OP Airway

[stewmac91]

Hi guys, hoping someone could answer what should be a pretty straightforward question, although it's one I can't seem to find the answer to !

I'm giving a short presentation on the use and insertion of OP airways. I was always taught that when sizing them you measure from the angle of the jaw to the corner of the mouth, but someone has told me this in now from the angle of the jaw to the centre of the teeth. This is to allow for the possibility of facial weakness from CVA ?

Not exactly trauma I know, but I don't want to look silly.

Thanks in advance,

Stew

[Paul999]

Hi Stew,

I'd agree, with the airway curved upwards, flange at midline of upper lip/ teeth and tip of airway at angle of jaw. After all thats more like the actual distance that it will be required to fit into.

Interestingly enough I attended a critical care/trauma forum recently and one of the guys talking suggested that, if we are appropriately trained in the use of a laryngoscope we should be using it to visually inspect the airway as we insert the airway.


When you think about it, it makes a lot of sense. After all we can only see a small portion of the airway without laryngoscopy, and could you swear in a coronors court that the lower oropharynx/upper laryngopharynx was definitely clear prior to airway insertion if you couldn't see exactly where you were looking to place it?

One counter argument, and probably the biggest, to laryngoscopy for OP airway insertion is the possibilty of vagal stimulation resulting in bradycardia. However when you think about it, if using a tongue depressor, it could be over inserted and have the same effect as indeed could an incorrectly oversized OP Airway. With the correct tools and the correct training it shouldn't occur.

Cheers,
Paul.

[DeploymentMedicineIntl.]

Stew, the two methods of sizing an OPA are to measure from soft structure to soft structure (tragus of ear to corner of mouth) or hard structure to hard structure (angle of jaw to centre of front teeth) either one is fine. Using any form of light whilst inspecting the airway is always preferable, it doesn't have to be a laryngoscope though, a pen torch will do.

Hope this helps,


John
DMI (UK)

[stewmac91]

Thanks guys, you've cleared that up for me.

Paul, that's an iteresting point you make about using the laryngoscope prior to insertion of any airway, although in this case the presentation is aimed towards community first responders, so maybe not .

Cheers guys, Stew

[Paul999]

Hi John,

Over the years I've used both of those sizing methods, so I consider them both perfectly valid, but my employer (South Western Ambulance Services NHS Trust) deems that the teeth to jaw method is best practice, and I think I'm inclined to agree as these are structures that are fixed and not going to move.

Just playing devils advocate a bit here, but how do you get to view beyond a big fat flacid tongue, when the patient is unconscious and possibly on there back? Over the years I've used tongue depressors and a pen torch, but I couldn't swear to getting the best view. Also, by using the laryngoscope you gain a well lit view of the patient's air way, and keep the other hand free to place the OP whilst maintaing the view.

I have never liked the method of inserting the airway with the tip pointing up at the palate, advancing and then being rotated through 180. I appreciate the thinking behind this was to reduce the risk that you push the tongue further back onto the airway with the tip of the OP but I think there is real scope for lacerating the palate, maybe a little or maybe more, but then you have possible bleeding into the airway to contend with.

The laryngoscope method allows you to insert the OP with the curve as it would sit at end of placement, almost as if you were tubing a patient, therefore avoiding the tongue and going nowhere near the palate.

All of my airway maintenance kit is in one pouch, so laryngoscope is right next to ET tubes, OP and NP airways etc, and takes zero extra time to get together. No delay in begining to provide some protection to the patients air way.

Not looking for an arguement in anyway, just thought I'd share my opinion, based on the recent information I've recieved. Healthy debate and exchange of views can ultimately only lead to a better experience for all of our patients.

Regards,
Paul.

[DeploymentMedicineIntl.]

I think those are all good points Paul, the more visibility and control you have over airway structures, the greater your chances of a successful intervention will be.


All the best lads,


John
DMI (UK)

[M4MED]

The ever changing world of med protocols. We love it! But, it's the only way to improve things and find out what really works.
As far as trauma goes, I have always gone with your original thought and measured from tip of ear to corner of the mouth (or from structure to structure). I know this is taught widely and used on the ground, although I always favour a NPA, especially when there are multiple casualties.
The thought being, if the casualtys' level of consciousness improves while you are tending to another casualty; a casualty with an OPA may gag, vomit and obstruct their airway, where as the NPA doesn't affect the gag reflex. One less thing to worry about (unless they have a head injury!)

I'd keep it simple and stick with your original thought. But as ever, I'm open to new ideas.

I like the idea of revising the airway with a laryngoscope and agree it will take little extra time but for basic first aiders, they won't have the training and for more advanced, why not intubate? It is an excellent happy medium for those trained in it's correct use.

Taking the airway management a step further but short of intubation, what do you think of LMAs?

Thanks everyone. Keep the ideas and info flowing

[Paul999]

I agree with the keeping it simple, and I would also choose an NP over an OP if possible.

With regards to LMA, I'm not a massive fan I have to say. Although fairly straight forward to use I don't personally think they can touch ET intubation for airway protection. LMA's are great for patients who are anaesthatised and undergoing pre planned surgery. In this situation the patient is starved, therefore massively reducing the risk of a patient vomiting.

I have used LMA's, with varying success, when I was a technician and unqualified to carry out ET intubation. I can recall a couple of occasions where I have attended patients and had a seriously labour intensive job to manage their airways.

One was a large guy in cardiac arrest, I placed an LMA and during CPR he vomited and I noticed we had some smallish bubbles blowing through the vomit. On investigation I found this to be air blowing back out of the lungs past the LMA when the venilator was inflating his lungs. I suctioned as much out as I could and after getting to hospital and the docs calling it, we removed the LMA and there was vomit on the "lung side" suggesting the LMA seal had leaked some in. I couldn't say ow much or even if he had aspirated any.

The other was a multi system trauma patient that arrested during a difficult and physical extrication. There was some significant facial trauma and plenty of bleeding into the mouth. I'm fairly sure we had a smilar situation as above but with blood instead of vomit. This was further compounded by by the fact that we were jiggling him about a fair bit as slow time and perfectly smooth took a back seat once they arrested.

I think they have their place in theatres but not really suitable for pre-hospital care. An LMA does not fully protect against aspiration in the non-fasted patient and doesn't allow high positive pressure ventilation for patients who have arrested due to asthma or LVF with heavy congestion.

For me ET intubation will always be the gold standard.

Whats others experience and take on airway management?

Cheers Paul.

[hope2421]

Mine is a short and simple answer to the above.

LMAs are good in hospital ie pre planned surgery but in the pre hospital setting i dont like them because of vomit probelms and find that no matter how well you try to secure it they will move, then dislodge when moving them pt.

ET intubation is the Gold standard imo.

[cpmedic]

Piss heads, GCS 15/15, then LMA PR is advisable. Inflate before insertion.

OPA side ways in, laterally, prior to digital placement of ET Tube is advisable also, as my old instructor Three Fingered Bob taught us, post a reflex bite down................