Airway management techniques
Simple as it seems, the ability to mask–ventilate a patient is the essential airway management technique that needs to be practised and learned by every health-care provider. Most important is the patient’s head position: Do not let the patient’s neck flex and thus potentially occlude the airway, which makes mask–ventilation difficult to impossible. Proper mask technique includes the following:
(i) Select an appropriate size mask to fit over the patient’s nose and mouth and provide an airtight seal without pressure on the eyes.
(ii) Place the head in sniffing position (occiput elevated, neck extended) or directly supine, with the neck neutral to slightly extended.
(iii) Positioning yourself at the patient’s head, apply the mask to the face with a pincer grip by thumb and index finger of the left hand. Place the third finger on the mentum and pull the chin upward. The fourth finger remains on the mandible so as not to compress the soft tissue, with the pinkie at the angle of the mandible where the jaw can be pushed forward to open the posterior pharynx (a painful maneuver in an awake patient!) (Fig. 2.2).
(iv) Then ventilate the patient’s lungs with a self-inflating bag, Mapleson or anesthesia machine circle system. Keep inflation pressures to the minimum required to ventilate the lungs, in an effort to prevent inflation of the stomach.
What to do when mask–ventilation proves to be difficult:
· Reposition. Make sure the mandible is being pulled anteriorly.
· Add a second person to try two-handed mask–ventilation. Use both hands to hold the mask and pull the jaw anteriorly. The other person compresses the breathing bag.
· Use an oral or nasal airway to establish a pathway past the pharyngeal tissue and tongue. This is not advisable in the awake patient (he would retch) nor under light anesthesia (he might develop a tight laryngospasm, which would make matters worse). A nasal trumpet can be inserted after lubrication with a local anesthetic jelly, even if the patient is awake.
· If the patient has a beard, try placing an occlusive dressing (with a hole for the mouth) over the beard, or apply Vaseline to the mask.
· The edentulous patient usually does better with his false teeth in place. If the patient is comatose, an oral airway may help, or stuff the cheeks with gauze to provide enough shape for the mask to seal properly. Just be sure to remove all material from the mouth when the patient is ready to resume spontaneous breathing – material left behind has been aspirated and has caused acute airway obstruction and death!
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