critical care medicine
Airway Establishment and Control
Clearing and Opening the Upper Airway
To relieve airway obstruction caused by soft tissues of the upper airway and provide optimal position for Bag-Valve-Mask Devices and A: The head is flat on the stretcher; the airway is constricted. B: The ear and sternal notch are aligned, with the face parallel to the ceiling, opening the airway. Adapted from Levitan RM, Kinkle WC: The Airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007. Anatomic restriction, various abnormalities, or considerations caused by trauma (eg, inadvisability of moving a possibly fractured neck) may obviate the operator’s ability to properly position the neck, but careful attention to optimal positioning when possible can maximize airway patency and improve bag-valve-mask ventilation and laryngoscopy. Obstruction by dentures or oropharyngeal foreign material (eg, blood, secretions) may be removed by finger sweep of the oropharynx and suction, taking care not to push the material deeper (more likely in infants and young children, in whom a blind finger sweep is contraindicated). Deeper material can be removed with Magill forceps or by suction. The Heimlich maneuver (for more detailed instructions, see How To Do the Heimlich Maneuver in the Conscious Adult or Child ) consists of manual thrusts to the upper abdomen or, in the case of pregnant or extremely obese patients, chest thrusts until the airway is clear or the patient becomes unconscious; it is the preferred initial method in the awake, choking patient. Inconscious adults,the rescuer stands behind the patient with arms encircling the patient’s midsection. One fist is clenched and placed midway between the umbilicus and xiphoid. The other hand grabs the fist, and a firm inward and upward thrust is delivered by pulling with both arms (see Figure). with an upper airway obstruction is initially managed with Cardiopulmonary Resuscitation (CPR) in Adults (cardiopulmonary resuscitation). In such patients, chest compressions increase intrathoracic pressure in the same manner that abdominal thrusts do in conscious patients. Rescuers should provide cycles of 30 chest compressions at a rate of 100 to 120 compressions/minute followed with 2 rescue breaths. Rescuers should examine the oropharynx before each set of breaths and use their fingers to remove any visible objects. Direct laryngoscopy with suction or Magill forceps can also be used to remove a foreign body in the proximal airway, but once an object has passed through the vocal cords positive pressure from below the obstruction is more likely to be successful. If rescuers do not know how or are unwilling to give rescue breaths compressions-only In older children, the How To Do the Heimlich Maneuver in the Conscious Adult or Child may be used. However, in children ). This sequence of back blows and chest thrusts is repeated until the airway is cleared. For more detailed instructions, see How To Treat the Choking Conscious Infant . Chest thrusts are delivered on the lower half of the sternum, just below the nipple level. 