Maintaining an Airway

[KayceeLeeRN, BSN, RN]

:chair: Okay, I wish I didn't have to ask this question, but better to ask it here....annonymously, then made look like an idiot in person.......

How EXACTLY do I maintain an airway??? It has been drilled in my head all throughout nursing school and I can TELL you that it is always priority, especially in certain situations. BUT...HOW? I know suctioning is clearing the airway, but how else am I maintaining an airway?

...gosh I feel like such an idiot, be nice

(P.S. New grad starting March 5th...scared as hell, can you tell???)

[Bluehair]

Good for you for asking! Sometimes we think we are being so clear when we explain things and sometimes our explanations are clear as mud!

I will bet you are doing more than you know. When you walk into a patient's room you look at them and evaluate them right away - is their color good, are they breathing, moving, walking, talking, etc. If they are doing all that they chances are their airway is just fine. If they aren't breathing, why not? It's the ABC thing - Airway, Breathing, Circulation. You can't breathe if you don't have an airway.

Sometimes after patients receive pain meds/anesthesia/sedative of some sort, they snore - and snore so hard their tongue falls back in their throat and they aren't breathing. Remove pillow, tilt head, and voila, they breathe. You have just maintained their airway. If that didn't work you might have to do the ol' head tilt/chin thrust maneuver in combination with a little sternal rub. If that didn't work you proceed to a little action with an ambu bag (tho I am assuming an in-hospital situation here). No ambu? Well then you are on to mouth-to-mouth. In the PACU (& sometimes ER & ICU) they maintain the airway with an oral airway or nasopharyngeal airway to keep the tongue in check until the patient wakes up more. Sometimes it does mean suctioning to get a mucus plug out of the way.

Bottom line - make sure the passage ways to the lungs are as open as you can so the breathing can happen.

Not breathing is another question......

:roll

[Mel in MO]

There are no stupid questions. And if my airway were obstructed, I certainly would prefer that you had taken the time to ask . If not, you wouldn't be the only red face!

It is actually a very simple and complicated answer...

It depends on what the problem is with the airway.

Are they choking? Remove the object, do the Heimlich, get them to where they can get a trach or suction on them.

Have they just stopped breathing? Do rescue breathing, bag them, get them vented, whatever it takes.

Is it an asthma attack, or are they anaphylactic? Get them epinephrine, steroids, or their rescue inhaler (if they have enough air to take it in).

Bottom line is, no matter what it is, you have to keep the oxygen flowing to the brain before you move on to anything else. It sounds obvious, but when you have someone just 'falling apart' on you, you really do have to prioritize that specifically, and very quickly.

Good luck, and keep asking questions :) You may be my nurse some day, and I want you to know!

Smiles,

Mel

[chare]

Excellent question. Do not feel like an idiot for asking this. I remember my first EMT course. The instructor kept stressing the importance of maintaining and airway but it never seemed like he talked a lot about how to do it.

This might be as simple as positioning the patient in the optimal position to promote air exchange. If the patient is conscious, unless you need to insert an assistive device or assist ventilations, allow them to assume a position that will maximize their ventilatory effort. This will typically be sitting upright and probably leaning forward in what is referred to as the tripod position (they will lean forward and support themselves with an outstretched arm).

If they are unresponsive or unable to support themselves in a sitting position you will more than likely need to lay them supine to manage their airway.

If you need to support their airway, your first intervention should be a manual airway maneuver, of which there are 2 that I usually use: the head tilt - chin lift or the modified jaw thrust. Although most references recommend using the head tilt - chin lift in the absence of known/suspected trauma, I prefer to use the modified jaw thrust on all unresponsive patients.

Regardless of which maneuver you use, after you open the patient's mouth, look inside for and clear any foreign object that you find. The patient might require suction, manual removal of a foreign body, or even the application of sub-diaphragmatic abdominal thrusts to clear a foreign body obstruction.

At this time, if the patient is still unresponsive I will usually insert an airway adjunct - either an oropharyngeal airway if there is no gag reflex or a nasopharyngeal airway in the presence of an intact gag reflex. If I place a nasopharyngeal airway I usually place one in both nares as well.

I know that breathing comes after the airway, but while all you are taking care of the airway try and provide supplemental oxygen by blow by to support any spontaneous respiratory effort that the patient might have and be prepared to assist ventilations with a resuscitation bag after you have established an airway.

I have included a link to the 2002 Airway Supplement to the 1994 USDOT EMT-Basic Curriculum Module 2/Lesson 2-1-2:Airway. While this module was developed for EMT Basic instruction, it is important to remember that basic airway maneuvers are the same regardless of level of training/education or certification.

Good luck in your future career, and don't ever become afraid of asking questions.

[RunnerRN, BSN, RN]

Great replies above. I don't know if this is why you're asking, but I remember in nursing school how the instructors would also say (in reference to NCLEX questions) "alway maintain your airway" or "remember your ABCs." Basically, you have to have an A (airway) to do anything medically. It doesn't matter if the patient is bleeding out of a massive abd wound....if he doesn't have an airway, you have to establish one (with the maneuvers listed above) or all the IVFs, pressure, blood, etc isn't going to change a thing in the eventual outcome. When you are looking at NCLEX questions, ask yourself if they're asking about an ABC prioritization. There are so many questions that seem straightforward (ex: what is the first nursing action for a patient who has been vomiting for 6 days and has a BP of 80/60? Your gut says "get an IV in her and tank her up" but if one of the answers is "verify your airway is patent" then that is the answer.)

I don't know if this has helped you out at all. Good luck with boards and starting work!

[burn out]

Just remember that you are never alone in the hospital. If the pateint isn't breathing when you enter the room call a code and start cpr. If the patient is in distress call Respiratory Therapy stat and they will help you with maintaining the airway while you call the doctor, get other orders and can get abgs or give treatments. Always though when you are doing assessments always be familiar as to where the flowmeters are kept, where is the cannulas and ventimasks kept and portable oximeters even have them on hand if you think the patient may require them later.

[KayceeLeeRN, BSN, RN]

Thank you so much for your responses, I was so afraid I was going to hear that I was incompetent! I'm just really starting to think about these real life situations I will be in VERY soon. I'm often wondering if I am actaully capable of handling them :stone ....I actaully had a nightmare that my patient coded and I didn't know what to do!

Actually, after reading some of your responses I realized that I DO KNOW how to maintain an airway and I've done it many times! I think it's just the phrase, "MAINTAIN AIRWAY" that sounds so intimidating!

[KayceeLeeRN, BSN, RN]

Thank you Chare!!! GREAT info!