A BLS Guide To Airway Management
In the prehospital environment we have several BLS means by which we can maintain an airway, oxygenate, and ventilate our patients.
Airway management: In conscious patients, we usually do not have to do anything. These patients may be altered, but generally are able to maintain their own airway. However, the unconscious patient requires intervention in many cases. As a general rule, a patient who responds to painful stimuli, and does not present with sonorous respirations, can be managed with a head-tilt-chin-lift, or positioning in recovery. Patients with a GCS <8, or who are completely unresponsive are going to require head-tilt-chin-lift, a modified jaw thrust, or use of an adjunct. Patient's in cardiac arrest should ideally have a supraglottic airway inserted.
OPA: The oropharyngeal airway is the first adjunct to attempt in an unresponsive patient. It effectively lifts the tongue out of the way for proper air entry, and can be removed quickly if the patient regains consciousness.
NPA: The nasopharyngeal airway is useful in situations where the gag reflex is intact, or the patient is expected to recover rapidly, as in an opioid overdose. It is contraindicated in head trauma where there is evidence of basal skull fracture.
Supraglottic airway: LMA, Igel, King LT, etc. These airways sit above the glottis and hold the epiglottis over the esophagus. They are ideal in a BLS cardiac arrest. Placement needs to be confirmed with ETCO2, and auscultation.
Advanced airways include: ETT, NTT, and Tracheostomy. These are beyond the scope of the BLS provider.
Oxygen devices:
We have several oxygen delivery devices available in the field.
Nasal Cannula: The nasal cannula is best utilized in patient's with mild respiratory distress, who have an oxygen saturation that is above 90% (or 88% for COPD patients), and are still breathing within the 12-20/min rate.
NRB: These are out of vogue during covid, due to high output and poor seal. The NRB is intended for moderate to severe respiratory distress (low SPO2, and RR above 22).
High concentration, low flow masks: These are masks that seal and have a filter. They deliver high concentration oxygen at lower pressures than that of the NRB. They are intended for moderate to severe respiratory distress.
Bag-Valve-Mask:This device is intended for patients who require ventilatory assistance in addition to oxygen delivery. At 15LPM they deliver 100% oxygen. They are intended for moderate to severe respiratory distress, respiratory failure, and patients who are VSA.
CPAP: This device is designed to end expiratory pressure, splinting open collapsed airways. It also functions to increase the partial pressure of oxygen across the alveolar membrane. We use it in patients with obstructive lung disease, and pulmonary edema.
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