Equipment for managing the airway

Contents of the airway drawer will vary; indeed, some systems may not identify this section of their trolley or bag as 'airway'. Often the airway and breathing are considered to be the same thing and equipment such as a pocket mask may be found in the airway drawer as opposed to the breathing drawer. Figure 3.1 is an example of how the 'airway drawer' may be set out. With this particular type of trolley system, each drawer can actually be removed from the trolley, so the airway drawer, for example, may be passed up to the head of the patient to allow the healthcare professional managing the airway easier access to the equipment they are likely to require. The drawers also have a plastic lid type cover to them (not shown), which works well in preventing the accumulation of dust on the equipment.

Oropharyngeal airways

• This is often referred to as a Guedel airway™ (see Figure 3.1, item 1).

• It is a plastic, curved tube, with a reinforced section and flange at the oral end. The reinforced section is a bite block and is designed to sit between the teeth. The remainder of the tube fits between the tongue and posterior pharyngeal wall.

• The oral airway can only be used in patients who are unconscious or sedated with no gag reflex. It will cause gagging or straining in a patient whose reflex responses are intact. Such a patient may be a suitable candidate for a nasopharyngeal airway.

• The oropharyngeal airway comes in a range of sizes to fit newborns up to large adults.

• For guidelines on sizing and insertion, see Chapter 7.

Nasopharyngeal airways

• Designed to help maintain a patent airway. They are indicated in the patient who is not deeply unconscious and therefore unable to tolerate an oropharyngeal airway, yet needs a simple adjunct to help maintain airway patency.

• Nasopharyngeal airways are soft, flexible plastic tubes with an angular end and a trumpet-shaped end.

• They may be particularly useful in patients with maxillo-facial injuries or in situations where it is impossible to open the patient's mouth (clenched or wired jaws, trismus).

• This device is best avoided in a patient with a base-of-skull fracture for fear of intracranial insertion.

• For guidelines on sizing and insertion, see Chapter 7.

Laryngeal mask airway (LMA)

The LMA is an adjunctive airway composed of a wide-bore tube with an elliptical inflatable cuff that, when inflated, provides a seal around the laryngeal opening (see Figure 3.1, item 3). The LMA is an extremely reliable device that can be used during a resuscitation attempt by nurses and other paramedical staff who may not be skilled in endotracheal intubation (Anonymous 1994). It is important, as with any piece of equipment, that the operator has undergone the necessary training and assessment procedures as outlined by their place of work.

For guidelines on sizing and insertion, see Chapter 7.

Endotracheal tube (ETT)

• Designed to offer full protection in securing the patient's airway. Considered to be the 'gold standard' in maintaining an airway.

• The cuffed tube is inserted directly into the trachea under clear and direct vision using a laryngoscope.

• Prior to inflation of the cuff, the operator checks for correct tube placement by auscultation of the lungs with a stethoscope.

• The ETT may be attached directly to a ventilation device such as a bag-valve system with or without oxygen attached.

• A fine-bore suction catheter may be inserted through the ETT to remove secretions, etc. from the lower airways.

• The ETT is an alternative route for drug delivery in the event of intravenous access (IV) access not being achieved.

McGill forceps

• Forceps with long angled levers designed to assist in removing objects or foreign bodies from the patient's airway, for example a dislodged denture plate.

• They may also be used in assisting intubation.

Catheter mount with swivel connector

• Designed to fit between the end connection port of an ETT, LMA or Combitube (see Chapter 7) and the bag-valve ventilation system.

• The catheter mount gives an extra bit of leeway between the bag and any tube, generally resulting in less possibility of dislodging a tube.

• An added bonus is that a port on top of the catheter mount will allow the passage of a soft suction catheter down through the tube to remove any secretions. This can be performed without having to disconnect the bag from the tube on each occasion, hence reducing the risk of dislodging the tube.

Introducers

• Two types of introducers are shown in Figure 3.1, item 7. There is a rigid introducer (or stylet) and a gum elastic flexible introducer, known as a bougie.

• During intubation the rigid introducer may be used inside an ETT to alter the natural curvature of the tube dependent on the patient's airway anatomy.

• The bougie can also aid in difficult intubation but this tends to be inserted into the airway first and the ETT would then be slipped over the bougie and into the correct place using the bougie as a guide.

Laryngoscope

• The laryngoscope (see Figure 3.1, item 8) is a device generally used for intubation and to give direct clear vision of a patient's oropharynx. It may have other uses, such as providing a light source during the removal of foreign material.

• During daily or weekly checking of the trolley, the blade of the laryngoscope should be pulled up to a 90° angle and locked in place to assess the brightness of the light source and battery function.

• Different sized blades are recommended although for most adult patients a size 3 Macintosh blade will suffice.

• It is a good idea to have a second laryngoscope on the trolley in the event of failure of the first.

• Spare batteries and bulbs (if it is not of a fibreoptic type) should always be available on the trolley.

Miscellaneous

There are other things which will be necessary in airway management, such as:

• lubricating jelly - to assist in nasopharyngeal, LMA or ETT insertion;

• tape or ribbon gauze - to tie in or secure an airway device such as an LMA or ETT;

• syringe - airway devices such as the ETT and LMA will require inflation with air. An LMA, dependent on size, may require up to 40 ml of air to be inserted.

More information on the use of airway equipment may be found in Chapter 7.

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