Advanced airway management is the subset of

airway management Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either c ...

that involves advanced training, skill, and

invasiveness Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definition ...

. It encompasses various techniques performed to create an open or patent

airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to ...

– a clear path between a patient's lungs and the outside world. This is accomplished by clearing or preventing obstructions of airways. Obstructions can be caused by many things, including the patient's own

tongue The tongue is a muscular organ in the mouth of a typical tetrapod. It manipulates food for mastication and swallowing as part of the digestive process, and is the primary organ of taste. The tongue's upper surface (dorsum) is covered by taste bu ...

or other anatomical components of the airway, foreign bodies, excessive amounts of

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in th ...

and body fluids, or aspiration of food particles. Unlike basic airway management such as

head tilt/chin lift The head-tilt/chin-lift is a procedure used to prevent the tongue obstructing the upper airways. The maneuver is performed by tilting the head backwards in unconscious patients, often by applying pressure to the forehead and the chin. The maneuve ...

or jaw-thrust maneuver, advanced airway management relies on the use of medical equipment and advanced training. Certain invasive airway management techniques can be performed "blind" or with visualization of the

glottis The glottis is the opening between the vocal folds (the rima glottidis). The glottis is crucial in producing vowels and voiced consonants. Etymology From Ancient Greek ''γλωττίς'' (glōttís), derived from ''γλῶττα'' (glôtta), ...

. Visualization of the glottis can be accomplished either directly by using a

laryngoscope Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during ge ...

blade or by utilizing newer video technology options. In roughly increasing order of invasiveness are the use of supraglottic devices such as oropharyngeal (''OPA''), nasopharyngeal (''NPA''), and laryngeal mask airways (''LMA''). Laryngeal mask airways can even be used to deliver general anesthesia. These are followed by infraglottic techniques, such as tracheal intubation and finally surgical techniques. Advanced airway management is a key component in

cardiopulmonary resuscitation Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spon ...

, anaesthesia, emergency medicine, and intensive care medicine. The ''A'' in the ABC

initialism An acronym is a word or name formed from the initial components of a longer name or phrase. Acronyms are usually formed from the initial letters of words, as in ''NATO'' (''North Atlantic Treaty Organization''), but sometimes use syllables, as ...

mnemonic A mnemonic ( ) device, or memory device, is any learning technique that aids information retention or retrieval (remembering) in the human memory for better understanding. Mnemonics make use of elaborative encoding, retrieval cues, and image ...

for dealing with critically ill patients stands for airway management. Many airways are straightforward to manage. However, some can be challenging. Such difficulties can be predicted to some extent; a recent Cochrane systematic review examines the sensitivity and specificity of the various bedside tests commonly used to predict difficulty in airway management.

Pharnygeal airways

Pharyngeal airway devices are used in spontaneously breathing patients to move the tongue away from the back of the throat to restore airway patency. Obstruction of the

upper airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...

caused by the tongue most commonly occurs during times of decreased levels of consciousness. Pharyngeal airway devices include nasopharyngeal airways (NPAs) and oropharyngeal airways (OPAs). These devices are the simplest artificial airways.

Oropharyngeal airways

An oropharyngeal airway (OPA) is a rigid tube that is inserted into the mouth through the oropharynx and placed above the tongue to move it away from the back of the throat. They are more commonly used than nasopharyngeal airways (NPAs). OPAs should only be used in profoundly unresponsive or unconscious patients without a gag reflex. Placement of the device may stimulate the gag reflex and cause vomiting, aspiration, and laryngospasm. Complications from OPA placement include damage to the teeth and the lingual nerve, which may cause changes in taste and sensation of the tongue.

Nasopharyngeal airways

A nasopharyngeal airway (NPA) is a flexible tube that is passed through the nose into the back of the throat. They are the artificial airways of choice in patients who are conscious and have intact gag reflexes because they are less likely to stimulate the gag reflex than oropharyngeal airways (OPAs). NPAs can also be used in other sitations where OPAs cannot, such as in patients with restricted mouth opening or oral trauma. NPAs are generally not recommended if there is suspicion of a fracture to the base of the skull due to the risk of the tube entering the

cranium The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone. However two parts are more prominent: the cranium and the mandible. In humans, ...

. They are also contraindicated in the presence of significant facial trauma. Epistaxis is a complication of NPAs that may result from the use of excessive force during placement.

Extraglottic airways

Extraglottic airway devices (EGDs) create a patent airway without entering the

trachea The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends from th ...

. These devices are highly effective for providing oxygenation and ventilation. They can be used as primary airway devices, such as during CPR, or as rescue devices in situations where securing an airway using other devices has failed. EGDs are especially good rescue devices for obese patients and patients with significant facial trauma. EGDs do not protect the trachea from obstruction or aspiration. They may be used for several hours until a definitive airway can be secured. Each type of EGD has different features, including the ability to remove air from the stomach (gastric decompression) and perform tracheal intubation. All EGDs can be placed without directly seeing the

(also called "blind" placement). EGDs can be classified into supraglottic airways and retroglottic airways.

Supraglottic airways

Supraglottic airway devices (SGAs) create a seal over the glottic opening to send oxygen directly into the trachea. The SGAs consist entirely of laryngeal masks. Several manufacturers produce these devices, the most well known being the laryngeal mask airway (LMA). Success rates of SGAs in securing airways are similar between the different models, and these devices provide effective ventilation in more than 98% of patients. SGAs can be placed in under 30 seconds, making them advantageous for emergency use. Serious complications are rare and usually result from nerve and soft tissue trauma in the pharynx during placement.

Retroglottic airways

Retroglottic airway devices (RGAs) pass behind the glottis and into the esophagus to create a seal allowing oxygen to be delivered directly to the trachea. The RGAs are designed as laryngeal tubes. Examples of RGAs include the Combitube and The King LT. Studies comparing the effectiveness between the RGAs are lacking. Like SGAs, most complications from RGAs result from trauma to the pharynx during placement.

Tracheal intubation

Tracheal intubation, often simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of

asphyxia Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that ca ...

tion or airway obstruction. The most widely used route is orotracheal, in which an endotracheal tube is passed through the mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea.

Indications

There are specific indications or guidelines for deciding a more invasive and more secure airway is worth the associated risk:Avva U, Bhimji SS. Airway, Management. pdated 2017 Dec 15 In: StatPearls nternet Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470403/ * respiratory failure *

apnea Apnea, BrE: apnoea, is the temporal cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are (patency), there may ...

or the suspension of breathing * decreased or altered level of consciousness, rapid mental status change, Glasgow Coma Scale score less than 8 (GCS<8). * major trauma, such as

penetrating injury Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or ''non-penetrating'' trauma may have some deep da ...

to abdomen or chest * direct airway injury or facial burns * high risk of aspiration

Methods

Classically tracheal intubation has been performed utilizing laryngoscopy to obtain direct visualization of the

vocal cords In humans, vocal cords, also known as vocal folds or voice reeds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speech ...

. There are multiple different laryngoscope blade styles, shapes and lengths from which to choose. Multiple intubation tools are now available with built-in video technology. A Glidescope utilizes a laryngoscopic blade connected by a cable to a large video screen and requires a slightly different technique than that of a traditional laryngoscope. The

McGrath model Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation durin ...

has a compact design with a smaller screen directly attached to the blade. Studies have shown that video laryngoscopes when compared to classic models resulted in fewer failed intubation attempts, especially in those patients designated as more difficult airways.

Confirming placement

The gold standard for confirming successful placement of an endotracheal tube is direct visualization of the tube passing through the vocal cords. Secondary methods of confirmation include capnography, oxygen saturation,

chest x-ray A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in me ...

, or equal chest rise and

breath sound Respiratory sounds, also known as lung sounds or breath sounds, refer to the specific sounds generated by the movement of air through the respiratory system. These may be easily audible or identified through auscultation of the respiratory system ...

s heard on both sides of the chest.

Surgical airways

Surgical methods for airway management rely on making a surgical incision below the glottis in order to achieve direct access to the lower respiratory tract, bypassing the upper respiratory tract. Surgical airway management is performed as a last resort in cases where tracheal intubation has failed, is not feasible, or is contraindicated. Surgical methods for airway management include cricothyrotomy and tracheostomy. A cricothyrotomy is a procedure during which an incision is made through the cricothyroid membrane, allowing an artificial airway to be placed in the trachea. It is the first-line surgical procedure to access an airway in an emergency because it can be performed more quickly than a tracheotomy and is less likely to cause bleeding and damage to thyroid tissue. A cricothyrotomy creates a temporary airway that can be used until a more definitive airway can be secured. A tracheotomy is a surgical procedure creating an incision in the front of the neck down to the trachea. A tracheostomy tube can be placed through the opening created by the incision, which allows breathing through the tube rather than the nose and mouth. Although the terms are sometimes used interchangeably, a "tracheotomy" is the surgical procedure creating an incision into the trachea, while "tracheostomy" refers to the opening in the trachea created by the incision. The most common acute complications of a tracheotomy are difficulty speaking or swallowing due to nerve damage, prolonged bleeding at the incision site, and

pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...

. A tracheotomy is rarely indicated in an emergent setting. It more commonly performed in a controlled environment to create an airway that can be used long-term, such as for prolonged mechanical ventilation.

Pediatric considerations

Children are not just small adults. They are unique in far more ways than simply being smaller in size. There are many basic differences in anatomy compared to adults that can affect airway management. For example, children's heads are proportionally larger in relation to their overall body size. This can cause alignment issues that have the potential to make it substantially more difficult to obtain good visualization of the appropriate airway landmarks. The differences in a child's anatomy can also affect equipment choices, such as choosing a straight laryngoscope blade instead of a curved one to achieve better control of a more elastic airway. Making the right equipment choices is so important that a color-coded tape measure (known as Broselow tape) was created to help facilitate rapid and accurate decisions in pediatric emergency situations. Birth complications, congenital syndromes (such as

Down syndrome Down syndrome or Down's syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is usually associated with child development, physical growth delays, mild to moderate ...

) and even recent illness or nasal congestion can affect how airway management is approached in a child. When ventilation, various airway options and even intubation are unsuccessful, this is a terrifying situation known as "cannot ventilate, cannot intubate". Typically this is when a cricothyrotomy would be attempted as mentioned above. However, this tricky procedure is even more difficult in kids due to their extra flexible airways. The chance of accidentally puncturing all the way through the trachea to the esophagus increases substantially. The risk is considered so high that the procedure is contraindicated in children under the age of 5–6 years old.Harless J, Ramalah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci 2014; 4:65–70.

References

{{First aid Medical procedures Airway management