Airway Opening Maneuvers^1,2

^{Figure 1. Airway opening maneuvers. Aminnejad R. Airway management. https://www.slideshare.net/rezaaminnejad/airway-management-79135709. Uploaded August 24th 2017. Accessed November 30th 2020.}

Jaw Thrust

Stabilize the patient’s head relative to their torso alignment, then displace the mandible anteriorly (using both of your hands) without extending the head of the patient.
Placement of fingers should be under the mandibular rami
Take care if patient is in C-Spine precautions
Lift mandible upward (anteriorly) with your fingers until the lower incisors are above the upper incisors

Head Tilt-Chin Lift

Recommended to avoid using this technique if the patient is under spinal precautions and Jaw Thrust is possible
Use if Jaw-Thrust fails
Place one hand on patient’s temple and the other below the mandible, tilt the head back (mandible/chin pointing upwards)

Bag Mask Ventilation

KEY SKILL - HAS TO BE MASTERED !

Bag-mask ventilation (BMV) is a critical skill in anesthesiology and resuscitation.* Effective BMV requires an adequate mask seal, and a patent airway maintained through a proper head tilt and/or chin lift. This is done by gently extending the patient’s neck, and lifting the mentum and mandible anteriorly. Often BMV is successfully completed by one hand (left) while the other is providing ventilation by squeezing the bag with the other hand (right). The mask should be held by the thumb and the index finger tightly over the face. The middle finger should support the mentum, while the ring and/or pinky fingers support and lift the angle of the mandible.

* This skill is assessed in a workplace-based assessment during your anesthesiology rotation. You are expected to be competent in this skill by the time you graduate from medical school.

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Figure 2. Correct one-handed bag-mask ventilation technique.
This image shows the technique with a child but is also applicable to adults. The middle finger supports the mentum and the ring and/or pinky fingers support and tilt the angle of the mandible to form an "E" while thumb and index finger form a "C" to maintain a seal between the mask and the face. This technique is also called the EC clamp technique. (Wikimedia Commons. Mask Ventilation. https://commons.wikimedia.org/wiki/File:Mask_Ventilation.jpg. Uploaded Sept 21st 2007. Accessed Nov 30th 2020.)

Image from Figure 5 in Berg MD, Schexnayder SM, Chameides L, et al. Pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics 2010; 126(5):S862-75.

Oropharyngeal (OPA) and Nasopharyngeal (NPA) Airways

Following anesthetic induction (and in other unconscious patients), the upper airway muscle tone decreases significantly, which can allow the tongue to fall back against the pharynx, obstruct the airway, and make bag-mask ventilation challenging. Airway obstruction can be relieved by manual maneuvers (chin lift, jaw thrust) and / or placement of an oropharyngeal or nasopharyngeal airways. Oropharyngeal airways (also called oral or Guedel airways) stimulate the gag reflex so they should be inserted after loss of consciousness following anesthetic induction and removed before a patient regains consciousness. In contrast, nasopharyngeal airways do not stimulate the gag reflex and are well-tolerated in awake or semi-conscious patients. They are best avoided in patients with anticoagulation or thrombocytopenia (due to increased risk of epistaxis) and in patients with mid-face or skull-base fractures.

oral airway

Figure 3. Different sizes of oropharyngeal airways
Image by Rama - Own work, CCA-SA 2.0 France, https://commons.wikimedia.org/wiki/File:Canule_de_Goedel_2.jpg

Figure 4. Nasopharyngeal airway
Image from https://upload.wikimedia.org/wikipedia/commons/thumb/b/b3/Nasopharyngeal_Airway.JPG/220px-Nasopharyngeal_Airway.JPG

Figure 5. OPA Sizing. (RRapid. Airway. http://rrapid.leeds.ac.uk/pRRAPID/03-airway-05.html. Accessed Nov 30th 2020.)

Technique: Inserting an OPA¹

- - Indications: unresponsive patient without intact gag reflex
  - Steps:
    - Sizing: OPA should stretch from angle of jaw to the midline of the mouth
    - Insert the OPA upside-down or obliquely (90 degree angle) then rotate after passing the tongue into the correct position
    - Ensure that suction is available to clear the airway

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Figure 6. NPA Sizing. (The Anesthesia Practice Guide. Airway/Intubation/Ventilation. narkosguiden.se. https://narkosguiden.se/eng/book/andning-och-luftvagskontroll/. Updated 2016. Accessed Nov 30 2020.

Technique: Inserting an NPA¹

Indications: semi-responsive patient or unresponsive patient, patients with/w/o intact gag reflexes
Contraindicated: facial or head trauma
Steps:

Sizing: should stretch from the tip of the nose to mid-ear
Use suction to clear the mouth of secretions/debris
Lubricate the NPA
Insert the NPA into the larger nostril, moving it midline along the nasal floor along the natural anatomical curvature (anterior posterior plane)Do not attempt to move superiorly as this can cause additional trauma.
Ensure that suction is available to clear the airway

Difficult Airways Algorithm (ASA)

Figure 7. Difficult Airways. (ASA. Difficult Airways Algorithm.Openanesthesia.org. http://www.openanesthesia.org/wp-content/uploads/2015/02/algorithm_1.jpg. Uploaded 2015. Accessed Nov 30th 2020.)

References:

1. BCEHS. Basic Airway Management. handbook.bcehs.ca. https://handbook.bcehs.ca/treatment-guidelines/clinical-procedures/airway-management-and-oxygenation/basic-airway-management/. Accessed Nov 30th 2020.

2. Habrat D. How to do head tilt-chin lift and jaw-thrust maneuvers. merckmanuals.com.https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-basic-airway-procedures/how-to-do-head-tilt-chin-lift-and-jaw-thrust-maneuvers. Updated August 2019. Accessed Nov 30th 2020.