This chapter builds on the ABCDE Approach chapter, which explains how to assess the airway (A - Airway), the expected common interventions, and the objectives in a critical patient's initial approach and management. You can return to that chapter here:

Below, you will find a summary of the chapter's content. The topic is discussed in detail in the Oxford Handbook of Critical Care (see Suggested Reading). The airway management approach was taught in previous courses (First Aid, Basics of Internal Propedeutics, and, more recently, Anesthesiology), so this chapter serves as a review. It will draw on your knowledge from those previous courses.

Manual Airway Opening

Assessing and ensuring airway patency is a fundamental skill in managing a critical patient. It should be performed immediately after addressing the patient if they do not respond to verbal and tactile stimulation. In the links below, you can review the techniques for assessing and opening the airway in both adults and children from the First Aid pre-learning material:

Bag-Mask Ventilation (BMV)

BMV is one of the essential ventilation skills for managing critical patients that every clinician should master.

Although the technique may seem simple, performing it effectively on critical patients requires the correct technique. You practised it in Basics of Internal Propedeutics, and this short video is intended to remind you of the key aspects of this technique in the situation of cardiac arrest: 

Oral and Nasal Airways

Airways assist in facilitating oxygenation and ventilation of the patient.

The Nasal Airway

• is typically softer.
  
• causes less irritation than an oral airway if inserted into the oropharynx without touching the epiglottis.
• is usually better tolerated (as long as its length does not provoke coughing or gagging).
• is contraindicated in cases of suspected or confirmed skull base fracture
• bleeding may occur during insertion; therefore, severe coagulopathies are a relative contraindication.
  

The Oral Airway

• is usually tolerated and effective at maintaining an open airway only with a more profound impairment of consciousness than the nasal airway.
• when the correct size is chosen and inserted using the proper technique, it usually holds the airway open more effectively.

Laryngeal mask (LMA)

The laryngeal mask is a supraglottic device used to secure the airway.

Due to its ease of insertion, it becomes an effective tool even for doctors who do not regularly secure the airway. As the European Resuscitation Council recommends, it has become the method of choice for this case.

Newer generations include a drainage channel that allows for the suction of gastric contents from the end of the LMA.

Introduction of the Laryngeal Mask

Tracheal Intubation

Although securing the airway with endotracheal intubation is considered the gold standard in intensive care, performing this procedure on a critical patient should be reserved for experienced professionals. Therefore, this technique will not be taught or required during the Intensive Care Medicine classes.

The indications mentioned above should prompt consideration of intubating the patient and contacting an intensive care consultant, activating the Early Warning System (EWS), or making a Met-call, who will evaluate the situation and perform the intubation if necessary.

Surgical Airway Management and Tracheostomy

Intensive care medicine classes focus on airway management and the initial approach to critical patients. The topics of surgical airway management and tracheostomy exceed the scope of this chapter and will be discussed elsewhere.

Suggested reading for this chapter: