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CG03 | VERSION 1.1 1/12

© South Western Ambulance Service NHS Foundation Trust 2014

1. Scope1.1 This guideline details the range of interventions available to each staff grade, to

enable effective airway management.

2. Background and Definitions2.1 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 The airway interventions authorised for use by each grade of ambulance clinician are detailed in Table 1.

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

Ambulance Care Assistant Paramedic (non-ECP) Emergency Care Assistant Nurse (non-ECP) Student Paramedic ECP Advanced Technician Doctor

Clinical Publication Category

Guidance (Green) - Deviation permissible; Apply clinical judgement



CG03 | VERSION 1.1 2/12


2.4 Table 1 - Use of Airway Interventions by Each Clinical Grade

Key:

1. Student Paramedic Level 1 skill set - Supraglottic airway, intubation and needle cricothyroidotomy skills are authorised at agreed points during the course.

Res

po

nd

er

AC

A

ECA

/Stu

den

t

Para

med

ic1

Ad

van

ced

Te

chn

icia

n

Para

med

ic

Nu

rse

Do

cto

r

Head Tilt - Chin Lift 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 3 3 3 3

Intubation 7 7 7 7 3Enhanced Skill 3

Rapid Sequence Induction (RSI) 7 7 7 7

Only Under Medical Supervision


Enhanced Skill

Cricothyroidotomy - Needle 7 7 7 7 3

Enhanced Skill 3

Cricothyroidotomy - Surgical 7 7 7 7

Enhanced Skill

Enhanced Skill

Enhanced Skill

3 Core skill

7 Skill not authorised

Enhanced SkillSkill may be practiced once competency has been demonstrated and the skill authorised by the Executive Medical Director under the Enhanced Skills Policy.


Skill may only be practiced as part of a team consisting of at least one Doctor who is competent and confident in the procedure.



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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

Exit algorithm

Head tilt, chin liftOR

Jaw thrust (if c-spine injury is suspected)Can airway be maintained?

Insert oropharyngeal airwayor

nasal pharyngeal (consider insertion in both nares)Can airway be maintained?

Insert SGA (LMA Igel) - 2 attemptsCan airway be maintained?

Intubate - (First attempt)Can airway be maintained?

Intubate - (Second / third attempt)Reconsider position, neck fl exion/head extension,laryngoscope techique and vector, bougie, BURP

Can airway be maintained?

Needle cricothyroidotomyOR

Surgical cricothyroidotomy(If clinician qualifi ed to conduct the intervention present)

Can airway be maintained?

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.

Can patient maintain AND protect their own airway?

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO



CG03 | VERSION 1.1 4/12


3.3 Suction3.3.1 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.

3.4 Ventilation3.4.1 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.



CG03 | VERSION 1.1 5/12


3.6 Intubation Verification Procedure3.6.1 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 Situations4.1 Trismus4.1.1 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.



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4.2 Paediatric Nasopharyngeal Airways4.2.1 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 Injuries4.3.1 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.



CG03 | VERSION 1.1 7/12


4.4 Tracheostomy4.4.1 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

TracheostomyLaryngectomy

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).



CG03 | VERSION 1.1 8/12


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.



CG03 | VERSION 1.1 9/12


4.4.8 Figure 2 - Tracheostomy Emergency Guidance:

Is the patient breathing?

Assess tracheostomy patency

Deflate cuff if present.Look, listen and feel at

mouth and tracheostomy

CPR if pulselessProceed to ventilation

Continue ABCDE assessment

TRACHEOSTOMY TUBE PARTIALLY OBSTRUCTED

OR DISPLACED.Reassess, ATMIST to ED

Remove the tracheostomy tube.Look, listen and feel at the mouth

and tracheostomy.

TRACHEOSTOMY TUBE IS PATENTPerform suctionReassessVentilate as outlined below if not breathingCPR if pulseless, follow ALS guidance

Remove speaking valve or cap if present.

Remove inner tube

Can you pass a suction catheter?

Is patient stabilising or improving?


PRIMARY EMERGENCY OXYGENATION ❙ Cover the stoma ❙ Consider oral/nasal airway ❙ Use BVM ❙ Supraglottic airway if required ❙ High fl ow O2

TRACHEOSTOMY STOMA VENTILATION ❙ If adequate infl ations not gained use BVM with paediatric size mask applied over stoma

SECONDARY EMERGENCY OXYGENATIONAttempt ORAL intubation

Uncut tube, advance beyond stomaIf unsuccessful attempt intubation of

Stoma with 6.0 Cuffed ETTConstantly reassess, continue as per

airway and cardiac arrest clinical guideline

Ventilate. Begin CPR if pulseless

Apply high flow oxygen to face whilst assessing tube patency

No

No

No

No

Yes

Yes

Yes

Yes



CG03 | VERSION 1.1 10/12


4.5 Laryngectomy4.5.1 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.



CG03 | VERSION 1.1 11/12


Figure 3 - Laryngectomy Emergency Guidance:

Is the patient breathing?Look, listen & feel at the stoma site

Assess laryngectomy stoma patency.Most laryngectomy patients will not have

a tube in situ

Deflate cuff if present.Look, listen and feel at

stoma site

CPR if pulselessProceed to ventilation

Continue ABCDE assessment

Reassess ABCDE

Remove the laryngectomy tube if presentLook, listen and feel at the mouth and

laryngectomy.

LARYNGECTOMY PATIENTS HAVE AN END STOMA AND CANNOT BE OXYGENATED VIA THE MOUTH OR NOSE

THE LARYNGECTOMY STOMA IS PATENTPerform suctionReassessVentilate as outlined below if not breathing.CPR if pulseless, follow ALS guidance

Remove stoma cover (if present)Remove inner tube (if present)

Can you pass a suction catheter?

Is patient stabilising or improving?


PRIMARY EMERGENCY OXYGENATION

LARYNGECTOMY STOMA VENTILATIONUse bag valve mask with paediatric size face mask applied over stoma, 100% 02

SECONDARY EMERGENCY OXYGENATIONAttempt intubation of stoma

with 6.0 Cuffed ETTConstantly reassess, continue as per airway and cardiac clinical guideline

Ventilate. Begin CPR if pulseless

Apply high flow oxygen to Stoma.

No

No

No

No

Yes

Yes

Yes

Yes



CG03 | VERSION 1.1 12/12


5. Episode Closure5.1 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 on-arrival.

6. Documentation6.1 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.

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