Keeping airway open and assisting breathing

   

  • Emergency life-saving procedures to keep person’s airway open when unable to maintain it themself (eg unconscious or semiconscious)
  • For newborn — see Newborn resuscitation

Open, clear and maintain airway

What you need

  • Suction equipment
  • Oropharyngeal airway
  • Nasopharyngeal airway
  • Oxygen equipment with non-rebreather or ordinary face mask

Open airway

  • Do not delay log roll if vomit or debris in mouth — log roll and clear mouth immediately — if proficient use HAINES roll 
    • In an unconscious person — clearing blocked airway takes priority over protecting spine
  • For unresponsive adult or child — open the airway using the head tilt-chin lift — chin lift preferred in trauma, head tilt may damage spinal cord
  • For an infant, open airway — placing head in neutral position and lift jaw (jaw thrust) 

Head tilt/Chin lift

  • Place one hand on the forehead. The other hand is used to provide Chin Lift. The head (not the neck) is tilted backwards. Grip chin and gently lift it up — Figure 3.14

Figure 3.14  

Jaw thrust

  • Hold jaw at point under both ears, push upward and forward until chin juts out and airway opens — Figure 3.15

Figure 3.15  

Infant in neutral position

  • Head may be tilted backwards very slightly with a gentle movement — Figure 3.16

Figure 3.16  

Clear airway

Passive

  • If breathing normally and no risk of spinal injury — put unconscious person in recovery position to help protect airway — Figure 3.17. Rest person's head on extended arm to help neck alignment

Finger sweep

If unconscious person vomits or debris in the mouth

  • First roll onto side

Figure 3.17  
  • Use something tough (eg bite block) between molars if available
  • Only do finger sweep if
    • Person unconscious
    • Suction or long-nose or angled forceps not available
    • Debris obvious and close to opening of mouth — do not finger sweep if debris not visible
  • With gloves on, use 2 fingers to gently clear person’s mouth of dirt, vomit, broken teeth, loose dentures (leave well fitting ones in place)
  • Be careful not to push anything further back and block airway

Suction

  • Do not touch back of throat — this can make person vomit
  • If you have suction equipment — put Yankauer sucker at side of person’s mouth. Suck out any fluid — be careful not to damage teeth, tongue, back of throat

Keep airway open

Attention

  • Do not use nasopharyngeal airway if
    • Broken nose or cheekbones
    • Bruising behind ears, blood and/or clear fluid coming from ears or nose, any signs of skull fracture — consider how person was injured
  • Choose type of airway to use
    • Oropharyngeal airway — only used for unconscious person
    • Nasopharyngeal airway — better for semiconscious person

What you do
Oropharyngeal airway

Choose right sized airway. Should reach from front teeth to angle of jaw — Figure 3.18, or corner of mouth to earlobe

Figure 3.18  

Figure 3.19  
  • For adults
    • Open mouth and gently push airway in upside down with tip pointing up
    • Push airway back along roof of mouth, turn it over to slip the rest of the way over tongue — Figure 3.19
  • For small child (under 8 years)
    • Use wooden spatula to push tongue down, gently push airway straight in
Nasopharyngeal airway
  • Choose right sized airway. Measure from tip of nostril to angle of jaw (or front of ear lobe) — Figure 3.20
  • Approximate sizes
    • Average height woman/short man — size 6
    • Average height man/tall woman — size 7
    • Tall person  — size 8

Figure 3.20  

Inserting airway

  • If needed put safety pin through flange (or tie piece of long, thin string or tape under flange) to stop airway falling back into nose once in place
  • Lubricate airway — can use persons saliva
  • Gently push tip of airway straight back into biggest nostril
  • Push along base of nose and into back of throat until flange and safety pin rest against nostril — Figure 3.21. Don’t push upward
    • If resistance — take out and try other nostril

Figure 3.21  

Assisting breathing

Sniffing position — Figure 3.22

  • Extends head and flexes neck
  • Take care if cervical spine could be damaged
  • Cushion from shoulder to occiput (back of head)
  • Ear canal level with sternal notch
  • Support the head by chin lift or put finger against the chin

Figure 3.22  Ear canal in line with sternal notch

Giving oxygen

Attention

  • If in shock give high flow oxygen — 15L/min non-rebreather mask
  • In other cases only give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD 88–92%
  • Take care not to give too much oxygen — may cause harm

Mask

  • Use mask for oxygen delivery for all trauma and severely ill people
  • Choose right sized mask for person’s face. Person will get less oxygen if mask doesn’t fit well
  • Non-rebreather mask with reservoir bag
    • Keep adult and paediatric non-rebreather masks in emergency pack
    • Give oxygen at 15L/min adult, 10–15L/min child, 10L/min infant. Mask won’t work properly if rate lower
    • Reservoir bag must be filled before you put mask on face
  • Oxygen mask — simple face mask, Hudson mask
    • Give oxygen at 5–10L/min

Remember: Non-rebreather masks need higher flow rates — consider how much oxygen you have, how many people need it, how long it will last

Bag-valve-mask — manual ventilation

Attention

If not used properly bag-valve-mask will not give enough oxygen. If you are not confident about using this equipment — do mouth-to-mask or mouth-to-nose resuscitation at 15 breaths/min

  • Bags come in 3 sizes — adult, child, preterm. Clinics need all 3
  • Mask must
    • Fit firmly around nose, chin, sides
    • Not leak when bag squeezed
  • Best with 2 operators — second person can get a better fit/seal with mask
  • Reservoir bag will only inflate (fill up) with high-flow oxygen. Fill reservoir bag first
    • Give oxygen at 12–15L/min for adult, 8L/min for child, 3L/min for infant

What you need

  • Helper
  • Oropharyngeal or nasopharyngeal airway in place
  • Oxygen equipment with tubing connected
  • Suction equipment with rigid nozzle (eg Yankauer sucker)
  • Correct size mask and bag

What you do

  • Clear and open airway
  • If person unconscious — put in oropharyngeal or nasopharyngeal airway 
  • Select correct sized mask — Adult 4 or 5, child 3, infant 00 or 0/1 or 2

1 operator

  • If using oxygen — connect tubing to bag and turn on oxygen at 15L/min adult, 8L/min child, 3L/min infant
  • Stand/sit/kneel at top of person’s head
  • Put head in sniffing position to open airway
  • Hold bag in dominant (main) hand. Put mask over face with other hand
  • Keep index finger and thumb on mask. Hold under jaw with last 3 fingers — Figure 3.23

Figure 3.23  
  • Try to keep seal all around mask
  • Squeeze bag — watch to make sure person’s chest rises with each squeeze. If any problem — check airway, head position, equipment
  • Ventilate at 15 breaths/min. Count slowly to get this right (eg 1 — and 2 — and 3 — etc)
    • Don’t go too fast, don't overfill lungs

2 operators

  • As above, except 1 person uses both hands to hold mask on and keep airway open, and other squeezes bag — Figure 3.24

Figure 3.24  

If further assistance needed AND person unconscious — see Advanced airway management