BLS Airway Adjuncts

Magill Forceps

When a larger foreign object results in an upper airway obstruction, the foreign object must be cleared from the airway to establish a patent airway.  Blind finger sweeps are no longer recommended by the American Heart Association as they may result in driving the foreign object further into the airway.  Current recommendations from the AHA recommend that the patient’s mouth be opened to allow the rescuer to look for a foreign object.  If a foreign object is visible, the rescuer may reach in with a gloved hand and retrieve the foreign object.6 More advanced medical teams will use a bite stick to open a patient’s airway and retrieve a foreign object with a pair of Magill Forceps.  Evidence Category C

Suction Units
Suction units provide a means for removing blood, fluid, pulmonary secretions, and small foreign particles from an injured or ill patient’s airway.  Suction units may be mounted or portable, but neither is appropriate for removal of large or solid objects such as teeth, large foreign bodies, or food particles.  Portable suction devices are easily carried on-field and may be effective in helping athletic trainers maintaining a patent airway until EMS arrives.  Effective suction units will generate a negative vacuum suction pressure of 300 mm Hg and be powerful enough to provide airflow greater than 40 L/min at the end of the suction tubing.7

Suction is indicated when a gurgling sound is heard during breathing or during positive pressure ventilation, when ventilation is ineffective due to vomitus, blood, bodily fluids, respiratory secretions, and/or when small particles block the airway.  Use of suction to maintain a patent airway during management of the potentially spine injured patient may prevent the need to log roll the patient to clear the airway.  A soft suction tip catheter is indicated for suctioning fluids.   When a patient is unresponsive, or requires suctioning of vomit or thick secretions, use of a rigid suction tip is indicated.

The following procedure is suggested when suctioning is indicated:

1.       Open the patient’s mouth using a bite stick;

2.       Observe body substance isolation precautions;

3.       Remove solid foreign material using Magill forceps;

4.       Measure the distance of insertion of the suction tip from the patient’s ear lobe to the corner of the mouth;

5.       Insert the suction tip into the throat using the measurement from above as a guide. Do not insert the suction tip deeper than the base of the tongue or further than what can be visualized;

6.       Suction from the back of throat outward, use a circular method, and avoid losing sight of the tip. Suction an adult no longer than 15 seconds and 10 seconds in a pediatric patient;

7.       Monitor the patient’s response to suctioning and provide necessary interventions such as positive pressure ventilations using a bag-valve. If the patient begins to gag, withdraw the suction tip until they stop gagging and then resume suctioning.  Evidence Category C.

Bag Mask Ventilation
A bag valve mask (BVM) is a hand-held device commonly used to provide positive-pressure ventilation to patients who are not breathing or not breathing adequately.   The principal type of manual resuscitator used in the pre-hospital setting is one that is self-filling with air, although additional oxygen (O2) can be added, it is not necessary for the device to function.  When used alone, a BMV can deliver oxygen concentrations of 21% as the device draws in room air.  Connecting supplemental oxygen at a rate of 10 to 15 L/min to the inlet valve of a BVM without the use of a reservoir bag increase the oxygen concentration delivered to the athlete to 40 % – 60%.  Using a BMV with a reservoir bag and supplemental oxygen at a rate of 10 to 15 L/min will result in an oxygen concentration of 90% or more being delivered to an injured athlete. 8,9  Therefore, medical teams should be prepared to provide supplemental oxygen during BVM use in the pre-hospital setting.

Figure 1 depicts the various components of a typical BVM.  Part 1 depicts the flexible face mask that seals over the patient’s face.    A filter and valve prevent back flow into the bag itself to prevent patient deprivation and bag contamination (Part 2).  The soft bag element (Part 3) is squeezed to expel air to the patient.

When the face mask is properly applied and the “bag” is squeezed, the device forces air through the trachea and bronchus and into the patient’s lungs.  The bag self-inflates upon release by drawing in either ambient air or low pressure oxygen supplied by a regulated cylinder during which time the patient’s lungs deflate to the ambient environment (not the bag) through the one way valve.  When used without supplemental oxygen a BVM will provide ambient air (21% oxygen) to the patient, however when connected to supplemental oxygen the amount of oxygen delivered to the patient to nearly 100%.8,9 A BVM may also also be attached to an alternate airway adjunct, such as a endotracheal tube (ET) or laryngeal mask airway (LMA).

BVM come in different sizes.   Most BVM are disposable and therefore single use, while others are designed to be cleaned and reused.  For patients with a lot of facial hair or when it is difficult to get a proper seal with a traditional flexible mask, the medical team may consider an easy seal mask (Figure 2).

Method of operation
Manual resuscitators cause the gas inside the inflatable bag portion to be force-fed to the patient via a one-way valve when compressed by the rescuer; the gas is then ideally delivered through a mask and into the patient’s trachea, bronchus and into the lungs. To be effective, a bag valve mask must deliver between 500 and 800 milliliters of air to a normal male adult patient’s lungs, but if supplemental oxygen is provided 400 ml may still be adequate.  Squeezing the bag once every 5–6 seconds for an adult or once every 3 seconds for an infant or child provides an adequate respiratory rate (10–12 respirations per minute in an adult and 20 per minute in a child or infant).

Professional rescuers are taught to ensure that the mask portion of the BVM is properly sealed around the patient’s face to ensure adequate pressure needed to force-inflate the lungs and to avoid leaking oxygen into the ambient environment.   During two-rescuer CPR the BVM is the preferred means of providing ventilations for a patient with a patent airway.  During two-rescuer rescue breathing one rescuer secures the mask to the patient’s face with both hands and focus entirely on maintaining a leak-proof mask seal, while the other rescuer squeezes the bag and focuses on breath (or tidal volume) and timing.  Ventilation via a BVM is difficult when a single rescuer attempts to maintain a face mask seal with one hand while squeezing the bag with the other as depicted in Figure 3. Current practice standards suggest lone rescuers provide rescue breathing via mouth-to-mouth or mouth-to-mask.1

To decrease the risk of gastric inflation, rescuers should deliver each breath from the BVM over a 1 second interval, resulting in a visible chest rise and delivering a tidal volume of 500-600 mL2 at a rate of 10 to 12 breaths per minute with a expiratory time greater than 1:2 (inspiration:expiration).8

Oropharyngeal Airways (OPA)

An oropharyngeal airway (OPA) is an airway adjunct used to maintain or open a patient’s airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.

OPAs come in a variety of sizes, from infant to adult, and are used commonly in pre-hospital emergency care and for short term airway management post anesthetic or when manual methods are inadequate to maintain an open airway.  The OPA is indicated when tracheal intubation is either not available, not advisable, or the need for airway assistance is of short term duration.  The Guedal style OPA has a hollow cavity that allows the use of a flexible suction catheter to facilitate clearing the airway of secretions.  The Berman style OPA does not have a hollow to permit use of a flexible suction catheter.  OPAs are indicated only in unconscious patients due to likelihood that the device will stimulate a gag reflex in conscious or semi-conscious patients, resulting in vomiting and resulting airway obstruction.

OPAs need to be sized and inserted correctly to maximize effectiveness and minimize possible complications, such as oral trauma.  The OPA is sized by measuring from the center of the mouth to the angle of the jaw, or from the corner of the mouth to the earlobe.  Traditionally, the mouth is opened using the “crossed or scissors” finger technique, but more experienced medical teams will consider use of a bite stick. Evidence Category C

The OPA airway is inserted into the person’s mouth upside down. Once contact is made with the back of the throat, the OPA is rotated 180 degrees, allowing for easy insertion, and assuring that the tongue is secured.  An alternative method for insertion, the method that is recommended for OPA use in children and infants, involves holding the tongue forward with a bite stick and inserting the airway right side up.  An OPA is removed when the person regains a gag-reflex and can protect their own airway, or it is substituted for an advanced airway. It is removed simply by pulling on it without rotation.

Use of an OPA does not remove the need for the recovery position and ongoing assessment of the airway and it does not prevent obstruction by liquids (blood, saliva, food, cerebrospinal fluid) or the closing of the glottis. It can, however, facilitate ventilation during CPR. 1,7,8

The main risks of its use are:

●      if the person has a gag-reflex they may vomit

●      when it is too large, it can close the glottis and thus close the airway

●      improper sizing can cause bleeding in the airway

The following protocol shall be used to place an OPA when indicated:

1.       Activate the emergency action plan and ensure that ALS is dispatched by communicating the EMS dispatch that the patient is in respiratory distress;

2.       Attempt ventilations using a BVM;

3.       If unable to ventilate a patient who is not at risk of chocking with the BVM; prepare to place an OPA;

4.       Determine the proper size OPA by measuring from the patient’s ear to the mouth;

5.       Position the patient in cervical neutral position;

6.       Lubricate the OPA with a water-based lubricant;

7.       Open the patient’s mouth using a bite-stick;

8.       Place the OPA by slinging along the roof or side of the patient’s mouth until the OPA reaches the base of the throat; rotate the OPA into place;

9.       Ventilate using a BVM;

10.    Monitor and support vital signs until ALS arrives;

11.    If the patient begins to vomit, suction shall be used to maintain a patent airway. A log roll technique may be employed to clear the airway of vomit if suction is not able to clear the airway of vomit.

Nasopharyngeal Airway (NPA)
A nasopharyngeal airway (NPA) is a tube that is designed to be inserted into the nasal passageway to secure an open airway.  These devices are used by emergency care professionals in situations where an artificial form of airway maintenance is necessary, but tracheal intubation is impossible, inadvisable, or outside the practitioner’s scope of practice. An NPA is often used in conscious patients where an OPA would trigger the gag reflex.

The correct size airway is chosen by measuring the device on the patient.  The device should reach from the patient’s nostril to the earlobe or the angle of the jaw. Ensure that the diameter of the NPA is not larger than the nostril.  The outside of the tube is lubricated with a water-based lubricant so that it enters the nose more easily. The device is inserted until the flared end rests against the nostril. Some tubes contain a safety pin to prevent inserting the tube too deeply. Care must be taken to ensure the pin does not stick into the nostril. If a pin is not available, you may also stop insertion just short of the natural gag reflex and tape the remaining exposed portion of the NPA to the surrounding facial tissue. 1,7,8

Insertion of an NPA is absolutely contraindicated in patients with severe head or facial injuries, or have evidence of a basilar skull fracture (Battle’s sign, raccoon eyes, cerebrospinal fluid/blood from ears, etc.) due to the possibility of direct intrusion into brain tissue. 1,7,8,9,10

The following protocol will be used to place an NPA:

1.       Activate the emergency action plan and ensure that ALS is dispatched by communicating the EMS dispatch that the patient is in respiratory distress;

2.       Determine the appropriate length NPA to be placed by measuring from the tip of the ear to the jaw line;

3.       Determine the proper NPA diameter by referencing the patient’s little finger;

4.       Lubricate the NPA with a water-based lubricant;

5.       Place the NPA with the bevel side toward the septum;

6.       In conscious patients, connect a non-rebreather mask to the oxygen tank and place non-rebreather on the patient and administer oxygen at rate of 15 L/min;

7.       Check the inspiratory and expiratory valves of the non-rebreather to ensure they are working properly;

8.       In unconscious patients begin ventilations using a BVM;

9.       Monitor and support the patient’s vital signs;

10.    If the patient begins to vomit, suction shall be used to maintain a patent airway. A log roll technique may be employed to clear the airway of vomit if suction is not able to clear the airway of vomit.

Supplemental Oxygen
Normal room (ambient) air oxygen concentrations of 21% are more than adequate to sustain life in healthy athletes.  However, traumatic injury or illness may result in higher oxygen concentrations in order ensure adequate perfusion and prevent hypoxia when normal body system function is compromised.  Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level.  Hypoxia can lead to cardiac arrhythmia, tissue and cell damage, renal damage, and eventual cerebral damage.  Significant hypoxia lasting more than 4 to 6 minutes may result in cardiopulmonary arrest and irreversible brain and vital organ damage. 7 Sign and symptoms of hypoxia include, but are limited to:

·         Altered mental status;

·         Neurological compromise;

·         Tachycardia;

·         Angina;

·         Dyspnea, tachypnea, or hypoventilation;

·         Cyanosis;

·         Headache, nausea, vomiting;

·         Restlessness, anxiety, agitation.

The use of supplemental oxygen during management of an injured athlete demonstrating signs and symptoms of hypoxia increases the amount of oxygen being delivered to body tissues and may increase the athlete’s chance of survival. 7,8   Indications for use of supplemental oxygen include, but are limited to:

·         Altered mental status;

·         Cardiac arrest or angina;

·         Drug overdose;

·         Internal trauma;

·         Fractures;

·         Respiratory arrest;

·         Respiratory distress;

·         Shock;

·         Stroke.

There are no absolute contraindications to the use of supplemental oxygen in the athletic setting.  Therefore, medical teams need not wait for the specific signs and symptoms of hypoxia to become evident.  Supplemental oxygen should be administered when an athlete presents with dyspnea or respiratory distress to prevent the onset of hypoxia. 7  However, administration of supplemental oxygen should not interfere with completion of chest compressions during CPR .1

Nasal Cannula
The nasal cannula (NC) is a device used to deliver supplemental oxygen or increased airflow to a patient in need of respiratory help. The NC consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows. The other end of the tube is connected to an oxygen supply. The cannula is generally attached to the patient by way of the tube hooking around the patient’s ears or by elastic head band. Generally, the common adult nasal cannula carries 1–5 liters of oxygen per minute.  Supplemental oxygen via nasal cannula at 4-6L/min delivers 36-44% oxygen, ideal for administering supplemental oxygen for most medical emergencies when the athlete is breathing on their own. 7,8,9

A nasal cannula is generally used wherever small amounts of supplemental oxygen are required, without rigid control of respiration, such as in oxygen therapy. Most cannulae can only provide oxygen at low flow rates—up to 5 liters per minute (L/min)—delivering an oxygen concentration of 28–44%. Rates above 5 L/min can result in discomfort to the patient, drying of the nasal passages, and possibly nose bleeds (epistaxis). Also with flow rates above 6 L/min, the laminar flow becomes turbulent and the oxygen therapy being delivered is only as effective as delivering 5-6 L/min. 7,8

Non-Rebreather Oxygen Mask
A non-rebreather mask (NRB, non-rebreather, non-rebreather facemask, etc.) is a device used in medicine to assist in the delivery of oxygen therapy. An NRB requires that the patient can breathe unassisted, but unlike low flow nasal cannula, the NRB allows for the delivery of higher concentrations of oxygen.

The non-rebreather mask covers both the nose and mouth of the patient and attaches with the use of an elastic cord around the patient’s head. The NRB has an attached reservoir bag, typically 1 liter, that connects to an external oxygen supply. Before an NRB is placed on the patient, the reservoir bag is inflated to greater than two-thirds full of oxygen, at a rate of 6-15 liters per minute (lpm). 8 Approximately ¹⁄₃ of the air from the reservoir is depleted as the patient inhales, and it is then replaced by the flow from the O2 supply.   If the bag becomes completely deflated, the patient will no longer have a source of air to breathe.  Generally, delivery of 10 L/min is standard practice for delivery of supplemental oxygen through a NRB in the prehospital setting. 8

Exhaled air is directed through a one-way valve in the mask, which prevents the inhalation of room air and the re-inhalation of exhaled air. The valve, along with a sufficient seal around the patient’s nose and mouth, allows for the administration of high concentrations of oxygen, approximately 60% – 80% O2.8 The patient must partially deflate the reservoir bag during inspiration or the high oxygen concentration will not be achieved, and the mask will provide only the liter flow rate setting on the flowmeter.

The non-rebreather mask is utilized for athlete with physical trauma or who require high-concentration oxygen, but do not require breathing assistance. Patients uncomfortable with having a mask on their face, such as those with claustrophobia, or patients with injuries to the mouth are more likely to benefit from a nasal cannula, or passive blow-by oxygen.  Patients who are unable to breathe on their own would require invasive or noninvasive mechanical ventilation.

BLS Airway Adjunct Considerations
Placement of an OPA only requires that a patient be lacking a gag reflex and in neutral cervical position.  Therefore, airway management for the potentially spine injured athlete can be facilitated by use of the OPA when maintaining in-line stabilization is desired.  However, use of an OPA is contraindicated when there is a potential airway obstruction.  In athletics, an airway obstruction would likely be caused by swallowing a mouth guard or chewing gum.  Therefore, when there appears to be an airway obstruction, the medical team will complete a visual inspection of the patient’s mouth.  If an obstruction is visible, the medical team will attempt to remove the obstruction using forceps.  If the obstruction cannot be removed, the OPA is contraindicated and the medical team will attempt airway management via the NPA or other appropriate advanced airway management technique.

Suction may be used to remove fluids from the airway to facilitate breathing.   Should the need for airway management be deemed necessary by the athletic training staff prior to the availability of prehospital ALS, the athletic training staff will determine the patient’s level of consciousness.  If the patient is alert and responsive, but in need of airway assistance, an NPA shall be used to provide airway support.  An NPA shall also be indicated for airway support in patients for whom an airway obstruction cannot be ruled out.

BLS Emergency Airway Management Supplies List

Ancillary Content

OPA Demonstration NPA Demonstration Airway Management Considerations