ACLS Provider: Course

Advanced Airway Techniques

When basic airway maneuvers such as the head-tilt/chin-lift or jaw-thrust are insufficient to maintain a patent airway, or in cases of prolonged resuscitation efforts, advanced airway techniques become essential. These techniques provide more effective ventilation and oxygenation, securing the airway and minimizing the risk of aspiration (inhalation of stomach contents into the lungs). Proficiency in these techniques is crucial for advanced life support providers.

Common Advanced Airway Devices:

Nasopharyngeal Airway (NPA)

The NPA is a flexible tube inserted through the nostril into the posterior pharynx. It helps maintain an open airway by separating the tongue from the posterior pharyngeal wall. NPAs are generally well-tolerated in semi-conscious or even conscious patients with an intact gag reflex, making them a useful option when an OPA is contraindicated (e.g., due to oral trauma). However, they should be used with caution in patients with suspected facial fractures or basilar skull fractures. Proper sizing is crucial to avoid complications such as epistaxis (nosebleeds).

Oropharyngeal Airway (OPA)

The OPA is a rigid, curved plastic device inserted into the mouth over the tongue. It prevents the tongue from obstructing the airway by holding it forward. OPAs are only appropriate for unconscious patients without a gag reflex, as insertion in a conscious or semi-conscious patient will likely induce vomiting and aspiration. Correct sizing is essential; an OPA that is too large can push the tongue back and worsen the obstruction, while one that is too small will be ineffective.

Laryngeal Mask Airway (LMA)

The LMA is a supraglottic airway device, meaning it sits above the glottis (the opening to the trachea). It consists of an inflatable cuff that seals around the laryngeal inlet, allowing for effective ventilation. LMAs are easier to insert than endotracheal tubes and can be placed by trained personnel even without advanced intubation skills. They provide a good seal for ventilation and can be used as a temporary airway until more definitive airway management (such as endotracheal intubation) can be performed. However, they do not provide the same level of airway protection against aspiration as an endotracheal tube.

Endotracheal Intubation (ETI)

Endotracheal intubation involves inserting a tube directly into the trachea through the mouth or nose. This is considered the “gold standard” for airway management, providing a definitive airway that protects against aspiration, allows for positive pressure ventilation, and facilitates suctioning of secretions. However, ETI is a complex skill that requires extensive training and experience. Successful intubation requires visualization of the vocal cords using a laryngoscope. Complications can include esophageal intubation, right mainstem bronchus intubation, and trauma to the airway.

Key Considerations for Advanced Airway Management:

Device Selection

Choosing the appropriate device depends on several factors, including the patient’s level of consciousness, the presence of a gag reflex, the suspected cause of the airway compromise, the availability of equipment, and the provider’s skill level.

Proper Placement and Confirmation

After insertion of any advanced airway device, proper placement must be confirmed. This involves:

• Visualizing chest rise with ventilation.
• Auscultating (listening) for bilateral breath sounds over the lungs.
• Confirming the absence of gurgling sounds over the epigastrium (upper central abdomen), which could indicate esophageal intubation.
• Using a capnograph (a device that measures the amount of carbon dioxide in exhaled breath) — the most reliable method to confirm tracheal intubation.

Securing the Airway Device

Once proper placement is confirmed, the airway device must be securely fixed to prevent dislodgement. This is typically done using tape, commercial securing devices, or ties. Regular reassessment of the airway and securing device is essential.