CG03 | VERSION 1.1 1/12
trust clinical guideline
Guideline ID
CG03
Version
1.1
Title
Airway Management
Approved by
Clinical Effectiveness Group
Date Issued
01/10/2014
Review Date
31/09/2017
Directorate
Medical
Authorised Staff
Clinical
Publication
Category
Ambulance Care Assistant
Emergency Care Assistant
Student Paramedic
Advanced Technician
Paramedic (non-ECP)
Nurse (non-ECP)
ECP
Doctor
Guidance (Green) - Deviation permissible;
Apply clinical judgement
1.Scope
1.1
This guideline details the range of interventions available to each staff grade, to
enable effective airway management.
2.
Background and Definitions
2.1
Timely, effective and decisive airway management in an emergency can mean
the difference between life and death, or between long term ability and
disability. The loss of a patent airway, with the resultant failure of ventilation and
oxygenation, is a potentially terminal pathway with which ambulance clinicians
are often presented.
2.2
A stepped approach to airway management is promoted within JRCALC
guidelines, commencing with a head tilt-chin lift or jaw thrust. The clinician then
moves up the airway ladder until the airway is sufficiently maintained. In some
cases this may require little more than a manual head tilt or the insertion of an
oropharyngeal airway, whereas at extremis a surgical cricothyroidotomy may be
required.
2.3
responsive
committed
effective
The airway interventions authorised for use by each grade of ambulance clinician
are detailed in Table 1.
© South Western Ambulance Service NHS Foundation Trust 2014
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trust clinical guideline
Paramedic
Nurse
Doctor
3 3
3
3
3
3
3
Jaw Thrust
3 3
3
3
3
3
3
Oropharyngeal
Airway
3 3
3
3
3
3
3
Nasopharyngeal
Airway
7 7
3
3
3
3
3
Supraglottic Airway
7 7
7 7
7
7
3
3
3
3
7
3
Intubation
ACA
Head Tilt - Chin Lift
Responder
Advanced
Technician
Table 1 - Use of Airway Interventions by Each Clinical Grade
ECA/Student
Paramedic1
2.4
Rapid Sequence
Induction (RSI)
7 7
7
7
Only Under
Medical
Supervision
Cricothyroidotomy Needle
7 7
7
7
3
Cricothyroidotomy Surgical
7 7
7
7
Enhanced
Skill
Enhanced
Skill
Only Under
Medical
Supervision
3
Enhanced
Skill
Enhanced
Skill
3
Enhanced
Skill
Enhanced
Skill
Key:
3
Core skill
7
Skill not authorised
Enhanced Skill
Skill may be practiced once competency has been
demonstrated and the skill authorised by the Executive
Medical Director under the Enhanced Skills Policy.
Only Under Medical
Supervision
Skill may only be practiced as part of a team consisting of
at least one Doctor who is competent and confident in the
procedure.
1.
Student Paramedic Level 1 skill set - Supraglottic airway, intubation and needle
cricothyroidotomy skills are authorised at agreed points during the course.
responsive
committed
effective
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trust clinical guideline
3.Guidance
3.1
In order to ensure a stepped approach to airway management, the airway
management algorithm (Figure 1) must be applied by all clinical grades, working
up to the level of their scope of practice. During cardiac arrest, the importance
of maintaining good quality chest compressions whilst applying a stepwise
approach to airway management cannot be over emphasised.
3.2
Figure 1 - Airway Management Algorithm
Can patient maintain AND
protect their own airway?
YES
Exit algorithm
NO
Head tilt, chin lift
OR
Jaw thrust (if c-spine injury is suspected)
Can airway be maintained?
YES
NO
Insert oropharyngeal airway
YES
or
nasal pharyngeal (consider insertion in both nares)
Can airway be maintained?
NO
Insert SGA (LMA Igel) - 2 attempts
Can airway be maintained?
YES
NO
Intubate - (First attempt)
Can airway be maintained?
YES
NO
Intubate - (Second / third attempt)
Reconsider position, neck flexion/head extension,
laryngoscope techique and vector, bougie, BURP
Can airway be maintained?
YES
NO
Needle cricothyroidotomy
OR
Surgical cricothyroidotomy
(If clinician qualified to conduct the intervention present)
Can airway be maintained?
NO
Although airway can be
maintained, consider if further
measures may be taken to ensure
the airway can be protected.
If further protection is required,
re-enter algorithm and
continue through steps until
airway is protected to the
maximum degree possible.
responsive
committed
effective
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trust clinical guideline
3.3Suction
3.3.1 If suction is required apply before, and if necessary, after each stage of the
airway algorithm. The yankeur catheter must only be used to suction what can
be visualised.
3.4Ventilation
3.4.1 If the patient is not adequately ventilating themselves or is in respiratory/cardiac
arrest, attempt ventilation after completing each step of the algorithm. Only
move to ‘yes’ if the airway can be maintained AND ventilation is possible (either
spontaneous or assisted). Move to next step if ventilation is not possible after
two attempts. Where the patient is ventilated, use the pneumonic MOANS to
ensure bag mask ventilations are effective:
▲▲ Mask Seal - Mask size, facial hair, facial fractures;
▲▲ Obesity/obstruction - Obesity and pregnancy;
▲▲ Age - Age older than 55 years is associated with a higher risk of difficult BVM
ventilation due to loss of muscle and tissue tone;
▲▲ No Teeth - Adequate mask seal may be difficult as the cheeks tend to cave in;
▲▲ Stiff - Non-compliant lungs in conditions such as life-threatening asthmatic
episodes.
3.4.2 Mechanical ventilators must only be carried on double crewed (frontline
emergency) ambulances, critical care response vehicles and air ambulances. The
use of mechanical ventilators is only authorised for patients where the airway
has been secured by intubation in the following situations:
▲▲ Respiratory arrest;
▲▲ Cardiac arrest being transported to hospital where it is not possible for an
additional ambulance clinician to travel with the patient to manually ventilate
using a BVM;
▲▲ Use advised by CCP or Doctor.
3.5
End Tidal Carbon Dioxide Monitoring (ETCO2)
3.5.1 It is mandatory that where available on any resource on-scene, end tidal carbon
dioxide monitoring (ETCO2) is utilised whenever a BVM or mechanical ventilator
is used by an ambulance clinician to ventilate a patient. Where a unit is not
available at the commencement of the airway intervention or ventilation, the
rationale for this must be recorded in the procedural exclusion section of the
PCR. Conducting advanced airway management without ETCO2 monitoring
when a device is available on-scene may be seen by the Trust and the clinicians
regulatory body as negligent. Disciplinary action may be taken should this
occur, as it is vital that equipment provided to ensure patient safety is used
appropriately.
responsive
committed
effective
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trust clinical guideline
3.6
Intubation Verification Procedure
3.6.1 Following intubation, the tube verification procedure must be followed
(considered mandatory, with no deviation acceptable):
▲▲ The tube must be visualised passing through the vocal cords (use bougie);
▲▲ Inflate the cuff;
▲▲ Auscultate the patient’s chest to ensure that breath sounds are equal and
audible;
▲▲ Auscultate over the epigastrium; gurgling indicates oesophageal intubation;
▲▲ Where available on any resource on-scene, end tidal CO2 (ETCO2) monitoring
must be applied using the Easy Cap, EMMA, Mobimed or other device. The
monitoring of end tidal CO2 is detailed within Clinical Guideline CG11 (End
Tidal CO2 Monitoring).
3.6.2 If there is any doubt as to the placement of the tube, it must be immediately
removed and the patient ventilated for at least 1 minute using other airway
maintenance techniques, prior to further attempts. During a cardiac arrest the
importance of maintaining good quality chest compressions whilst applying a
stepwise approach to airway management cannot be over emphasised.
3.6.3 The ET tube must be manually held until it is secured by a tube holder.
4.
Special Situations
4.1Trismus
4.1.1 If the patient presents with trismus (the jaw cannot be opened) and the airway
is compromised by the presence of vomit or other fluids, in addition to following
the airway algorithm consider the following points:
▲▲ Insert a nasopharyngeal airway to enable suctioning;
▲▲ Apply suction through the nasopharyngeal airway using an appropriately
sized flexible suction catheter;
▲▲ Consider using a Yankeur catheter to suction fluid from the bucal space
(between the cheeks and teeth);
▲▲ Consider more advanced airway techniques within the Paramedic skill set.
▲▲ Consider the availability of further medical support to enable advanced
airway management, or rapid hospital transport where this is not possible.
responsive
committed
effective
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trust clinical guideline
4.2
Paediatric Nasopharyngeal Airways
4.2.1 Nasopharyngeal airways provide a useful tool for maintaining an airway
in patients with an intact gag reflex. Although JRCALC guidelines include
the use of nasopharyngeal airways for paediatric patients, paediatric sized
nasopharyngeal airways are not commercially available. The use of a cut down
ET tube provides a useful improvised airway using the following technique:
▲▲ Select an appropriate diameter un-cuffed ET tube. In most individuals one
nostril has a larger diameter than the other; the diameter should be roughly
the size of the patient’s little finger;
▲▲ Cut the tube to length, so that it measures from the tip of the nostril to the
tragus of the ear (the tough fold of cartilage that sticks out, away from the
ear, at the entrance to the ear canal);
▲▲ The plastic 15mm adaptor at the proximal end must be re-inserted into the
ET tube, to prevent the tube from slipping further into the nose;
▲▲ Generously lubricate the tube;
▲▲ Insert gently, with the bevel facing the septum. Slide downwards against the
nasopharyngeal floor, parallel to the mouth; do not use force.
4.3
Head Injuries
4.3.1 Head injuries present specific challenges and the following additional points
should be considered:
▲▲ The head-tilt chin lift manoeuvre is to be used as a last resort due to the risk
of spinal injury. A jaw trust is the initial manoeuvre;
▲▲ If the airway is obstructed and an oral airway is not possible, then the
theoretical risk of the nasopharyngeal airway passing through a basal skull
fracture is outweighed by the need to maintain an airway;
▲▲ Due to the vaso-pressor response, intubation in the non-anaesthetised
patient can lead to increased intracranial pressure. In patients with a head
injury who are not in cardiac arrest, endotracheal intubation should only be
performed if all other airway management options have failed and they have
no gag reflex;
▲▲ A balance must be sought between the benefits of airway manoeuvres and
the risk of a physical response such as retching or vomiting, which may raise
the intracranial pressure and exacerbate any secondary brain injury.
▲▲ In the case of head or facial injuries with bleeding into the mouth, nose
airways where immobilisation is indicated, extreme care must be taken when
considering placing the patient in the supine position to ensure that the
airway does not become compromised. If it is not possible to manage the
airway with suction and basic adjuncts, the need to maintain a clear airway
over rides the need to provide immobilisation.
responsive
committed
effective
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trust clinical guideline
4.4 Tracheostomy
4.4.1 It is important to determine if the patient has a tracheostomy or laryngectomy.
Figure 1 details the key differences.
4.4.2 Figure 1 - Laryngectomy vs Tracheostomy
Laryngectomy
Tracheostomy
4.4.3 A tracheostomy is an artificial opening made into the trachea through the neck.
A tracheostomy tube is usually inserted, providing a patent opening. The tube
enables air flow to enter the trachea and lungs directly, bypassing the nose,
pharynx and larynx, although there may still be a connection/patent airway
above.
4.4.4 Common reasons for a tracheotomy include:
▲▲ To facilitate the removal of bronchial secretions;
▲▲ Laryngeal incompetence and aspiration on swallowing;
▲▲ Poor cough effort with sputum retention;
▲▲ To protect the airway of patients who are at high risk of aspiration and have
poor laryngeal and tongue movement on swallowing (e.g. neuromuscular
disorders, unconsciousness, head injuries and stroke).
responsive
committed
effective
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trust clinical guideline
4.4.5 Physiological changes with a tracheostomy:
▲▲ Upper airway anatomical dead space can be reduced by up to 50%, which
improves ventilation to the lungs;
▲▲ Loss of natural warming, humidification and filtering of air that usually takes
place in the upper airway;
▲▲ Ability to speak is removed;
▲▲ Ability to swallow adversely affected;
▲▲ Sense of taste and smell can be lost.
4.4.6 The tracheostomy may either be permanent, or will remain until the indication
for insertion has resolved.
4.4.7 It is important to consider that patients with a tracheostomy potentially have
a patent upper airway which may provide an alternative means of ventilating
and oxygenating if the tracheostomy should become blocked or displaced.
Emergency tracheostomy guidance is detailed in Figure 2.
responsive
committed
effective
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trust clinical guideline
4.4.8 Figure 2 - Tracheostomy Emergency Guidance:
Is the patient breathing?
No
Yes
Ventilate. Begin CPR
if pulseless
Apply high flow oxygen to face
whilst assessing tube patency
Assess tracheostomy
patency
Remove speaking valve or
cap if present.
Remove inner tube
Can you pass a suction
catheter?
Yes
No
TRACHEOSTOMY TUBE IS PATENT
Perform suction
Reassess
Ventilate as outlined below if not
breathing
CPR if pulseless, follow ALS guidance
Deflate cuff if present.
Look, listen and feel at
mouth and tracheostomy
Is patient stabilising or
improving?
Yes
TRACHEOSTOMY TUBE
PARTIALLY OBSTRUCTED
OR DISPLACED.
Reassess, ATMIST to ED
No
Remove the tracheostomy tube.
Look, listen and feel at the mouth
and tracheostomy.
Is the patient breathing?
No
CPR if pulseless
Proceed to ventilation
PRIMARY EMERGENCY OXYGENATION
❙
❙
❙
❙
❙
Cover the stoma
Consider oral/nasal airway
Use BVM
Supraglottic airway if required
High flow O2
TRACHEOSTOMY STOMA VENTILATION
❙ If adequate inflations not gained use BVM
with paediatric size mask applied over
stoma
Yes
Continue ABCDE
assessment
responsive
committed
effective
SECONDARY EMERGENCY OXYGENATION
Attempt ORAL intubation
Uncut tube, advance beyond stoma
If unsuccessful attempt intubation of
Stoma with 6.0 Cuffed ETT
Constantly reassess, continue as per
airway and cardiac arrest clinical guideline
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trust clinical guideline
4.5 Laryngectomy
4.5.1 A laryngectomy involves surgical removal of the larynx, usually as treatment for
cancer of the larynx. The remaining trachea is brought to the front of the neck
as an end stoma. The mouth, nose and upper airways are no longer connected
to the lungs. All breathing, ventilation and oxygen delivery can only occur via the
stoma in the neck.
4.5.2 In contrast to a tracheostomy, patients who have had a laryngectomy do not
have any connection between the upper airways (nose, mouth, pharynx) and
the lungs; they can only be oxygenated and ventilated via the laryngectomy
opening. The opening is formed by the cut ends of the trachea being sutured
onto the skin. Figure 1 demonstrates the difference between a laryngectomy and
tracheostomy. Emergency laryngectomy guidance is detailed in Figure 3.
responsive
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trust clinical guideline
Figure 3 - Laryngectomy Emergency Guidance:
Is the patient breathing?
Look, listen & feel at the stoma site
No
Yes
Ventilate. Begin CPR
if pulseless
Apply high flow oxygen to
Stoma.
Assess laryngectomy stoma patency.
Most laryngectomy patients will not have
a tube in situ
Remove stoma cover (if present)
Remove inner tube (if present)
Can you pass a suction
catheter?
Yes
No
Deflate cuff if present.
Look, listen and feel at
stoma site
Is patient stabilising or
improving?
Yes
THE LARYNGECTOMY STOMA IS
PATENT
Perform suction
Reassess
Ventilate as outlined below if not
breathing.
CPR if pulseless, follow ALS guidance
Reassess ABCDE
No
Remove the laryngectomy tube if present
Look, listen and feel at the mouth and
laryngectomy.
Is the patient breathing?
No
CPR if pulseless
Proceed to ventilation
PRIMARY EMERGENCY OXYGENATION
LARYNGECTOMY STOMA VENTILATION
Use bag valve mask with paediatric size
face mask applied over stoma, 100% 02
Yes
Continue ABCDE
assessment
responsive
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effective
SECONDARY EMERGENCY OXYGENATION
Attempt intubation of stoma
with 6.0 Cuffed ETT
Constantly reassess, continue as per
airway and cardiac clinical guideline
LARYNGECTOMY PATIENTS HAVE AN END STOMA AND CANNOT BE OXYGENATED
VIA THE MOUTH OR NOSE
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trust clinical guideline
5.
Episode Closure
5.1
Where a skill is required which is not within the scope of practice of the
clinicians’ on-scene, back-up from a clinician with the required skill set should
be requested. Consideration should be given to rapidly transporting the patient
to hospital, where this may result in the skill being delivered at an earlier
opportunity. The option of a further clinician meeting the ambulance on-route to
hospital should also be considered.
5.2
Call for help early if it is suspected that it may not be possible to maintain the
airway using manual manoeuvres and the insertion of basic airway adjuncts.
Consider the early need for attendance of the air ambulance, BASICs Doctor or
the Critical Care Team if advanced techniques may be required.
5.3
Patients should be managed according to JRCALC guidelines, and admitted
as appropriate. For patients with an unstable/unsecure airway, ensure that an
ATMIST pre-alert is placed to request a resuscitation team to be present onarrival.
6.Documentation
6.1 In line with Trust Policy, a Patient Clinical Record must be completed and
annotated appropriately. A Cardiac Arrest form must also be completed for all
patients where resuscitation has been commenced. The PCR must clearly identify
the clinician who completed each airway maneuver. Any deviation from this
guideline must be recorded, with any potential or actual adverse event reported
through the incident reporting system.
responsive
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effective
© South Western Ambulance Service NHS Foundation Trust 2014