5.1

Airway/Breathing

 Chapter 5

Airway/Breathing

Introduction

Skillful, rapid, assessment and management of airway and

ventilation are critical to preventing morbidity and mortality.

Airway compromise can occur rapidly or slowly and may recur.

Frequent reassessment is necessary. Preventable causes of death

from airway problems in trauma include the following:

 Failure to recognize the need for an airway.

 Inability to establish an airway.

 Failure to recognize the incorrect placement of an airway.

 Displacement of a previously established airway.

 Failure to recognize the need for ventilation.

 Aspiration of the gastric contents.

Initial airway management at any level, but especially outside

of medical treatment facilities (MTFs).

Immediate goal: Move tongue, pharyngeal soft tissues, and

secretions out of airway. Until a formal airway is established,

place patients in the lateral or prone position (rescue position).

 Chin-lift and head tilt: Place fingers under the tip of the

mandible to lift the chin outward from face.

 Two-Handed Jaw Thrust: Place both hands behind the angles

of the mandible and displace forward. This method can be

used on the patient with cervical injury.

 Oropharyngeal airway:

ο Insert oral airway upright if a tongue depressor is used

(preferred method).

ο Keep the airway inverted past the tongue then rotate 180°.

ο Too small an airway will not alleviate the obstruction.

Too long an airway may fold the epiglottis caudally,

worsening the obstruction.

ο Estimate airway size by distance from corner of mouth

to ear lobe.

ο Oral airways are not used in conscious patients.
5.2

Emergency War Surgery

 Nasopharyngeal airway.

ο Pass lubricated nasal airway gently through one nostril.

ο Not used in suspected facial or basal skull injuries.

ο Is tolerated by conscious patients.

 Field expedient.

ο Pull tongue forward and safety pin or suture it to corner

of mouth.

 Cricothyrotomy.

Ventilation

 Ventilate patient with bag valve mask (BVM).

ο Bring the face into the mask rather than pushing the

mask onto the face.

ο The chin-lift and head tilt are also employed during mask

ventilation unless they are contraindicated due to

cervical spine precautions.

Assess air movement during mask ventilation by observing

rise and fall of the chest, auscultation, absence of a mask

leak, compliant feel of self-inflating bag, and stable oxygen

saturation.

ο If air movement is not achieved, use two-person mask

ventilation (Fig. 5-1).

Fig. 5-1. Two-person mask ventilation.
5.3

Airway/Breathing

♦ One person lifts the jaw aggressively at the angles of the

mandible; the other holds the mask and ventilates.

Alternatively, one person may lift and hold the mandible

with both hands, while at the same time holding down

the mask on both sides. The other person ventilates the

patient.

♦ If air movement is still not present, obtain a definitive

airway.

ο Unsuccessful and aggressive attempts at ventilation may

result in inflation of the stomach, placing the patient at

increased risk for vomiting and aspiration.

Positive pressure ventilation can convert a simple

pneumothorax into a tension pneumothorax. Perform

frequent assessment and have equipment available for

needle chest decompression.

Orotracheal Intubation

Rapid Sequence Intubation (RSI)—7 steps.

1. Preoxygenate with 100% oxygen by mask.

2. Consider fentanyl—titrate to maintain adequate blood

pressure and effect (2.0–2.5 μg/kg).

3. Cricoid Pressure—Sellick maneuver until endotracheal tube

(ETT) placement is confirmed and balloon is inflated.

4. Induction Agent: etomidate 0.1–0.4 mg/kg IV push.

5. Muscle Relaxant: succinylcholine 1.0–1.5 mg/kg IV push.

6. Laryngoscopy and orotracheal intubation.

7. Verify tube placement.

 Direct laryngoscopy technique.

ο Ensure optimal “sniffing” position is achieved unless

contraindicated by cervical spine injury.

ο Open the mouth by scissoring the right thumb and

middle finger.

ο Hold the laryngoscope in the left hand and insert the

blade along the right side of the mouth, slightly

displacing the tongue to the left.

♦ Macintosh (curved) blade: Advance the tip of the blade
5.4

Emergency War Surgery

into the space between the base of the tongue and the

epiglottis (valecula). Apply force at a 30°–45° angle,

lifting the entire laryngoscope/blade, without rocking

it backward (Fig. 5-2).

♦ Miller(straight) blade: Advance the tip of the blade into

the posterior oropharynx, picking up the epiglottis and

tongue base anteriorly and laterally, and apply a force

vector like that of the Macintosh blade. Avoid rocking

the laryngoscope backward (Fig. 5-3).

ο Visualize the vocal cords.

ο Consider the “BURP” maneuver when the laryngoscopic

view is poor (Fig. 5-4).

♦ “Backward-Upward-Rightward-Pressure” of the larynx,

also referred to as external laryngeal manipulation.

♦ Place the fingers of an assistant onto the larynx with

your right hand and manipulate the glottic opening into

the field of view.

♦ Assistant then holds the position for intubation.

Eschmann stylet or Gum Elastic Bougie (GEB) (Fig. 5-5).

♦ Blindly guide the tip of the stylet beneath the epiglottis,

then anteriorly through the vocal cords.

♦ Advance the bougie deeply. Placement into the trachea

results in the sensation of tracheal ring “clicks”, and

turning of the stylet as it passes airway bifurcations.

Fig. 5-3. Use of straight blade

laryngoscope.

Fig. 5-2. Use of curved blade

laryngoscope.
5.5

Airway/Breathing

♦ The patient may cough as the stylet passes through the

airway.

♦ When passed beyond the trachea, the stylet will stop at

a terminal bronchus. If placed into the esophagus, it will

pass indefinitely into the stomach without any tactile

feedback.

♦ The ETT is guided over the stylet into the airway, and

tracheal intubation is confirmed.

o Advance the ETT between the vocal cords, withdraw

stylet, and advance the ETT to 20–21 cm at the teeth for

adult females, 22–23 cm for adult males. Deeper

placement may result in right mainstem intubation.

o Confirm placement of the ETT in the trachea.

o Auscultate over the axilla to ensure breath sounds are

equal.

Avoid making more than 3 attempts at direct laryngoscopy.

Excessive attempts may result in airway trauma and

swelling, potentially turning a “cannot intubate” urgency

into a “cannot intubate-cannot ventilate”emergency.

Difficult Airway

After three unsuccessful attempts at direct laryngoscopy,

abandon the technique and try alternatives.

 Alternative intubation techniques.

ο Tactile intubation.

♦ Requires no instruments.

Force Vector

Fig. 5-4. BURP maneuver. Fig. 5-5. Eschmann stylet in place.
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Emergency War Surgery

♦ No light use—good in light control situations.

♦ Slide hand closest to patient over tongue to hold it down.

♦ Lift epiglottis with first two fingers.

♦ Slide ETT along the “v” between the two fingers into

the airway.

ο Lighted stylet or “light wand” intubation.

♦ Flexible wand, lighted at the tip, is placed through the

ETT.

♦ Wand is advanced by tactile guidance into the

trachea.

♦ Position in trachea is verified by transillumination.

♦ The ETT is advanced over the wand.

ο Flexible fiberoptic oral or nasal intubation.

ο Retrograde wire intubation.

ο Rigid fiberoptic intubation (Bullard laryngoscope).

ο Alternative Airways.

♦ May NOT be definitive airways.

♦ Allow for oxygenation and ventilation when standard

airways cannot be placed.

♦ “Fastrach” model laryngeal mask airway (LMA).

♦ Esophageal-tracheal combitube (ETC).

 Perform a surgical airway.

 Wake the patient up and attempt an awake technique if

possible.

Surgical Cricothyrotomy

 Identify cricothyroid membrane (between cricoid ring and

thyroid cartilage [Fig. 5-6a]).

 Prep skin widely.

 Grasp and hold trachea until airway is completely in place.

 Make a vertical SKIN incision down to the cricothyroid

membrane (a No. 10 or 11 blade).

 Bluntly dissect the tissues to expose the membrane.

 Make a horizontal MEMBRANE incision (Fig. 5-6b).

 Open the membrane with forceps or the scalpel handle.

 Insert a small, cuffed ETT, 6.0–7.0 inner diameter (ID), to just

above the balloon (Fig. 5-6c).

 Confirm tracheal intubation.
5.7

Airway/Breathing

 Suture the ETT in place, and secure it with ties that pass

around the neck.

Laryngeal Mask Airway

Do NOT use in penetrating upper airway trauma or central

airway obstruction (foreign body).

 Insert blindly without a laryngoscope. LMA rests over the

laryngeal inlet (Fig. 5-7).

a b

c

Fig. 5-6 a,b,c. Steps of surgical cricothyrotomy.

a b c

Hyoid Bone

Thyroid Cartilage

Thyroid gland

Cricoid cartilage

Trachea

Cricothyroid

Membrane

Fig. 5-7 a,b,c. Fastrach laryngeal mask airway placement.

Illustration courtesy of LMA North America, Inc.
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Emergency War Surgery

 May be used alone or as a conduit to advance an ETT.

 Compared to an ETT, the LMA supports less airway

pressures, and offers less aspiration protection.

 Check LMA cuff, then deflate it until the down side (inner)

surface is smooth and flat; lubricate the pharyngeal (upper)

side of LMA.

 The sniffing position works best, but LMA may be inserted

in different patient positions.

ο Insert LMA (3–4 for women, 4–5 for men) with upper

(pharyngeal) side gliding along the hard palate, down

and around into the posterior pharynx—this allows

proper direction and reduces the chance of cuff folding.

ο Do NOT push the LMA directly back into the mouth—

this folds the cuff and prohibits proper placement.

ο Inflate cuff with 20–30 cc of air via syringe—slight

upward movement of LMA tubing is seen.

ο Secure the LMA.

Blind nasal-tracheal intubation

Contraindications: Coagulopathy, midface trauma, basilar

skull fracture, and suspected elevated intracranial pressure.

 Nasal-trachael intubation is better tolerated than orotracheal

techniques and requires less sedation and no paralysis.

 Prepare the nasopharynx and larynx (as conditions allow).

ο Spray vasoconstrictor into the nostril that appears largest

and most patent.

ο Insert a nasal trumpet soaked in lidocaine gel and leave

in place for a brief period.

ο Apply Cetacaine spray to oropharynx.

ο Administer a transtracheal injection of 4 cc lidocaine via

cricothyroid membrane.

 Insert an ETT (~ 7.0 ID for adults) slowly into the nostril,

perpendicular to the face.

 Advance the ETT slowly past the nasal turbinates and around

the curve of the posterior nasopharynx.

 Do not use excessive force!
5.9

Airway/Breathing

 The ETT is advanced as breath sounds of increasing volume

are heard at the distal end of the tube.

 The ETT is advanced beyond the vocal cords into the trachea.

If the tube fails to advance into the trachea, several maneuvers

can be employed.

ο Tilt the head.

ο Apply external, downward pressure to the larynx.

ο Inflate the ETT balloon to help center the tube, then deflate

and advance it once it is engaged in the glottic opening.
5.10

Emergency War Surgery