Airway Management and Suctioning

Getting O₂ to the lungs is the single most important thing that the paramedic can ensure happens in every patient encountered. This section will discuss obstructions to the airway and how to relieve them and will conclude by discussing the airway adjuncts available to the paramedic, including BLS airways through surgical airways.

Airway Obstruction

Assessing airway patency in a person who is talking is about as easy an assessment a paramedic will ever make. If the person is talking, he or she has an airway. Check. But if the person is unresponsive, ensuring that the person has an adequate airway becomes a bit more of a challenge. When assessing the airway, listen for stridor. This upper airway sound will accompany any of the following causes and is sometimes the only clue to a narrowed airway passage. Let’s look at some of the common causes of airway obstruction.

• Tongue. In the person who is unresponsive, the tongue is the most common obstruction to the airway. In this group of patients, the muscles relax, and the tongue falls back against the posterior wall of the pharynx, effectively shutting off the airway.
• Foreign Body and Aspiration. Mama Cass (Cass Elliot) legendarily died of choking on a ham sandwich. Although not thought to be a factor in Mama’s untimely demise, choking often is associated with alcohol consumption, loss of a gag reflex in those with a stroke, and laughing or talking with food in the mouth.
• Laryngeal Spasm, Edema, and Injury. Laryngeal spasm occurs when the vocal cords close off the airway, which can happen from intubation attempts or can be a diver’s reflex. Edema is swelling and results from a fluid shift in the larynx that closes or nearly closes off the airway. Allergic reaction, trauma, or inhaling hot air or steam are common causes of laryngeal edema.

Patient Positioning and Manual Airway Maneuver

With some airway problems, simple repositioning of the head is all that is needed to relieve the obstruction and restore spontaneous breathing. Sometimes, however, more aggressive treatment is necessary to provide an airway for the patient. Any patient who has a CGS reading <8 or who is unresponsive should be immediately placed in a supine position if not found that way. This allows paramedics to quickly assess airway patency, breathing effort, and circulatory status with minimal difficulty.

Head Tilt/Chin Lift

Indications: A patient who is unresponsive does not show any signs of trauma.

Contraindications: Patients suspected of having a cervical spine injury.

Procedure:

1. While at the patient’s side, place the hand nearest the head on the forehead.
2. Place 2 fingers on the mandible, staying clear of the soft tissue under the chin.
3. Simultaneously apply pressure to the patient’s forehead while lifting up on the mandible.

Jaw Thrust

Indications: A patient who is unresponsive and suspected of having a cervical spine injury.

Contraindications: None in unresponsive trauma. Otherwise, the head tilt/chin lift maneuver is preferred. This maneuver can be painful if performed on a person who is conscious.

Procedure:

1. Position yourself superior to a supine patient’s head.
2. Place your thumbs on the cheek bones of the patient and the tips of your first 2 fingers posterior to the angle of the jaw.
3. Pull the jaw upward (anteriorly) using your thumbs on the cheeks for leverage. This position is difficult to maintain for long periods of time, so be sure to have a plan for inserting an airway adjunct.

Suctioning

Now that you have been introduced to the potential causes of airway obstruction and have learned how to open an otherwise occluded airway, it is time to discuss the active removal of debris in the airway with suctioning. The suction unit must be capable of generating 300 mmHg of vacuum force; have rigid-suction catheters, soft-suction catheters, large-bore noncollapsible tubing to connect the catheter with the suction unit; and include an unbreakable, disposable collection vessel to go along with a supply of water for rinsing the catheters after each suctioning run. The rigid-suction catheters, or Yankauer catheters, are ideal for suctioning the mouth of vomit and blood and are easy to control. The soft-suction catheters, or French catheters, are best suited for suctioning out the lumen of an ETT or a nasopharygeal airway.

Indications: The airway has excessive blood, vomit, or secretions that pose an aspiration threat.

Contraindications: None.

Procedure, no advanced airway:

1. Select a rigid-suction (Yankauer) catheter.
2. Measure from the corner of the mouth to the earlobe. This is the maximum depth of insertion.
3. Open the mouth using the cross finger technique.
4. Kink the tubing or leave the catheter port open to ensure no suctioning on the way into the mouth. Insert the catheter to the depth measured in step 2.
   
5. Unkink the tubing or cover the catheter port to initiate suctioning when the premeasured depth is reached.
   
6. Suction on the way out of the mouth for a period of not longer than 15 seconds in the adult, 10 seconds in the child, or 5 seconds in the infant.
   
7. Dip the suction catheter into water to rinse. This prevents blood from clotting in the catheter.
   

Procedure, ETT in place:

1. Select a soft-suction (French) catheter.
2. Observe sterile technique. Measure from the end of the ETT to the earlobe to the suprasternal notch. This is the maximum depth of insertion.
3. Lubricate the tip of the catheter.
4. Preoxygenate the patient.
   
5. Kink the tubing or leave the catheter port open to ensure no suctioning on the way into the mouth. Insert the catheter to the depth measured in step 2.
   
6. Unkink the tubing or cover the catheter port to initiate suctioning when the premeasured depth is reached.
   
7. Suction only while slowly withdrawing the catheter from the ETT for a period of not longer than 15 seconds in the adult, 10 seconds in the child, or 5 seconds in the infant.
   
8. Dip the suction catheter into water to rinse. This prevents blood from clotting in the catheter.
   
9. Ventilate or direct the ventilation of the patient.

Practical Point

On the NRPE, suction is tested only after intubation is successful through the ETT. Failure to preoxygenate the patient prior to suctioning (step 4) is a critical failure. Inserting any adjunct in a manner dangerous to the patient also is a critical failure. This could be selected if you fail to measure the length of the catheter and insert it too far into the tube. Suctioning in the Ventilatory Management—Adult station is worth up to 6 points.