View source for Airway management

{{short description|Medical procedure ensuring an unobstructed airway}}
{{Infobox medical intervention
 | Name        = Airway management
 | Image       = Glidescope 02.JPG
 | Caption     = Photograph of an [[anesthesiologist]] using the Glidescope video [[laryngoscope]] to [[intubate]] the [[trachea]] of a morbidly obese elderly person with challenging airway anatomy
 | ICD10       =
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 | MeshID      = D058109
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'''Airway management''' includes a set of maneuvers and medical procedures performed to prevent and relieve an [[airway obstruction]]. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere.<ref>{{Cite journal|last1=Bingham|first1=Robert M.|last2=Proctor|first2=Lester T.|date=2008-08-01|title=Airway management|journal=Pediatric Clinics of North America|volume=55|issue=4|pages=873–886, ix–x|doi=10.1016/j.pcl.2008.04.004|issn=0031-3955|pmid=18675024}}</ref> This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as [[anaphylaxis]], the [[Obtundation|obtunded]] patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents ([[Pulmonary aspiration|aspiration]]).{{citation needed|date=February 2022}}

Airway management is commonly divided into two categories: [[Basic airway management|basic]] and [[Advanced airway management|advanced]].

Basic techniques are generally non-invasive and do not require specialized medical equipment or advanced training. Techniques might include head and neck maneuvers to optimize ventilation, [[abdominal thrusts]], and back blows.

Advanced techniques require specialized medical training and equipment, and are further categorized anatomically into supraglottic devices (such as [[Oropharyngeal airway|oropharyngeal]] and [[nasopharyngeal airway]]s), infraglottic techniques (such as [[tracheal intubation]]), and [[Surgical airway management|surgical methods]] (such as [[cricothyrotomy]] and [[tracheotomy]]).<ref>Tintinalli, Judith (2016). ''Tintinalli's Emergency Medicine: A Comprehensive Study Guide''. McGraw Hill. pp. 178–198. {{ISBN|978-0-07-180913-9}}</ref>

Airway management is a primary consideration in the fields of [[cardiopulmonary resuscitation]], [[anaesthesia]], [[emergency medicine]], [[intensive care medicine]], [[neonatology]], and [[first aid]]. The "A" in the [[ABC (medicine)|ABC treatment]] [[mnemonic]] is for airway.<ref>Wright, Pearce (2003-08-13). [https://www.theguardian.com/news/2003/aug/13/guardianobituaries.highereducation "Obituary: Peter Safar"]. London: The Guardian. Retrieved 2014-12-06</ref>

==Basic airway management==
{{Main|Basic airway management}}
Basic airway management involves maneuvers that do not require specialized [[medical equipment]] (in contrast to advanced airway management). It is mainly used in first aid since it is [[Minimally invasive procedures|non-invasive]], quick, and relatively simple to perform. The simplest way to determine if the airway is obstructed is by assessing whether the patient is able to speak.<ref name=":0" /> Basic airway management can be divided into treatment and prevention of an obstruction in the airway.[[File:AbdominalThrust HeimlichManoeuvre.jpg|thumb|Back slaps and abdominal thrusts are performed to relieve airway obstruction by foreign objects]] [[File:Principe heimlich profil.svg|thumb|Inward and upward force during abdominal thrusts]]{{citation needed|date=February 2022}}

===Treatment===
{{Main|Choking#Basic treatment (First-Aid)}}
Treatment includes different maneuvers that aim to remove the foreign body that is obstructing the airway. This type of obstruction most often occurs when someone is eating or drinking. Most modern protocols, including those of the [[American Heart Association]], [[American Red Cross]] and the [[European Resuscitation Council]],<ref name="ERC2010">{{cite journal |last1=Nolan |first1=JP |last2=Soar |first2=J |last3=Zideman |first3=DA |last4=Biarent |first4=D |last5=Bossaert |first5=LL |last6=Deakin |first6=C |last7=Koster |first7=RW |last8=Wyllie |first8=J |last9=Böttiger |first9=B |last10=ERC Guidelines Writing Group |title=European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary |journal=Resuscitation |volume=81 |issue=10 |pages=1219–76 |doi=10.1016/j.resuscitation.2010.08.021| pmid=20956052|year=2010 |hdl=10067/1302980151162165141 |hdl-access=free }}</ref> recommend several stages, designed to apply increasingly more pressure. Most protocols recommend first encouraging the patient to cough, and allowing them an opportunity to spontaneously clear the foreign body if they are coughing forcefully. If the person's airway continues to be blocked, more forceful maneuvers such as hard back slaps and [[abdominal thrusts]] (''Heimlich maneuver'') can be performed. Some guidelines recommend alternating between abdominal thrusts and back slaps while others recommend the same starting with the back slaps first.<ref name="ERC2010" /> Having the person lean forward reduces the chances of the foreign body going back down the airway when coming up.<ref name=":1">{{Cite web|url=http://resuscitation-guidelines.articleinmotion.com/article/S0300-9572(10)00435-1/aim/recovery-position|title=European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators - Article in Motion|website=resuscitation-guidelines.articleinmotion.com|access-date=2016-12-06|archive-url=https://web.archive.org/web/20160529215025/http://resuscitation-guidelines.articleinmotion.com/article/S0300-9572(10)00435-1/aim/recovery-position|archive-date=2016-05-29}}</ref>

Performing abdominal thrusts on a patient involves standing behind them, and providing inward and upward forceful compressions in the upper abdomen, in the area located between the chest and the belly button. The rescuer usually gives the compressions using a fist that is grasped with the other hand.{{citation needed|date=February 2022}}

Abdominal thrusts can also be performed on oneself with the help of the objects near, for example: by leaning over a chair. Anyway, when the choking patient is oneself, one of the more reliable options is the usage of any specific anti-choking device. In adults, there is limited evidence that the head down position can be used for self-treatment of suffocation and appears to be an option only if other maneuvers do not work.<ref>{{Cite journal|last=Luczak|first=Artur|date=June 2016|title=Head-down self-treatment of choking|url=http://www.resuscitationjournal.com/article/S0300-9572(16)00087-3/fulltext|journal=Resuscitation|volume=103|pages=e13|doi=10.1016/j.resuscitation.2016.02.015|pmid=26923159|doi-access=free|url-access=subscription}}</ref> In contrast, in children under 1 it is recommended that the child be placed in a head down position as this appears to help increase the effectiveness of back slaps and abdominal thrusts.<ref>{{Cite journal|last=Maconochie|first=Ian|year=2015|title=European Resuscitation Council Guidelines for Resuscitation 2015|journal=Resuscitation|volume=95|pages=223–248|doi=10.1016/j.resuscitation.2015.07.028|pmid=26477414|hdl=20.500.11940/8275|hdl-access=free}}</ref>

When the patient can not receive pressures on the abdomen (it can happen in case of pregnancy or excessive obesity, for example), chest thrusts are advised instead of abdominal thrusts. The chest thrusts are the same type of compressions but applied on the lower half of the chest bone (not in the very extreme, which is a point named xiphoid process and could be broken).

The American Medical Association and Australian Resuscitation Council advocate sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions, once the choking patient becomes unconscious.<ref name=AMA>{{Cite book| url=https://books.google.com/books?id=WuvXnhwU8nQC&q=AMA+Emergency&pg=PR8 | title= American Medical Association Handbook of First Aid and Emergency Care | author= American Medical Association | publisher= [[Random House]]| isbn=978-1-4000-0712-7| date=2009-05-05| author-link= American Medical Association }}</ref><ref>{{Cite web|url=https://resus.org.au/glossary/finger-sweep-guideline-4/|title=Finger Sweep|website=resus.org.au|language=en-AU|access-date=2018-02-04|archive-date=2018-02-04|archive-url=https://web.archive.org/web/20180204124125/https://resus.org.au/glossary/finger-sweep-guideline-4/}}</ref> However, many modern protocols and literature recommend against the use of the finger sweep.<ref>{{Cite journal|last1=Vunda|first1=Aaron|last2=Vandertuin|first2=Lynda|title=Nasopharyngeal Foreign Body following a Blind Finger Sweep|journal=The Journal of Pediatrics|volume=160|issue=2|page=353|doi=10.1016/j.jpeds.2011.08.061|pmid=22014606|year=2012}}</ref> If the person is conscious, they should be able to remove the foreign object themselves, and if they are unconscious, a finger sweep can cause more harm. A finger sweep can push the foreign body further down the airway, making it harder to remove, or cause aspiration by inducing the person to vomit. Additionally, there is the potential for harm to the rescuer if they are unable to clearly see the oral cavity (for example, cutting a finger on jagged teeth).

===Prevention===
[[File:Tongue blocking airway.svg|thumb|The [[head-tilt/chin-lift]] is the most reliable method of opening the airway.]]
[[File:Jaw thrust maneuver.jpg|thumb|The jaw thrust maneuver can also open up the airway with minimal spine manipulation]]
Prevention techniques focus on preventing airway obstruction by the tongue and reducing the likelihood of [[Pulmonary aspiration|aspiration]] of stomach contents or blood. The [[head-tilt/chin-lift]] and [[jaw-thrust maneuver]]s are useful for the former while the [[recovery position]] is useful for the latter. If head-tilt/chin-lift and jaw-thrust maneuvers are performed with any objects in the airways it may dislodge them further down the airways and thereby cause more blockage and harder removal.{{citation needed|date=September 2016}}

The head-tilt/chin-lift is the primary maneuver used in any patient in whom [[cervical spine injury]] is not a concern. This maneuver involves flexion of the neck and extension of the head at Atlanto-occipital joint (also called the sniffing position), which opens up the airway by lifting the tongue away from the back of the throat. Placing a folded towel behind the head accomplishes the same result.<ref name=":0" />

[[File:Recovery position.svg|thumbnail|All forms of the [[recovery position]] share basic principles. The head is in a dependent position so that fluid can drain from the patient's airway; the chin is well up to keep the [[epiglottis]] opened. Arms and legs are locked to stabilize the position of the patient]]The jaw-thrust maneuver is an effective airway technique, particularly in the patient in whom cervical spine injury is a concern.  It is easiest when the patient is positioned [[supine position|supine]]. The practitioner places their index and middle fingers behind the angle of the mandible to physically push the posterior aspects of the mandible upwards while their thumbs push down on the chin to open the mouth. When the mandible is displaced forward, it pulls the tongue forward and prevents it from occluding the entrance to the trachea.<ref>{{Cite book|title=Emergency Airway Management|last=Burtenshaw|first=Andrew|publisher=Cambridge University Press|year=2015|isbn=978-1-107-66125-7|pages=22–23}}</ref>

The [[recovery position]] is an important prevention technique for an unconscious person that is breathing casually. This position entails having the person lie in a stable position on their side with the head in a dependent position so fluids do not drain down the airway, reducing the risk of aspiration.<ref name=":1" />

Most airway maneuvers are associated with some movement of the [[cervical spine]].<ref name="pmid9201858">{{cite journal|vauthors=Donaldson WF, Heil BV, Donaldson VP, Silvaggio VJ | title=The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study. | journal=Spine | year= 1997 | volume= 22 | issue= 11 | pages= 1215–8 | pmid=9201858 | doi= 10.1097/00007632-199706010-00008| s2cid=28174117 }}</ref><ref name="pmid11049921">{{cite journal|vauthors=Brimacombe J, Keller C, Künzel KH, Gaber O, Boehler M, Pühringer F | title=Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers | journal=Anesth Analg | year= 2000 | volume= 91 | issue= 5 | pages= 1274–8 | pmid=11049921 | doi= 10.1213/00000539-200011000-00041| s2cid=32473385 | doi-access=free }}</ref>  When there is a possibility of cervical injury, [[Cervical collar|collars]] are used to help hold the head in-line. Most of these airway maneuvers are associated with some movement of the cervical spine. Even though cervical collars can cause problems maintaining an airway and maintaining a blood pressure,<ref name="pmid10102310">{{cite journal|vauthors=Kolb JC, Summers RL, Galli RL | title=Cervical collar-induced changes in intracranial pressure | journal=Am J Emerg Med | year= 1999 | volume= 17 | issue= 2 | pages= 135–7 | pmid=10102310 | doi= 10.1016/S0735-6757(99)90044-X}}</ref> it is not recommended to remove the collar without adequate personnel to manually hold the head in place.<ref name="pmid12121154">{{cite journal|vauthors=Mobbs RJ, Stoodley MA, Fuller J | title=Effect of cervical hard collar on intracranial pressure after head injury | journal=ANZ J Surg | year= 2002 | volume= 72 | issue= 6 | pages= 389–91 | pmid=12121154 | doi= 10.1046/j.1445-2197.2002.02462.x| s2cid=33930416 }}</ref>

== Advanced airway management ==
{{main|Advanced airway management}}

In contrast to basic airway management maneuvers such as head-tilt or jaw-thrust, advanced airway management relies on the use of medical equipment. Advanced airway management can be performed [[Blind insertion airway device|"blindly"]] or with visualization of the [[glottis]] by using a [[laryngoscope]]. Advanced airway management is frequently performed in the critically injured, those with extensive pulmonary disease, or anesthetized patients to facilitate oxygenation and [[mechanical ventilation]]. Additionally, implementation of a cuffing system is used to prevent the possibility of [[asphyxia]]tion or airway obstruction.<ref name=":3">{{Cite book|title=Principles of airway management|last1=Finucane|first1=Brendan T.|last2=Tsui|first2=Ban Chi-Ho|last3=Santora|first3=Albert H.|date=2011-01-01|publisher=Springer|isbn=978-0-387-09558-5|edition=4th|location=New York|doi=10.1007/978-0-387-09558-5}}</ref>

Many methods are used in Advanced airway management. Examples in increasing order of invasiveness include the use of supraglottic devices such as [[Oropharyngeal airway|oropharyngeal]] or [[nasopharyngeal airway]]s, infraglottic techniques such as [[tracheal intubation]] and finally surgical methods.<ref name=":4" /><ref>{{Cite web|url=https://www.uptodate.com/contents/devices-for-difficult-emergency-airway-management-in-adults|title=UpToDate|website=www.uptodate.com}}</ref>

===Removal of foreign objects===
[[File:Catheter Introducing Forceps 01.jpg|thumbnail|right|Foreign objects can be removed with a Magill forceps under inspection of the airway with a [[laryngoscope]]]]
The ingestion and aspiration of foreign objects pose a common and dangerous problem in young children. It remains one of the leading cause of death in children under the age of 5.<ref>{{Cite web|url=http://www.nsc.org|title=National Safety Council Accident Facts.|date=February 2000}}</ref> Common food items (baby carrots, peanuts, etc.) and household objects (coins, metals, etc.) may lodge in various levels of the airway tract and cause significant obstruction of the airway. Complete obstruction of the airway represents a [[medical emergency]]. During such crisis, caretakers may attempt back blows, abdominal thrust, or the [[Abdominal thrusts|Heimlich maneuver]] to dislodge the inhaled object and reestablish airflow into the lungs.<ref>Manning PB, Wesley JR, Polley TZ, et al. Esophageal and tracheobronchial foreign bodies in infants and children. Pediatr Surg Int 1987;2:346.</ref>

In the hospital setting, healthcare practitioners will make the diagnosis of foreign body aspiration from the medical history and physical exam findings. In some cases, providers will order chest radiographs, which may show signs of [[Air trapping|air-trapping]] in the affected lung. In advanced airway management, the inhaled foreign objects, however, are either removed by using a simple plastic suction device (such as a [[Yankauer suction tip]]) or under direct inspection of the airway with a [[laryngoscope]] or [[bronchoscope]]. If removal is not possible, other surgical methods should be considered.<ref>{{Cite book|title=Greenfield's Surgery: Scientific Principles and Practice, 5e|author1=TONY CAPIZZANI |author2=RONALD B. HIRSCHL |author3=ROBERT E. CILLEY |publisher=Lippincott Williams & Wilkins|year=2011|pages=Chapter 2016 (Pediatric Chest)}}</ref>

===Supraglottic techniques===

Supraglottic techniques use devices that are designed to have the distal tip resting above the level of the glottis when in its final seated position. Supraglottic devices ensure patency of the upper respiratory tract without entry into the trachea by bridging the oral and pharyngeal spaces.<ref name=":3" /> There are many methods of subcategorizing this family of devices including route of insertion, absence or presence of a cuff, and anatomic location of the device's distal end. The most commonly used devices are [[Laryngeal mask airway|laryngeal masks]] and supraglottic tubes, such as [[Oropharyngeal airway|oropharyngeal]] (OPA) and [[nasopharyngeal airway]]s (NPA).<ref name=":3" /> In general, features of an ideal supraglottic airway include the ability to bypass the upper airway, produce low airway resistance, allow both positive pressure as well as spontaneous ventilation, protect the respiratory tract from gastric and nasal secretions, be easily inserted by even a nonspecialist, produce high first-time insertion rate, remain in place once in seated position, minimize risk of aspiration, and produce minimal side effects.<ref name=":3" />

A ''nasopharyngeal airway'' is a soft rubber or plastic tube that is passed through the nose and into the posterior [[pharynx]]. Nasopharyngeal airways are produced in various lengths and diameters to accommodate for gender and anatomical variations. Functionally, the device is gently inserted through a patient's nose after careful lubrication with a viscous lidocaine gel. Successful placement will facilitate spontaneous ventilation, masked ventilation, or machine assisted ventilation with a modified nasopharyngeal airway designed with special attachments at the proximal end. Patients generally tolerate NPAs very well. NPAs are preferred over OPAs when the patient's jaw is clenched or if the patient is semiconscious and cannot tolerate an OPA.<ref name="pmid15911941">{{cite journal|year=2005|title=The nasopharyngeal airway: dispelling myths and establishing the facts|journal=Emerg Med J|volume=22|issue=6|pages=394–6|doi=10.1136/emj.2004.021402|pmc=1726817|pmid=15911941|vauthors=Roberts K, Whalley H, Bleetman A}}</ref> NPAs, however, are generally not recommended if there is suspicion of a [[Bone fracture|fracture]] [[Basilar skull fracture|to the base of the skull]]. In these circumstances, insertion of the NPA can cause neurological damage by entering the cranium during placement.<ref name="pmid15911941" /> There is no consensus, however, regarding the risk of neurological damage secondary to a basilar skull fracture compared to hypoxia due to insufficient airway management.<ref name="EMJ2006">{{Cite journal|year=2006|title=Intracranial placement of nasopharyngeal airways: Is it all that rare?|journal=Emergency Medicine Journal|volume=23|issue=8|page=661|doi=10.1136/emj.2006.036541|pmc=2564185|pmid=16858116|last1=Ellis|first1=D. Y.}}</ref><ref name="EMJ2004">{{Cite journal|last2=Whalley|first2=H.|last3=Bleetman|first3=A.|year=2005|title=The nasopharyngeal airway: Dispelling myths and establishing the facts|journal=Emergency Medicine Journal|volume=22|issue=6|pages=394–396|doi=10.1136/emj.2004.021402|pmc=1726817|pmid=15911941|last1=Roberts|first1=K.}}</ref> Other complications of Nasopharyngeal airways use includes laryngospasm, epistaxis, vomiting, and tissue necrosis with prolonged use.<ref name=":3" />[[File:Oropharyngeal Airways.jpg|thumb|right|Oropharyngeal airways in a range of sizes]]
''Oropharyngeal airways'' are curved, rigid plastic devices, inserted into the patient's mouth. Oropharyngeal airways are produced in various lengths and diameters to accommodate for gender and anatomical variations. It is especially useful in patients with excessive tongue and other soft tissues. OPAs prevent airway obstruction by ensuring that the patient's [[tongue]] does not obstruct the [[epiglottis]] by creating a conduit. Because an oropharyngeal airway can mechanically stimulate the [[Pharyngeal reflex|gag reflex]], it should only be used in a deeply sedated or unresponsive patient to avoid vomiting and aspiration.<ref name=anaUK2010>{{cite web|title=Guedel airway |url=http://www.frca.co.uk/article.aspx?articleid=101120 |work=AnaesthesiaUK |access-date=23 May 2013 |date=14 May 2010 |archive-url=https://web.archive.org/web/20130124010243/http://frca.co.uk/article.aspx?articleid=101120 |archive-date=24 January 2013 }}</ref> Careful attention must be made while inserting an OPA. The user must avoid pushing the tongue further down the patient's throat. This is usually done by inserting the OPA with its curve facing cephalad and rotating it 180 degrees as you enter the posterior pharynx.<ref name=":4">{{Cite web|url=https://www.uptodate.com/contents/basic-airway-management-in-adults|title=UpToDate|website=www.uptodate.com}}</ref>

''Extraglottic devices'' are another family of supraglottic devices that are inserted through the mouth to sit on top of the larynx''.''<ref name="Hernandez2011">{{cite journal|last1=Hernandez|first1=MR|last2=Klock|first2=Andranik|author-link2=Andranik Ovassapian|last3=Ovassapian|first3=A|s2cid=14421707|year=2011|title=Evolution of the Extraglottic Airway: A Review of Its History, Applications, and Practical Tips for Success|journal=Anesthesia and Analgesia|volume=114|issue=2|pages=349–68|doi=10.1213/ANE.0b013e31823b6748|pmid=22178627|doi-access=free}}</ref> Extraglottic devices are used in the majority of operative procedures performed under general anaesthesia.<ref name="Cook2010">{{cite journal|last1=Cook|first1=T|last2=Howes|first2=B.|s2cid=49413173|year=2010|title=Supraglottic airway devices: recent advances|journal=[[Continuing Education in Anaesthesia, Critical Care & Pain]]|volume=11|issue=2|pages=56–61|doi=10.1093/bjaceaccp/mkq058|doi-access=free}}</ref> Compared to a cuffed tracheal tube, extraglottic devices provide less protection against aspiration but are more easily inserted and causes less laryngeal trauma.<ref name="Hernandez2011" /> Limitations of extraglottic devices arise in morbidly obese patients, lengthy surgical procedures, surgery involving the airways, laparoscopic procedures and others due to its bulkier design and inferior ability to prevent aspiration.<ref name="Davies1990">{{cite journal|year=1990|title=Laryngeal mask airway and tracheal tube insertion by unskilled personnel|url=http://www.thelancet.com/journals/lancet/article/PII0140-6736(90)92429-L/abstract|journal=[[The Lancet]]|volume=336|issue=8721|pages=977–979|doi=10.1016/0140-6736(90)92429-L|pmid=1978159|vauthors=Davies PR, Tighe SQ, Greenslade GL, Evans GH|s2cid=30763681|access-date=25 July 2010|url-access=subscription}}</ref> In these circumstances, endotracheal intubation is generally preferred. The most commonly used extraglottic device is the [[laryngeal mask airway]] (LMA). An LMA is a cuffed perilaryngeal sealer that is inserted into the mouth and set over the glottis. Once it is in its seated position, the cuff is inflated.<ref name=":2" /> Other variations include devices with oesophageal access ports, so that a separate tube can be inserted from the mouth to the stomach to decompress accumulated gases and drain liquid contents.<ref name="Hernandez2011" /> Other variations of the device can have an endotracheal tube passed through the LMA and into the trachea.<ref name="Hernandez2011" />

===Infraglottic techniques===
[[File:Intubasion boru.jpg|thumb|right|A cuffed endotracheal tube used in tracheal intubation]]
In contrast to supraglottic devices, infraglottic devices create a conduit between the mouth, passing through the glottis, and into the trachea. There are many infraglottic methods available and the chosen technique is reliant on the accessibility of medical equipment, competence of the clinician and the patient's injury or disease. [[Tracheal intubation]], often simply referred to as [[intubation]], is the placement of a flexible plastic or rubber [[catheter|tube]] into the [[vertebrate trachea|trachea]] to maintain an open [[airway]] or to serve as a conduit through which to administer certain drugs.<ref name=":2">{{Cite journal|last1=Thierbach|first1=Andreas R.|last2=Werner|first2=Christian|date=2005-12-01|title=Infraglottic airway devices and techniques|journal=Best Practice & Research. Clinical Anaesthesiology|volume=19|issue=4|pages=595–609|issn=1521-6896|pmid=16408536|doi=10.1016/j.bpa.2005.06.001}}</ref> The most widely used route is orotracheal, in which an [[tracheal tube|endotracheal tube]] is passed through the mouth and [[larynx|vocal apparatus]] into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea. Alternatives to standard endotracheal tubes include [[laryngeal tube]] and [[combitube]].{{citation needed|date=February 2022}}

===Surgical methods===
{{main|surgical airway management}}
[[File:Larynx external en.svg|thumb|right|200px|alt=In [[cricothyrotomy]], the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage|In cricothyrotomy, the incision or puncture is made through the [[Cricothyroid ligament|cricothyroid membrane]] in between the [[thyroid cartilage]] and the [[cricoid cartilage]]]]
[[File:Tracheostomy tube.jpg|thumb|Photograph of a tracheostomy tube|216x216px]]
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 often performed as a last resort in cases where orotracheal and nasotracheal [[intubation]] are impossible or [[contraindicated]]. Surgical airway management is also used when a person will need a [[mechanical ventilator]] for a longer period. Surgical methods for airway management include [[cricothyrotomy]] and [[tracheostomy]].{{citation needed|date=September 2016}}

A cricothyrotomy is an emergency surgical procedure in which an incision is made through the [[Cricothyroid ligament|cricothyroid membrane]] to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, [[angioedema]], or massive facial trauma.<ref name=Mohan2009>{{cite journal|last1=Mohan|first1=R|last2=Iyer|first2=R|last3=Thaller|first3=S|title=Airway management in patients with facial trauma|journal=Journal of Craniofacial Surgery|volume=20|issue=1|pages=21–3|year=2009|pmid=19164982|doi=10.1097/SCS.0b013e318190327a|s2cid=5459569}}</ref> Cricothyrotomy is much easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer immediate complications.<ref name=Katos2007>{{cite journal|first1=MG|last1=Katos|first2=D|last2=Goldenberg|title=Emergency cricothyrotomy|journal=Operative Techniques in Otolaryngology|volume=18|issue=2|pages=110–4|year=2007|doi=10.1016/j.otot.2007.05.002|doi-access=free}}</ref> Some complications of cricothyrotomy include bleeding, infection, and injury to surrounding skin and soft tissue structures.

A tracheotomy is a surgical procedure in which a surgeon makes incision in the neck and a breathing tube is inserted directly into the trachea.<ref name=":5">{{Cite journal|last1=Andriolo|first1=Brenda N. G.|last2=Andriolo|first2=Régis B.|last3=Saconato|first3=Humberto|last4=Atallah|first4=Álvaro N.|last5=Valente|first5=Orsine|date=2015-01-12|title=Early versus late tracheostomy for critically ill patients|journal=The Cochrane Database of Systematic Reviews|volume=1|issue=12 |article-number=CD007271|doi=10.1002/14651858.CD007271.pub3|issn=1469-493X|pmc=6517297|pmid=25581416}}</ref> A common reason for performing a tracheotomy includes requiring to be put on a mechanical ventilator for a longer period.<ref name=":5" /> The advantages of a tracheotomy include less risk of infection and damage to the trachea during the immediate post-surgical period.<ref name=":5" /> Although rare, some long term complications of tracheotomies include [[Laryngotracheal stenosis|tracheal stenosis]] and tracheoinnominate fistulas.<ref>{{Cite book|title=Greenfield's Surgery: Scientific Principles and Practice, 5e|last=REDDY|first=RISHINDRA M.|publisher=Lippincott Williams & Wilkins|year=2011|pages=Chapter 80. CHEST WALL, PLEURA, MEDIASTINUM, AND NONNEOPLASTIC LUNG DISEASE}}</ref>

==Airway management in specific situations==

=== Cardiopulmonary resuscitation ===
{{Main|Cardiopulmonary resuscitation}}
The optimal method of airway management during CPR is not well established at this time given that the majority of studies on the topic are observational in nature. These studies, however, guide recommendations until prospective, randomized controlled trials are conducted.{{citation needed|date=February 2022}}

Current evidence suggests that for out-of-hospital cardiac arrest, basic airway interventions (head-tilt–chin-lift maneuvers, bag-valve-masking or mouth-to-mouth ventilations, [[Nasopharyngeal airway|nasopharyngeal]] and/or [[Oropharyngeal airway|oropharyngeal]] airways) resulted in greater short-term and long-term survival, as well as improved neurological outcomes in comparison to advanced airway interventions (endotracheal intubation, laryngeal mask airway, all types of supraglottic airways (SGA), and trans-tracheal or trans-cricothyroid membrane airways).<ref>{{Cite journal|last1=Fouche|first1=Pieter F.|last2=Simpson|first2=Paul M.|last3=Bendall|first3=Jason|last4=Thomas|first4=Richard E.|last5=Cone|first5=David C.|last6=Doi|first6=Suhail A. R.|s2cid=207521831|date=2014-04-03|title=Airways in Out-of-hospital Cardiac Arrest: Systematic Review and Meta-analysis|journal=Prehospital Emergency Care|volume=18|issue=2|pages=244–256|doi=10.3109/10903127.2013.831509|issn=1090-3127|pmid=24111481}}</ref><ref>{{Cite journal|last1=Bernhard|first1=Michael|last2=Benger|first2=Jonathan R.|title=Airway management during cardiopulmonary resuscitation|journal=Current Opinion in Critical Care|volume=21|issue=3|pages=183–187|doi=10.1097/mcc.0000000000000201|pmid=25922892|year=2015|s2cid=21363140|url=http://eprints.uwe.ac.uk/26477/|url-access=subscription}}</ref> Given that these are observational studies, caution must be given to the possibility of confounding by indication. That is, patients requiring an advanced airway may have had a poorer prognosis in relation to those requiring basic interventions to begin with.

For the management of in-hospital cardiac arrest however, studies currently support the establishment of an advanced airway. It is well documented that quality chest compressions with minimal interruption result in improved survival.<ref>{{Cite journal|last=Wik|first=Lars|title=Rediscovering the importance of chest compressions to improve the outcome from cardiac arrest|journal=Resuscitation|volume=58|issue=3|pages=267–269|doi=10.1016/s0300-9572(03)00267-3|pmid=12969601|year=2003}}</ref> This is suggested to be due, in part, to decreased no-flow-time in which vital organs, including the heart are not adequately perfused. Establishment of an advanced airway ([[endotracheal tube]], [[laryngeal mask airway]]) allows for asynchronous ventilation, reducing the no-flow ratio, as compared to the basic airway ([[Bag valve mask|bag-valve mask]]) for which compressions must be paused to adequately ventilate the patient.<ref>{{Cite journal|last1=Yeung|first1=Joyce|last2=Chilwan|first2=Mehboob|last3=Field|first3=Richard|last4=Davies|first4=Robin|last5=Gao|first5=Fang|last6=Perkins|first6=Gavin D.|title=The impact of airway management on quality of cardiopulmonary resuscitation: An observational study in patients during cardiac arrest|journal=Resuscitation|volume=85|issue=7|pages=898–904|doi=10.1016/j.resuscitation.2014.02.018|pmid=24594093|year=2014}}</ref>

Bystanders without medical training who see an individual suddenly collapse should call for help and begin chest compressions immediately. The [[American Heart Association]] currently supports [[Cardiopulmonary resuscitation#Compression only|"Hands-only" CPR]], which advocates chest compressions without rescue breaths for teens or adults.<ref>{{Cite journal|last1=Sayre|first1=Michael R.|last2=Berg|first2=Robert A.|last3=Cave|first3=Diana M.|last4=Page|first4=Richard L.|last5=Potts|first5=Jerald|last6=White|first6=Roger D.|date=2008-04-22|title=Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest|journal=Circulation|language=en|volume=117|issue=16|pages=2162–2167|doi=10.1161/CIRCULATIONAHA.107.189380|issn=0009-7322|pmid=18378619|s2cid=8249049 |doi-access=}}</ref> This is to minimize the reluctance to start CPR due to concern for having to provide [[mouth-to-mouth resuscitation]].{{citation needed|date=February 2022}}

===Trauma===
[[File:Bagging.JPG|thumb|182x182px|Bag-valve mask ventilation.]]
Airway represents the "A" in the [[ABC (medicine)|ABC mnemonic]] for trauma resuscitation.

Management of the airway in trauma can be particularly complicated, and is dependent on the mechanism, location, and severity of injury to the airway and its surrounding tissues. Injuries to the cervical spine, traumatic disruption of the airway itself, edema in the setting of caustic or thermal trauma, and the combative patient are examples of scenarios a provider may need to take into account in assessing the urgency of securing an airway and the means of doing so.<ref>{{Cite journal|last1=Struck|first1=Manuel F.|last2=Beilicke|first2=André|last3=Hoffmeister|first3=Albrecht|last4=Gockel|first4=Ines|last5=Gries|first5=André|last6=Wrigge|first6=Hermann|last7=Bernhard|first7=Michael|date=2016-04-11|title=Acute emergency care and airway management of caustic ingestion in adults: single center observational study|journal=Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine|volume=24|article-number=45|doi=10.1186/s13049-016-0240-5|issn=1757-7241|pmc=4827211|pmid=27068119 |doi-access=free }}</ref><ref>{{Cite journal|last1=Langeron|first1=O.|last2=Birenbaum|first2=A.|last3=Amour|first3=J.|date=2009-05-01|title=Airway management in trauma|journal=Minerva Anestesiologica|volume=75|issue=5|pages=307–311|issn=1827-1596|pmid=19412149}}</ref>

The pre-hospital setting provides unique challenges to management of the airway including tight spaces, neck immobilization, poor lighting, and often the added complexity of attempting procedures during transport. When possible, basic airway management should be prioritized including head-tilt-chin-lift maneuvers, and bag-valve masking. If ineffective, a supraglottic airway can be utilized to aid in oxygenation and maintenance of a patent airway. An oropharyngeal airway is acceptable, however nasopharyngeal airways should be avoided in trauma, particularly if a [[basilar skull fracture]] is suspected.<ref>{{Cite journal|last1=Dupanovic|first1=Mirsad|last2=Fox|first2=Heather|last3=Kovac|first3=Anthony|date=2010-04-01|title=Management of the airway in multitrauma|journal=Current Opinion in Anesthesiology|volume=23|issue=2|pages=276–282|doi=10.1097/ACO.0b013e3283360b4f|issn=1473-6500|pmid=20042974|s2cid=12995535}}</ref> Endotracheal intubation carries with it many risks, particularly when paralytics are used, as maintenance of the airway becomes a challenge if intubation fails. It should therefore be attempted by experienced personnel, only when less invasive methods fail or when it is deemed necessary for safe transport of the patient, to reduce risk of failure and the associated increase in morbidity and mortality due to hypoxia.<ref>{{Cite journal|last1=Bossers|first1=Sebastiaan M.|last2=Schwarte|first2=Lothar A.|last3=Loer|first3=Stephan A.|last4=Twisk|first4=Jos W. R.|last5=Boer|first5=Christa|last6=Schober|first6=Patrick|date=2015-01-01|title=Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis|journal=PLOS ONE|volume=10|issue=10|article-number=e0141034|doi=10.1371/journal.pone.0141034|issn=1932-6203|pmc=4619807|pmid=26496440|bibcode=2015PLoSO..1041034B|doi-access=free}}</ref><ref>{{Cite journal|last1=Cranshaw|first1=Julius|last2=Nolan|first2=Jerry|date=2006-06-01|title=Airway management after major trauma|journal=Continuing Education in Anaesthesia, Critical Care & Pain|language=en|volume=6|issue=3|pages=124–127|doi=10.1093/bjaceaccp/mkl015|issn=1743-1816|doi-access=free}}</ref>
[[File:ProSeal Laryngeal Mask Airway inflated 001.jpg|thumb|164x164px|Laryngeal mask airway (LMA). Example of a supraglottic device.]]
Management of the airway in the emergency department is optimal given the presence of trained personnel from multiple specialties, as well as access to "difficult airway equipment" ([[Video laryngoscope|videolaryngoscopy]], [[eschmann tracheal tube introducer]], [[Fiberoptic intubation|fiberoptic bronchoscopy]], surgical methods, etc.).<ref name=":0">{{Cite book|title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition|last=Tintinalli|first=Judith|publisher=Mc-Graw Hill|year=2016|isbn=978-0-07-179476-3|pages=Ch 28}}</ref> Of primary concern is the condition and patency of the [[Facial trauma|maxillofacial]] structures, [[larynx]], [[trachea]], and [[Bronchus|bronchi]] as these are all components of the respiratory tract and failure anywhere along this path may impede ventilation. Excessive facial hair, severe burns, and maxillofacial trauma may prevent acquisition of a good mask seal, rendering bag-valve mask ventilation difficult. Edema of the airway can make laryngoscopy difficult, and therefore in those with suspected thermal burns, intubation is recommended in attempts to quickly secure an airway prior to progression of the swelling.<ref>{{Cite book|title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th Edition|last=Tintinalli|first=Judith|publisher=McGraw-Hill|year=2016|isbn=978-0-07-179476-3|pages=1403}}</ref> Furthermore, blood and vomitus in the airway may prove visualization of the vocal cords difficult rendering direct and video laryngoscopy, as well as fiberoptic bronchoscopy challenging.<ref>{{Cite journal|last1=Barak|first1=Michal|last2=Bahouth|first2=Hany|last3=Leiser|first3=Yoav|last4=El-Naaj|first4=Imad Abu|date=2015-06-16|title=Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach|journal=BioMed Research International|language=en|volume=2015|article-number=724032|doi=10.1155/2015/724032|issn=2314-6133|pmc=4486512|pmid=26161411|doi-access=free}}</ref> Establishment of a surgical airway is challenging in the setting of restricted neck extension (such as in a [[c-collar]]), laryngotracheal disruption, or distortion of the anatomy by a penetrating force or hematoma. Tracheotomy in the operating room by trained professionals is recommended over cricothyroidotomy in the case of complete laryngotracheal disruption or children under the age of 12.<ref>{{Cite journal|last1=Patel|first1=Sapna A|last2=Meyer|first2=Tanya K|date=2014-01-01|title=Surgical Airway|journal=International Journal of Critical Illness and Injury Science|volume=4|issue=1|pages=71–76|doi=10.4103/2229-5151.128016|issn=2229-5151|pmc=3982374|pmid=24741501 |doi-access=free }}</ref>

== See also ==
* [[Choking#Basic treatment (first aid)|Choking, First-Aid treatment]]

==References==
{{reflist|30em}}

==Further reading==
{{Wikibooks|First Aid|Airway Management}}
* {{cite book  | author = Daniel Limmer  | author2 = Keith J. Karren  | author3 = Brent Q. Hafen  | author4 = John Mackay  | author5 = Michelle Mackay  | title = Emergency Medical Responder (Second Canadian Version)  | publisher = Brady  | year = 2006  | pages = [https://archive.org/details/emergencymedical0000unse/page/92 92–97]  | isbn = 978-0-13-127824-0  | url-access = registration  | url = https://archive.org/details/emergencymedical0000unse/page/92  }}

{{Anesthesia}}
{{First aid topics}}

[[Category:Airway management| ]]