inexperienced people in a variety of interesting ways, my faith in them as a universal tool is slim. And if their airway is compromised enough to need/tolerate an LMA, they need an anaesthetic/ICU review anyway.
The urban legend of the person attempting to use an igel without removing the green casing comes to mind.
Reply 7
Avatar for Helenia
Helenia
20
Original post by Etomidate
The urban legend of the person attempting to use an igel without removing the green casing comes to mind.

I've seen it, I'm afraid. And trying to put them in upside down, sticking it in too far or not far enough with no real comprehension of assessing whether it's working or not, not knowing how to inflate the cuff on an LMA... I think it's also important to realise that an LMA/i-gel does not constitute a "secure" airway and in a resus situation it is almost never possible to ventilate adequately down one with dyssynchronous CPR.
Ah yes... the LMA that keeps coming loose and bouncing around during CPR... and you can't tell if you're ventilating properly with all the noise and continuous chest compressions...
Original post by Helenia
I've seen it, I'm afraid. And trying to put them in upside down, sticking it in too far or not far enough with no real comprehension of assessing whether it's working or not, not knowing how to inflate the cuff on an LMA... I think it's also important to realise that an LMA/i-gel does not constitute a "secure" airway and in a resus situation it is almost never possible to ventilate adequately down one with dyssynchronous CPR.


Saw someone try to ventilate an LMA with a BVM via facemask once. Heheeuuheheuh
Original post by MonteCristo
Ah yes... the LMA that keeps coming loose and bouncing around during CPR... and you can't tell if you're ventilating properly with all the noise and continuous chest compressions...


Original post by Helenia
I've seen it, I'm afraid. And trying to put them in upside down, sticking it in too far or not far enough with no real comprehension of assessing whether it's working or not, not knowing how to inflate the cuff on an LMA... I think it's also important to realise that an LMA/i-gel does not constitute a "secure" airway and in a resus situation it is almost never possible to ventilate adequately down one with dyssynchronous CPR.


Original post by Etomidate
The urban legend of the person attempting to use an igel without removing the green casing comes to mind.


Original post by Helenia
Theoretically, and they're certainly easier than intubating. But having seen them used by inexperienced people in a variety of interesting ways, my faith in them as a universal tool is slim. And if their airway is compromised enough to need/tolerate an LMA, they need an anaesthetic/ICU review anyway.


Original post by MonteCristo
They're fairly straight forward to put in but, if your patient has become so unresponsive that they are tolerating an LMA, you probably need some kind of help. They might also require a definitive airway +/- mechanical ventilation unless you want to stand there squeezing the bag indefinitely ;-)

It might be a little different if you are confident, surrounded by an experienced team, and in an appropriate setting, e.g. theatres, ED resus, or ITU. I was always taught that, as a rule of thumb, "if you ever find yourself managing an airway, there should already be a medical assistance team on the way".


Original post by Becca-Sarah
I thought the whole point of LMAs (or iGels at least) is their ease of use without training?


Original post by Helenia
This, plus suction to the oropharynx +/or with a fine bore catheter down the NPA. Though I would suggest that if you're thinking about putting in an LMA (which a lot of people are not very good at) you should be calling the anaesthetist already.


Original post by Becca-Sarah
Anything visible in the mouth? Take it out.
Head tilt, chin lift.
Jaw thrust.
OPA/NPA.
Call for help.
LMA.
Anaesthetist.

My experience is limited to steps 1-4, thankfully not yet had anything an NPA didn't improve.


Thanks all. I have never has to insert an artificial airway on any other than a mannequin in training though so just not so confident in doing this and feel i would end up calling anaesthetist first but I feel it would not be ideal to just use head tilt chin lift and removing and suction in the meantime either :s
Original post by BreatheDeep
Thanks all. I have never has to insert an artificial airway on any other than a mannequin in training though so just not so confident in doing this and feel i would end up calling anaesthetist first but I feel it would not be ideal to just use head tilt chin lift and removing and suction in the meantime either :s


Any FY1 should be more than comfortable at least putting in an OPA or NPA as basic resuscitation skills.

Doing an anaesthetics rotation as a student is a good opportunity to get comfortable managing an airway.
Also really silly q but if they have partial / complete airway obstruction but together with a pulse at this point you would not call the arrest team ? Sometimes I worry that if I am in situation where I feel someone has lost their airway but unable to feel a pulse I should just start cpr anyway ? Also to reiterate I have completed training but I have literally never been in this situation irl! (fortunately and unfortunately)
Original post by BreatheDeep
Also really silly q but if they have partial / complete airway obstruction but together with a pulse at this point you would not call the arrest team ? Sometimes I worry that if I am in situation where I feel someone has lost their airway but unable to feel a pulse I should just start cpr anyway ? Also to reiterate I have completed training but I have literally never been in this situation irl! (fortunately and unfortunately)


It's a bit of a vague hypothetical, but if you found someone with an obstructed airway you would at least be pulling the bedside alarm to get more hands ASAP.

This is also potentially a peri-arrest situation and nobody would criticise you for putting out an arrest call.

Just remember your resus algorithm:
Responding? No > Call for help
Breathing? Yes > A-E assessment
Breathing? No > Start CPR
Original post by Helenia
This, plus suction to the oropharynx +/or with a fine bore catheter down the NPA. Though I would suggest that if you're thinking about putting in an LMA (which a lot of people are not very good at) you should be calling the anaesthetist already.

Do you tend to put them in the recovery position?
Original post by Etomidate
Saw someone try to ventilate an LMA with a BVM via facemask once. Heheeuuheheuh


So which airways would you ventilate with ?
Original post by BreatheDeep
So which airways would you ventilate with ?


In an arrest, usually an OPA or iGel.

(but with a correct adapter instead of putting the mask over the end of an igel!!)
Original post by Etomidate
In an arrest, usually an OPA or iGel.

(but with a correct adapter instead of putting the mask over the end of an igel!!)


Thank you, I need to see what these look like ..
Original post by BreatheDeep
Thank you, I need to see what these look like ..


It's a requirement to do the ALS course as an FY1, often you can do it early on/before starting. It's a good opportunity to practice these skills and use the equipment.
Original post by BreatheDeep
Do you tend to put them in the recovery position?


I don't, because I'm going to be at the top end sorting out whatever definitive airway management is needed, and I need the patient on their back for that. Recovery position can be useful for some patients if you're concerned they might vomit and not protect their airway or whatever, but if you're going to be putting in airways, doing jaw thrust etc, on the back is easier.

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