Lesson 3 – Advanced Airway Devices

Advanced Airway Devices Overview

Advanced airway devices are essential tools for managing difficult airways and improving ventilation efficacy in critical situations. While some of these devices may be beyond an EMT's scope of practice, understanding them is crucial. As an EMT, you may assist advanced providers or encounter patients with these devices already in place. This lesson covers oropharyngeal and nasopharyngeal airways, supraglottic devices, and provides an awareness-level understanding of endotracheal intubation and surgical airways.

Oropharyngeal Airway (OPA)

Oropharyngeal airways (OPAs) are J-shaped plastic devices designed to prevent the tongue from occluding the airway in unconscious patients. They are sized by measuring from the corner of the mouth to the angle of the jaw. OPAs should only be used in deeply unconscious patients without a gag reflex, as they can stimulate vomiting in more responsive patients. When properly placed, the flange rests on the lips, and the tip lies above the epiglottis, creating a channel for air passage.

Nasopharyngeal Airway (NPA)

Nasopharyngeal airways (NPAs) are soft rubber or plastic tubes inserted through the nose into the posterior pharynx. Unlike OPAs, they can be used in patients with an intact gag reflex and are often better tolerated. NPAs are sized by diameter and length, typically measured from the tip of the nose to the earlobe. They are particularly useful in patients with clenched teeth or oral injuries but are contraindicated in patients with suspected basilar skull fractures due to the risk of entering the cranial cavity.

Inserting an OPA

To insert an OPA, first ensure the patient has no gag reflex. Size the OPA from the corner of the mouth to the angle of the jaw. Insert it inverted (curved end towards the hard palate) until you reach the soft palate, then rotate it 180 degrees to slide it into position. Ensure the OPA does not push the tongue down to obstruct the back of the throat. Verify proper placement after insertion and continue ventilations as needed. Never force the device into position.

Inserting an NPA

For NPAs, lubricate the device before insertion. Insert it along the floor of the nostril, parallel to the nasal septum, not angled upward. If you meet resistance, try the other nostril. Never force the device. After insertion, verify proper placement and ensure it doesn’t obstruct the airway. If airway obstruction persists, reassess the device placement. Always use NPAs with caution, particularly in trauma patients.

Supraglottic Airway Devices

Supraglottic airway devices are advanced tools for airway management that sit above the voice box (glottis). These devices are typically easier to place than endotracheal tubes and provide a better seal than face masks. Two common types are the Laryngeal Mask Airway (LMA) and the King Airway. The LMA resembles a mask with a tube attached, while the King Airway looks more like a tube with a balloon. These devices help guide oxygen into the lungs while preventing it from entering the stomach. Although you won’t be placing these devices as an EMT, it’s important to recognize and assist in their use. These airways are more secure than bag-valve mask (BVM) ventilation. You can attach a BVM directly to the device for ventilation if it’s in place.

Endotracheal Intubation

Endotracheal intubation is considered the gold standard for securing the airway in critical patients. It involves passing a tube through the vocal cords directly into the trachea, providing the most secure airway. This procedure typically requires direct visualization of the vocal cords using a laryngoscope. While intubation is usually performed by advanced providers, as an EMT, you may be called upon to assist. You may be asked to help with equipment preparation and post-intubation ventilation. It’s important to understand the process, equipment, and protocols involved.

Confirming Advanced Airway Placement

Confirming proper placement of any advanced airway is essential. The primary confirmation methods include watching for chest rise, listening for breath sounds in both lung fields, and the absence of gastric sounds. Use end-tidal CO2 detection if available. Secondary confirmation signs include condensation in the tube and misting with exhalation. Continuous monitoring of airway placement is crucial, especially during patient movement. If displacement is suspected, immediately reassess and be prepared to remove the device and resume bag-valve-mask ventilation if necessary.

Cricothyrotomy

Cricothyrotomy is an emergency procedure used in "can’t-intubate, can’t-ventilate" scenarios to establish an airway by creating an opening through the cricothyroid membrane. There are two types: needle cricothyrotomy and surgical cricothyrotomy. While this procedure is typically performed by advanced providers, as an EMT, you should be aware of it. In extreme situations, you may be asked to assist with equipment preparation or to assist in the procedure. Always be familiar with your local protocols and scope of practice regarding these procedures.

Risks and Complications of Advanced Airways

While advanced airways can be lifesaving, they are not without risks. Complications include trauma to the lips, teeth, or pharynx during insertion. Esophageal intubation is a critical complication where the tube is accidentally placed in the esophagus instead of the trachea. Airway edema, pneumothorax, vomiting, and aspiration are risks, especially if the airway isn’t secured quickly. Once placed, advanced airways can become displaced or obstructed. It’s essential to recognize and address these issues quickly to prevent further complications. While EMTs typically don’t place these devices, understanding these risks helps in monitoring patients and assisting advanced providers effectively.