first aid
Managing upper airway obstruction Margaret H Innes, Selly O a k H o sp ital, B irm ingham This article deals with the nurse-aid management of partial and complete airway obstruction both outside and in the hospital environment and describes the symptoms of airway obstruction so that nurses are alert to the change in the patient’s position on the health/illness continuum.
pper airway obstruction emergenc ies can occur in any environment, e.g. in a bath or river, at a meal table in a ward or restaurant, in a park or back garden, and in a work place or playground. Many con ditions affecting the person s airway cause asphyxia. Complete respiratory oostruction can lead to death in 3 minutes. The nurse aider must be alert to the signs of airway obstruction and be aware, in the words of a nursing model, when the per son’s position on the health/illness continu um changes. In the case of airway obstruc tion, this means recognizing either partial or complete obstruction.
732
IMPORTANT Movements of the chest are not always synonymous with a clear airway. IMPORTANT Although partial obstruction is accompanied by noisy respir ation, total obstruction is com pletely silent.
IMPORTANT It is essential that the nurse aider recognizes the signs and symptoms of airway obstruc tion and takes the appropriate action.
Ms Innes is Sister in the Recovery Unit at Solly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham
1. No movement of air is felt or heard pass ing through the nose or mouth. 2. There are no breath sounds. 3. There is a change in skin colour; signs of hypoxia will develop rapidly. 4. The pulse rate may change, and dysrhythmias and bradycardia may oc cur.
The signs and symptoms of partial air way obstruction are as follows: 1. Snoring or gurgling sounds; a fluid/mucus rattle indicates stentorious breathing. 2. Crowing noise on inspiration; this is known as inspiratory stridor. 3. Laboured breathing or breathing with great effort, as indicated by the use of the accessory muscles of respiration (the sternomastoid scalenus), flaring of the nostrils and retraction of the head. 4. The normal rhythm of respiration, in which the chest and abdomen rise and fall in phase together, changes so that the chest moves inwards on respiration while the abdominal wall continues to move outwards. This becomes more no ticeable as the degree of obstruction in creases. A paradoxical, or see-saw, pat tern of respiration occurs and as the ob struction increases, more muscular effort is involved. I he signs and symptoms of complete air way obstruction are as follows:
According to nursing theory, the causa tive factors of airway obstruction can be divided into external and internal stressors (Roy, 1924). Examples of these causative factors are listed in Table 1. Other situ ations and accidents that not only render people unconscious but also affect the air way include: electrical injuries; poisoning, e.g. from a drug overdose; paralysis (caused by a stroke or an injury to the spinal cord); breathing in air containing insufficient oxy gen, e.g. in a gas or smoke-filled room; and carbon monoxide poisoning.
Management of an obstructed airway This section will address both the action the nurse aider should take outside the ward environment and the action he/she should take while in the care environment before medical expertise arrives on the scene.
IMPORTANT The major goal is to maintain adequate ventilation.
British Journal of Nursing, 1992, Voi l,N o 14 Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
Managing upper airway obstruction
(In the unconscious patient, i f the jaw is relaxed, the tongue may fall into the posterior pharynx and obstruct the airway. 5
T a b le I. C a u s a tiv e fa c to rs o f a irw a y o b s tru c tio n Tongue
In the unconscious patient the jaw is relaxed, so the tongue may fall into the posterior pharynx and obstruct the airway.
Foreign m aterial in the pharynx
Excess mucus/saliva Gastric contents from vomiting/regurgitation Blood following traurpa or oral/nasal surgery Broken o r dislodged teeth.
Laryngeal oedema Laryngospasm External pressure on the trachea
This follows trauma such as scalds or stings, intubation or infection. This results from stimulation of the larynx. It may be caused by foreign material, clumsy extubation or suction. Haematoma following thyroid surgery or attempts at internal jugular cannulation Compression of the outside of the neck by hanging, strangulation or throttling, all of which squeeze the airway shut and block off the flow of air to the lungs._______________________________ _
Drow ning
This causes asphyxia from water entering the lungs or by causing the throat to go into spasm.
Compression of the chest
This may be caused by a fall of earth or sand.
Fits
These prevent adequate breathing.
Choking
This occurs when the airway is partially or totally obstructed by something which, in the act of swallowing, goes into the windpipe rather than down the food passage. Choking may occur at any meal table. Adults may choke on food which has been inadequately chewed and hurriedly swallowed. Children are at risk becuase they like putting objects other than food in their mouths. The neck veins are raised and congested.
It is important to remember that in the person with an altered level of conscious ness, there is the potential problem of acute respiratory obstruction. This may be the re sult of loss of his/her swallowing reflex or the inability to maintain his/her airway. Obstruction of the airway can be further aggravated by incorrect positioning or the inhalation of vomit or mucus. The steps to take to maintain adequate ventilation are shown in Table 2. However, it must be re membered that these actions should be carried out in any nurse-aid situation. Management outside the hospital First, assess the situation; then look, listen and feel for any signs of breathing. If none are present, a clear airway must be estab lished immediately as follows: 1. Position yourself beside/behind the per son. 2. Lift the chin forwards with one hand while pressing the forehead backwards with the other hand (Fig. /). The jaw will lift the tongue forwards, clear of the air way. Check for breathing. 3. Even when you have opened the per son’s airway, foreign matter may still British Journal of Nursing, 1992, Voi l,N o 14
block it. Any obvious obstruction should be removed from the mouth by hooking your first two fingers and sweeping them round inside the mouth (Fig. 2). N.B. Well-fitting dentures help to maintain a mouth seal during ventila tion and should not be removed. 4. If breathing is resumed, place the person in the recovery position. 5. If breathing does not return, commence mouth-to-mouth resuscitation (Fig. 3).
IMPORTANT Some injuries contraindicate putting a patient into the recov ery position Management within the hospital The patient is nursed in the left lateral posi tion, condition allowing, as this helps main tain a clear airway by preventing the tongue falling back and allowing vomit/mucus to drain out of the mouth by gravity. If obstruction occurs, the immediate ac tion is to stand behind the patient, extend ing the neck and pulling the jaw forward by placing your fingers behind the angle
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Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
Managing upper airway obstruction
‘I f vomiting occurs, utilize gravity by tilting the patient’s head down, and then apply suction to the pharynx using a rigid yank-out sucker o f a large-bore suction catheter. *
T a b le 2. Steps to e nsu re th a t a d e q u a te v e n tila tio n is m a in ta in e d 1. Assess the environment and make sure it is safe___________________ 2. Ensure the airway is clear_________ 3. Observe the pattern of breathing 4. Note any signs of oxygen deficiency
T a b le 3. E q u ip m e n t re q u ire d fo r m e ch a n ica l v e n tila tio n Laryngoscope______ Endotracheal tube of appropriate size
Fig. 1. If the airway is obstructed, lift the chin forwards with one hand while pressing the forehead backwards with the other.
I Omm syringe to inflate cuff of endotracheal tube__________________ Catheter mount to attach the re breathe circuit to endotracheal tube Bougie/introducer__________________ Tape to secure tube________________
Fig. 2. Obvious obstructions can be removed by hooking your first two fingers and sweep ing them round inside the mouth.
Fig. 3. If breathing does not return, com mence mouth-to-mouth resuscitation.
734
of the jaw and sliding the mandible for ward. The lips and teeth can then be separ ated by the action of your thumb pressure on the lower jaw. If possible, insert an oral airway. If vomiting occurs, utilize gravity by tilt ing the patient’s head down, and then apply suction to the pharynx using a rigid yankager sucker or a large-bore suction catheter. If indicated, commence manual ventilation with oxygen using an anaes thetic face-mask and a rebrcathe circuit.
IMPORTANT Always ensure that medical aid is sought Be prepared for the arrival of medical aid. The anaesthetist may wish to intubate and start mechanical ventilation. The equipment that should be made available for this pro cedure is listed in Table 3. In any nurse-aid situation, the following points must be remembered: 1. When a spinal cord injury is suspected, do not extend the patient’s neck to open the airway or put him/her into the recov ery position (Platt, 1992). 2. When a person has been rendered un conscious by smoke inhalation or carbon monoxide poisoning, the aims of the nurse aider are to remove the person to safety, restore fresh air and maintain the person’s breathing. British Journal of Nursing, 1992, Vol I, No 14 Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
Managing upper airway obstruction
Choking In the case of airway obstruction from choking, the obstruction must be removed as quickly as possible. A conscious choking victim should be encouraged to cough. If this does not work, the victim should be bent forwards so that the head is lower than the lungs. Slap the victim smartly between the shoulder blades with the heel of your hand. Repeat up to 4 times if necessary. If the object does not dislodge, administer the Heimlich manoeuvre. Heimlich manoeuvre on an adult Stand behind the person and put one arm around his/her abdomen, clench your fist and place it with your thumb inwards in the centre of the upper abdomen between the navel and the breast bone. Grasp your fist with your other hand. Pull both hands towards you with a quick inwards and up wards thrust so that you compress the up per abdomen (Fig. 4). The thrust must be hard enough to dislodge the obstruction. If it fails, repeat up to 4 times. Alternative ly, a series of alternating back slaps and ab dominal thrusts can be effective.
Fig. 4. The Heimlich manoeuvre.
KEY POINTS • A complete respiratory obstruction can lead to death in 3 minutes. • The first and constant duty of the nurse aider is to check that the person is breathing by looking, listening and feeling. • Partial obstruction is no less serious than complete obstruction. • The nurse aider, in any situation, should assess the problem and attempt to overcome the airway obstruction using the measures described.
British Journal of Nursing, 1992, Vol I,No 14
The unconscious choking victim Turn the person on to his/her back, open the airway and begin mouth-to-mouth re suscitation. If unsuccessful, roll the victim onto his/her side so that the chest is facing you and perform up to 4 back slaps. If the obstruction has not been dislodged, turn the person onto his/her back, and ensure that the head is in the open airway position. Kneel astride the thighs and deliver ab dominal thrusts by direct compression. Re peat up to 4 times if necessary. If the ob struction still remains, recommence mouthto-mouth resuscitation until help arrives, or actively seek aid. When there is no longer an obstruction place the person in the re covery position if his/her condition allows. Heimlich manoeuvre on a child With children, follow the sequence as for an adult but sit on a chair and lay the child over your knee, supporting the chest with one hand and slapping smartly between the shoulder blades with the other. For abdominal thrusts, sit the child on your knee, place one hand around the ab domen and clench your fist. Use the same thrusting movement as for an adult, but with less pressure. Support the child’s back with your other hand. If the child is uncon scious, place them in the same position as you would an adult. Use the same method but use only one hand and apply less pres sure. Technique for infants If an infant has inhaled a foreign body, hold them upside down by the feet and slap smartly between the shoulder blades. Much lighter pressure is required. Repeat up to 4 times. Alternatively, lay the infant head downwards so that the chest and abdomen are lying along your forearm. Use your hand to support the head and slap smartly between the shoulder blades up to 4 times. If the obstruction remains, perform ab dominal thrusts. Place the infant on a firm surface with the head in the open airway position. Place two fingers of one hand on the upper abdomen and press with a quick inward and upper movement. Repeat up to 4 times. I^j^J The photographs in this article were taken by Bob Evans, PO Box 792, King's Norton, Birmingham. Eltringham R, Dulkin M, Andrews S, Casey W (1989) Post-Anaesthetic Recovery — A Practical Ap proach. Springer Verlag, London. Platt W (1992) Behaviour at the scene of an accident, Br] Nitrs 1(13): 678-80 Roy C (1984) Introduction to Nursing: An Adapta tion Model, 2nd edn, Prentice Hall, Englewood Cliffs, New Jersey
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Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
Managing upper airway obstruction Margaret H Innes, Selly O a k H o sp ital, B irm ingham This article deals with the nurse-aid management of partial and complete airway obstruction both outside and in the hospital environment and describes the symptoms of airway obstruction so that nurses are alert to the change in the patient’s position on the health/illness continuum.
pper airway obstruction emergenc ies can occur in any environment, e.g. in a bath or river, at a meal table in a ward or restaurant, in a park or back garden, and in a work place or playground. Many con ditions affecting the person s airway cause asphyxia. Complete respiratory oostruction can lead to death in 3 minutes. The nurse aider must be alert to the signs of airway obstruction and be aware, in the words of a nursing model, when the per son’s position on the health/illness continu um changes. In the case of airway obstruc tion, this means recognizing either partial or complete obstruction.
732
IMPORTANT Movements of the chest are not always synonymous with a clear airway. IMPORTANT Although partial obstruction is accompanied by noisy respir ation, total obstruction is com pletely silent.
IMPORTANT It is essential that the nurse aider recognizes the signs and symptoms of airway obstruc tion and takes the appropriate action.
Ms Innes is Sister in the Recovery Unit at Solly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham
1. No movement of air is felt or heard pass ing through the nose or mouth. 2. There are no breath sounds. 3. There is a change in skin colour; signs of hypoxia will develop rapidly. 4. The pulse rate may change, and dysrhythmias and bradycardia may oc cur.
The signs and symptoms of partial air way obstruction are as follows: 1. Snoring or gurgling sounds; a fluid/mucus rattle indicates stentorious breathing. 2. Crowing noise on inspiration; this is known as inspiratory stridor. 3. Laboured breathing or breathing with great effort, as indicated by the use of the accessory muscles of respiration (the sternomastoid scalenus), flaring of the nostrils and retraction of the head. 4. The normal rhythm of respiration, in which the chest and abdomen rise and fall in phase together, changes so that the chest moves inwards on respiration while the abdominal wall continues to move outwards. This becomes more no ticeable as the degree of obstruction in creases. A paradoxical, or see-saw, pat tern of respiration occurs and as the ob struction increases, more muscular effort is involved. I he signs and symptoms of complete air way obstruction are as follows:
According to nursing theory, the causa tive factors of airway obstruction can be divided into external and internal stressors (Roy, 1924). Examples of these causative factors are listed in Table 1. Other situ ations and accidents that not only render people unconscious but also affect the air way include: electrical injuries; poisoning, e.g. from a drug overdose; paralysis (caused by a stroke or an injury to the spinal cord); breathing in air containing insufficient oxy gen, e.g. in a gas or smoke-filled room; and carbon monoxide poisoning.
Management of an obstructed airway This section will address both the action the nurse aider should take outside the ward environment and the action he/she should take while in the care environment before medical expertise arrives on the scene.
IMPORTANT The major goal is to maintain adequate ventilation.
British Journal of Nursing, 1992, Voi l,N o 14 Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
Managing upper airway obstruction
(In the unconscious patient, i f the jaw is relaxed, the tongue may fall into the posterior pharynx and obstruct the airway. 5
T a b le I. C a u s a tiv e fa c to rs o f a irw a y o b s tru c tio n Tongue
In the unconscious patient the jaw is relaxed, so the tongue may fall into the posterior pharynx and obstruct the airway.
Foreign m aterial in the pharynx
Excess mucus/saliva Gastric contents from vomiting/regurgitation Blood following traurpa or oral/nasal surgery Broken o r dislodged teeth.
Laryngeal oedema Laryngospasm External pressure on the trachea
This follows trauma such as scalds or stings, intubation or infection. This results from stimulation of the larynx. It may be caused by foreign material, clumsy extubation or suction. Haematoma following thyroid surgery or attempts at internal jugular cannulation Compression of the outside of the neck by hanging, strangulation or throttling, all of which squeeze the airway shut and block off the flow of air to the lungs._______________________________ _
Drow ning
This causes asphyxia from water entering the lungs or by causing the throat to go into spasm.
Compression of the chest
This may be caused by a fall of earth or sand.
Fits
These prevent adequate breathing.
Choking
This occurs when the airway is partially or totally obstructed by something which, in the act of swallowing, goes into the windpipe rather than down the food passage. Choking may occur at any meal table. Adults may choke on food which has been inadequately chewed and hurriedly swallowed. Children are at risk becuase they like putting objects other than food in their mouths. The neck veins are raised and congested.
It is important to remember that in the person with an altered level of conscious ness, there is the potential problem of acute respiratory obstruction. This may be the re sult of loss of his/her swallowing reflex or the inability to maintain his/her airway. Obstruction of the airway can be further aggravated by incorrect positioning or the inhalation of vomit or mucus. The steps to take to maintain adequate ventilation are shown in Table 2. However, it must be re membered that these actions should be carried out in any nurse-aid situation. Management outside the hospital First, assess the situation; then look, listen and feel for any signs of breathing. If none are present, a clear airway must be estab lished immediately as follows: 1. Position yourself beside/behind the per son. 2. Lift the chin forwards with one hand while pressing the forehead backwards with the other hand (Fig. /). The jaw will lift the tongue forwards, clear of the air way. Check for breathing. 3. Even when you have opened the per son’s airway, foreign matter may still British Journal of Nursing, 1992, Voi l,N o 14
block it. Any obvious obstruction should be removed from the mouth by hooking your first two fingers and sweeping them round inside the mouth (Fig. 2). N.B. Well-fitting dentures help to maintain a mouth seal during ventila tion and should not be removed. 4. If breathing is resumed, place the person in the recovery position. 5. If breathing does not return, commence mouth-to-mouth resuscitation (Fig. 3).
IMPORTANT Some injuries contraindicate putting a patient into the recov ery position Management within the hospital The patient is nursed in the left lateral posi tion, condition allowing, as this helps main tain a clear airway by preventing the tongue falling back and allowing vomit/mucus to drain out of the mouth by gravity. If obstruction occurs, the immediate ac tion is to stand behind the patient, extend ing the neck and pulling the jaw forward by placing your fingers behind the angle
733
Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
Managing upper airway obstruction
‘I f vomiting occurs, utilize gravity by tilting the patient’s head down, and then apply suction to the pharynx using a rigid yank-out sucker o f a large-bore suction catheter. *
T a b le 2. Steps to e nsu re th a t a d e q u a te v e n tila tio n is m a in ta in e d 1. Assess the environment and make sure it is safe___________________ 2. Ensure the airway is clear_________ 3. Observe the pattern of breathing 4. Note any signs of oxygen deficiency
T a b le 3. E q u ip m e n t re q u ire d fo r m e ch a n ica l v e n tila tio n Laryngoscope______ Endotracheal tube of appropriate size
Fig. 1. If the airway is obstructed, lift the chin forwards with one hand while pressing the forehead backwards with the other.
I Omm syringe to inflate cuff of endotracheal tube__________________ Catheter mount to attach the re breathe circuit to endotracheal tube Bougie/introducer__________________ Tape to secure tube________________
Fig. 2. Obvious obstructions can be removed by hooking your first two fingers and sweep ing them round inside the mouth.
Fig. 3. If breathing does not return, com mence mouth-to-mouth resuscitation.
734
of the jaw and sliding the mandible for ward. The lips and teeth can then be separ ated by the action of your thumb pressure on the lower jaw. If possible, insert an oral airway. If vomiting occurs, utilize gravity by tilt ing the patient’s head down, and then apply suction to the pharynx using a rigid yankager sucker or a large-bore suction catheter. If indicated, commence manual ventilation with oxygen using an anaes thetic face-mask and a rebrcathe circuit.
IMPORTANT Always ensure that medical aid is sought Be prepared for the arrival of medical aid. The anaesthetist may wish to intubate and start mechanical ventilation. The equipment that should be made available for this pro cedure is listed in Table 3. In any nurse-aid situation, the following points must be remembered: 1. When a spinal cord injury is suspected, do not extend the patient’s neck to open the airway or put him/her into the recov ery position (Platt, 1992). 2. When a person has been rendered un conscious by smoke inhalation or carbon monoxide poisoning, the aims of the nurse aider are to remove the person to safety, restore fresh air and maintain the person’s breathing. British Journal of Nursing, 1992, Vol I, No 14 Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
Managing upper airway obstruction
Choking In the case of airway obstruction from choking, the obstruction must be removed as quickly as possible. A conscious choking victim should be encouraged to cough. If this does not work, the victim should be bent forwards so that the head is lower than the lungs. Slap the victim smartly between the shoulder blades with the heel of your hand. Repeat up to 4 times if necessary. If the object does not dislodge, administer the Heimlich manoeuvre. Heimlich manoeuvre on an adult Stand behind the person and put one arm around his/her abdomen, clench your fist and place it with your thumb inwards in the centre of the upper abdomen between the navel and the breast bone. Grasp your fist with your other hand. Pull both hands towards you with a quick inwards and up wards thrust so that you compress the up per abdomen (Fig. 4). The thrust must be hard enough to dislodge the obstruction. If it fails, repeat up to 4 times. Alternative ly, a series of alternating back slaps and ab dominal thrusts can be effective.
Fig. 4. The Heimlich manoeuvre.
KEY POINTS • A complete respiratory obstruction can lead to death in 3 minutes. • The first and constant duty of the nurse aider is to check that the person is breathing by looking, listening and feeling. • Partial obstruction is no less serious than complete obstruction. • The nurse aider, in any situation, should assess the problem and attempt to overcome the airway obstruction using the measures described.
British Journal of Nursing, 1992, Vol I,No 14
The unconscious choking victim Turn the person on to his/her back, open the airway and begin mouth-to-mouth re suscitation. If unsuccessful, roll the victim onto his/her side so that the chest is facing you and perform up to 4 back slaps. If the obstruction has not been dislodged, turn the person onto his/her back, and ensure that the head is in the open airway position. Kneel astride the thighs and deliver ab dominal thrusts by direct compression. Re peat up to 4 times if necessary. If the ob struction still remains, recommence mouthto-mouth resuscitation until help arrives, or actively seek aid. When there is no longer an obstruction place the person in the re covery position if his/her condition allows. Heimlich manoeuvre on a child With children, follow the sequence as for an adult but sit on a chair and lay the child over your knee, supporting the chest with one hand and slapping smartly between the shoulder blades with the other. For abdominal thrusts, sit the child on your knee, place one hand around the ab domen and clench your fist. Use the same thrusting movement as for an adult, but with less pressure. Support the child’s back with your other hand. If the child is uncon scious, place them in the same position as you would an adult. Use the same method but use only one hand and apply less pres sure. Technique for infants If an infant has inhaled a foreign body, hold them upside down by the feet and slap smartly between the shoulder blades. Much lighter pressure is required. Repeat up to 4 times. Alternatively, lay the infant head downwards so that the chest and abdomen are lying along your forearm. Use your hand to support the head and slap smartly between the shoulder blades up to 4 times. If the obstruction remains, perform ab dominal thrusts. Place the infant on a firm surface with the head in the open airway position. Place two fingers of one hand on the upper abdomen and press with a quick inward and upper movement. Repeat up to 4 times. I^j^J The photographs in this article were taken by Bob Evans, PO Box 792, King's Norton, Birmingham. Eltringham R, Dulkin M, Andrews S, Casey W (1989) Post-Anaesthetic Recovery — A Practical Ap proach. Springer Verlag, London. Platt W (1992) Behaviour at the scene of an accident, Br] Nitrs 1(13): 678-80 Roy C (1984) Introduction to Nursing: An Adapta tion Model, 2nd edn, Prentice Hall, Englewood Cliffs, New Jersey
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Downloaded from magonlinelibrary.com by 154.059.124.102 on January 11, 2019.
