Talk:Airway management

Wiki Education Foundation-supported course assignment

This article is or was the subject of a Wiki Education Foundation-supported course assignment. Further details are available on the course page. Student editor(s): OnurYenigun, Yoursfrankly, Norvertrinidad, Randhillon. Peer reviewers: Jhandcox, Kinisem, Amlunatesan, VeeBabzel.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 13:41, 16 January 2022 (UTC)

Student Project

We are a group of Notre Dame Australia Doctor of Medicine Students reviewing and editing wikipedia pages to improve their quality.

Jaw thrust

My understanding is that jaw thrust is still an acceptable method of airway control, just not for the lay person. At least that's the accepted teaching in the UK. Anybody have any source for it being totally contraindicated by ILCOR? If not, I'll remove that comment. --John24601 21:23, 1 July 2007 (UTC)

No, it's not totally contraindicated. It should be made abundantly clear that lay rescuers are not to use the technique; that it is reserved exclusively for healthcare professionals. Link to ILCOR paper here (Circulation). I'll try to make it clearer in the article. -Mike.lifeguard 00:48, 2 July 2007 (UTC)

I've just tidied up the edit a bit, because it was still a bit how-to, and sounded like POV. Hope you like the revised version Owain.davies 09:23, 2 July 2007 (UTC)

• Whilst wikipedia should write for non-experts, I don't think we need to be assuming that when we discuss different techqniques, if we don't explicitly say it then they're going to do it. If we start doing that, we'd have to go to such ridiculous lengths as telling people not to perform a Heart transplant. I like the article as it currently stands (as revised by Owain). --John24601 09:32, 2 July 2007 (UTC)

New section on supraglottic airways?

I'd like to add a section on supraglottic airways such as laryngeal masks. I'm new to editing wikipedia, but I did notice that there's a picture of a proseal (which is a form of supraglottic airway) next to tracheal intubation. A proseal does not itself enter the trachea and is not an example of tracheal intubation, though you might intubate through it. A picture of an endotracheal tube might be better here. Also, the Adjuncts to airway management and Invasive airway management have some repetition re: intubation. So, here are some proposed sections that I'd like to reorganise/write under Invasive airway management:

• Unprotected airways
  • Oropharyngeal
  • Nasopharyngeal
  • Supraglottic
• Protected airways
  • Endotracheal
  • Surgical (cricothyroidotomy, tracheostomy etc.)

Any objections to these ideas? If not, might start work in a sandbox first. Any comments/help appreciated. Bron (talk) 05:21, 17 May 2013 (UTC)

Thank you for offering to expand the article. The most important factor is that you use reliable sources to support statements. Have you read WP:MEDRS? Regarding the categories that you describe, I would advise caution.

There are different levels of "protection" in this context. My understanding of the laryngeal mask airway (or "supraglottic" as you say) is that it partially protects the airway. Of course it won't prevent vomitus from entering the trachea, but it has more effect than the oropharyngeal airway in preventing saliva from doing so.

Endotracheal intubation per se does not protect the airway—rather it is the inflation of the cuff. (Of course this is one of the advantages of ET intubation.) I am aware of a case where an anaesthetist (anesthesiologist) passed a size 5 ET tube and left the cuff deflated in a patient with laryngeal necrosis. Cricothyroidotomy certainly does not protect the airway. Tracheostomy may or may not protect the airway, depending on whether a cuff is used. In long-term tracheostomy patients, often a cuff is not used. Indeed many of these patients have fenestrated tubes to allow speech. Axl ¤ [Talk] 10:46, 17 May 2013 (UTC)

- Yes agreed, surgical airways should have been one category up on its own, oops. Actually, even though it is the way we're usually taught (protected airway = cuffed endotracheal tube or conscious pt with intact airway reflexes), you're right to point out that there is still a risk of aspiration around the cuff and a LMA does seem to reduce the aspiration risk. I will do some more research, but it might be better just to list OPA/NPA/LMA/ETT/cric etc. all under 'invasive airways'. Terminology for LMA/ supraglottic / extraglottic / periglottic is not very well standardised it seems. I will work on the rewrite with good references. Thanks for your help. Bron (talk) 13:21, 17 May 2013 (UTC)

You're welcome. The best approach is to choose a good quality reference and follow the format that it uses. Not only does this avoid your dilemma, it also gives you supportive evidence if someone challenges you. I also suggest that you edit the article directly—not in a sandbox. This allows other readers to see your edits sooner, it allows other editors to edit and improve your work, and it potentially allows other editors to flag up problems sooner. Axl ¤ [Talk] 19:56, 17 May 2013 (UTC)

All the methods of airway management mentioned so far are invasive and should be classified as such. An example of Non-Invasive Ventilation would be the use of a facial mask or helmet on the patient in order to enable CPAP ventilation as an alternative to intubation in a conscious patient. While tracheal intubation (with blocked cuff) is the gold standard in airway management, giving the best possible protection against aspiration, it is not always possible or practical to intubate. Some alternatives not mentioned in this article include the ventilation with a facial mask, the Laryngeal tube we use a lot in Europe and the older and now little used double-lumen tubes such as the Carlens tube.Ochiwar (talk) 07:03, 18 May 2013 (UTC)

This article is about airway management, not ventilation. Non-invasive ventilation has no place in this article. Also, as I mentioned on your talk page, CPAP is not a form of ventilation. At a stretch, CPAP might be regarded as "airway management" in the broadest sense with respect to obstructive sleep apnoea, I doubt that sources about airway management would describe it as such. Axl ¤ [Talk] 12:19, 19 May 2013 (UTC)

As I said on my talk page, Yes I agree. I am not suggesting that CPAP should be part of this article. I only mentioned it in response to Brons suggestion above to list OPA/NPA/LMA/ETT/cric etc. all under 'invasive airways'. I was trying to explain that they all are indeed invasive and to demonstrate the difference between invasive and non-invasive ventilation (NIV) I mentioned CPAP as an example of non-Invasive (not with the intention of it being a part of the article). I do not regard CPAP as a method of airway management, as it is indicated only on concious patients with spontaneous breathing and intact reflexes, which means basically that they already (or still) have an intact and existing airway so there is not much "airway management" involved. Like you say, at a stretch OSAS may be an exeption in the broadest sense but even then I would not regard it as airway management in the context of this article. In a nutshell what I am saying is "Laryngeal tube and Carlens double-lumen are some forms of invasive airway management not mentioned in this article. The former has practical applications, while the latter is more a historical note." Technically speaking though I must correct your statement that CPAP is not a means of ventilation. In most textbooks and articles, CPAP is described as non-invasive ventilation (NIV) for example here and hereand here CPAP is distinctly mentioned as a form of ventilation, albeit non-invasive. I agree with you it has little or nothing to do with airway management though (In the context of this article). Ochiwar (talk) 14:42, 19 May 2013 (UTC)

I accept that some sources describe CPAP as a form on non-invasive ventilation. However, in my opinion, this is a convenience for want of a better phrase, and also because many bilevel non-invasive ventilators can be used to deliver CPAP. Consider this: what exactly is "ventilation"? Is oxygen delivered via face-mask a form of ventilation? Oxygen via nasal cannulae? Hyperbaric oxygen? Axl ¤ [Talk] 09:50, 20 May 2013 (UTC)

Well I agree as stated above. I have found an article on the double lumen tube I had been referring to as Carlens tube above (its actually called Combitube) and added it to the article. I am rewriting the Combitube article a little and adding references because some of the material in that article is not quite accurate, such as; "Inflation of the cuff allows the device to function similarly to an endotracheal tube and usually closes off the esophagus, allowing ventilation and preventing pulmonary aspiration of gastric contents". Maybe you could look at it later for a c/e after I have done some preliminary work on that. Ochiwar (talk) 10:47, 20 May 2013 (UTC)

Me? Sure. Let me know on my talk page when you want me to look over the article. Axl ¤ [Talk] 21:51, 21 May 2013 (UTC)

Ok here are some changes, what do you think? I won't be surprised if my edit gets rejected, just thought it would be worth having a go. (Be Bold and all that...) Still learning! More work needed, of course. I agree that the Artificial airway article could be merged, just noticed that suggestion, so I might look at what's involved there next... Bron (talk) 01:59, 23 May 2013 (UTC)

It looks good. Axl ¤ [Talk] 19:33, 23 May 2013 (UTC)

A few general comments

All: I have no expertise in this field, but I am teaching the class through which Bron came to improve this article. I took a look, and have a few general comments as a lay reader. Hopefully these will be helpful to anyone looking to improve the article:

• The lead section is very short for such a detailed article, may leave the reader wanting a broader overview before diving into the details. I would suggest, at minimum, mentioning the topics that are explored in the later sections. For instance: what are "airway maneuvers" and "

Invasive airway management"? Why are "Removal of vomit and regurgitation", "Airway management in specific situations" significant?

• Related to the first point, the first two sections could use a little introductory prose (either in addition to, or complementing, any summary info added to the lead section).
• There is a proposal to merge artificial airway into this article. It's best to create a section here on the talk page expressing why that merge would be a good idea, and creating the opportunity for others to express why they think the articles should remain separate (if they do). It's best not to take too long on decisions about merges, as it can have a somewhat paralyzing effect on the content; it's easier to expand the article(s) if there is a clear agreement about whether there will be one or two.
• This one may take more research and work than the others, but seems worth mentioning: what is the history of airway management? It seems likely to me that the understanding and techniques of the procedure(s) have evolved over the years. When was the concept first articulated? By whom? How has it evolved and changed? Have established medical societies or peer reviewed journals advocated for significant changes to how it's approached? A "history" section would be a welcome addition to the article.

Overall, it looks like the article has had significant improvement recently. Keep up the good work everyone! -Pete (talk) 17:26, 16 June 2013 (UTC)

Overhaul and splitting of the article

Hi. I know these things are usually discussed on the talk page before major changes are done, but I was stricken by the mood and did an overhaul of the article. More specifically; I simplified and reduced it where I could and split the article into basic, advanced and surgical airway management. While Airway management have lost some information (not much by the way, I more or less just update the language), more or less everything have just been moved to the three fore mentioned articles, although a lot of it have been rewritten to some extend. Thereby making this an overview article. Please have a look through it and correct what you don´t like. And again; sorry for proposing the split/forking of the article here. Kind regards JakobSteenberg (talk) 18:50, 19 December 2014 (UTC)

references/reviews

• [1] might be useful for this and related article(s)--Ozzie10aaaa (talk) 00:35, 12 September 2016 (UTC)

Article Overhaul (November-December 2016)

To readers/editors of the "airway management" article:

As a collaboration between Anesthesia, Surgery and Emergency Medicine students at The University of California - San Francisco Medical School, this article will be significantly improved over the next couple of weeks. It is our goal to improve and update the content, accuracy, readability and references of the article. Stay tuned for a more precise timeline of deliverables anticipated to be released by end of November. We appreciate any suggestions as we complete this work.

Update November 28, 2016 The individual sections/subsections of this Article will be edited by the corresponding individuals below

Lead Section: (Onur Yenigun-Emergency Medicine)

Basic Airway management (Ranvir Dhillon- Emergency Medicine)

• Treatment (Ranvir Dhillon- Emergency Medicine)
• Prevention (Ranvir Dhillon-Emergency Medicine)

Advanced Airway Management (Norver Trinidad- Anesthesiology)

• Removal of Foreign Objects (Frank Lu- General Surgery)
• Supraglottic Techniques(Norver Trinidad- Anesthesiology)
• Infraglottic Techniques(Norver Trinidad- Anesthesiology)
• Surgical methods (Frank Lu- General Surgery)

Airway Management in Specific Situations

• Cardiopulmonary Resuscitation (Onur Yenigun-Emergency Medicine)
• Trauma (Onur Yenigun-Emergency Medicine)
• The Difficult Airway (Norver Trinidad- Anesthesiology)

Overall, we believe the structure of article is appropriate (i.e. basic, advanced, specific situations) and will be maintaining this format. Again, we will do our best to incorporate the aforementioned suggestions by the community as well as any new suggestions. Broadly, we will utilize WikiMedicine's guidelines to ensure this article maintains a neutral point of view, presents well-documented and accurate information published in textbooks and secondary sources, is free from copyright violations, and is optimized for the lay-reader in mind using an Acrolinx report... Stay tuned.

Norvertrinidad (talk) 03:27, 24 November 2016 (UTC)

PEER REVIEW BY KIRAN SEMBHI Peer-review feedback for Norver: Anyway, here are my specific comments. Please take it leave as you see fit. It’s just my lay opinion. Overall, I really enjoyed reading it. Lead section: Overall, great summary of the subject. Just enough information so that it is not overwhelming. These are just a few thoughts I had: again, please take or ignore as you see best. “both prevent and relieve airway obstruction” Is there an easier way of saying this? Maybe I’m underestimating the lay reader…but I suggest: “Airway management includes a set of maneuvers and medical procedures performed to prevent airway obstruction or relieve it.” But may be okay as stands. Really like the 2nd sentence about the open pathway for exchange. 3rd sentence: very long, making it slightly complicated to follow. Suggest breaking it up. Current: “This is accomplished by either clearing a previously obstructed airway, which can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration), or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation.” Suggested rearrange: This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration). I really like the clear division in your explanation about basic & advanced categories. You make it easy to understand the structure. Great basic category explanation with examples. Advanced category-I suggest adding an immediate definition for the layperson supraglottic (above the vocal cords), infraglottic (below the VC). Although, I see how you are trying to keep things short. My suggestion: Advanced techniques require specialized medical training and equipment, and are further categorized anatomically into supraglottic devices (above the vocal cords), infraglottic techniques (below the vocal cords), and surgical methods (such as cricothyrotomy). Supraglottic devices include oropharyngeal and nasopharyngeal airways. Infraglottic includes tracheal intubation. Great last line.

Supraglottic I think this is well written and relatively easy to read even for the lay person. There are some terms eg.positive pressure, spontaneous ventilation…that may not necessarily be understood by the absolute layperson, but I can’t suggest an alternative. Otherwise, I really like the structure and the walk through the explanation. I think it is explained simply and easy to follow. I REALLY like the oropharyngeal and nasopharyngeal sections. They are well explained with pertinent information. Per your question, I do not think it is too long. I think the shorter sentences, make it easier to follow. I think the extraglottic section has a little more medical jargon that I think the layperson may know (cuffed perilaryngeal sealer…unless they have seen this before, it just sounds very medical. Again, I don’t know how to fix it. Maybe a picture?). However, I think it is deep enough in the article, that if a person is reading this far, they probably have enough acumen to be okay with this level of medical speak.) Overall, I think it is a very well-written section and flows well. Infraglottic Very reader friendly. Good summary. Concise. Surgical: Excellent section. Very readable. Definitely tailored to your target audience.

Norver, Hope this was what you were looking for. I’ve never done a peer review before. f not, please let me know and I’ll give it another try. — Preceding unsigned comment added by 128.218.43.254 (talk) 16:48, 13 December 2016 (UTC)

Peer Review for Onur, by Jordan

Overall, great job Onur. Your sections and content are very clear and well-organized. Some concepts and sentences are slightly technical, but it works well given the advanced content of your page. Great job supporting your text with citations. If you have time, try to comb through it one more time and shorten sentences where possible, to make translation of the page easier. Nice work!

Lead Section

This is a great lead section. I like the very clear, succinct division between basic and advanced management. One suggestion is to update the gray info box to follow the format of other medicine pages. I know a lot of categories do not apply to airway management, but you could include: Specialty, Symptoms, Causes, and possible Treatment (see Hepatitis page for example). Also, for clarity in translation, replace the “It” with Airway” in this sentence: “It represents the "A" In the ABC treatment mnemonic”

Airway Management in Specific Situations
Cardiopulmonary Resuscitation

• Could you perhaps include a photo of head-tilt chin-lift?
• Can you simplify this concept with a lay person in mind: “Given that these are observational studies, caution must be given to the possibility of confounding by indication. That is, patients requiring an advanced airway may have had a poorer prognosis in relation to those requiring basic interventions to begin with.”
• I like the section on what bystanders should do; can you add a link to a “Hands-Only” CPR page on wiki, if it exists?

Trauma

• This is a great section. I think it could benefit from 1 to 2 pictures, maybe of bag-valve masking in the pre-hospital section and a videolaryngoscope or ETT picture in the in-hospital section?
• Perhaps break up the last paragraph into 2 paragraphs: “in-hospital” management” and “difficulties in management.” The paragraph is long and can be conceptually split into Airway in ED and then things that make airway in ED difficult, e.g. the beards/trauma and blood/vomitus, edema sentences.
• Good citations in this section!

Conscious Sedation

• I think ya’ll deleted this section, let me know if there’s anything else you’d like for me to review.

Nice work! Jhandcox (talk) 18:40, 13 December 2016 (UTC)

'PEER REVIEW for Ranvir by Amlu:

Basic Airway Management Overall, awesome job! The language of your section is simple, concise and easy to understand. It is also well-organized and you do a good job of contextualizing your section in the greater topic! I just have a few minor comments that you may or may not want to incorporate:

Introduction Paragraph

• Could you maybe add a 1-liner about basic airway management as the first sentence of this paragraph? Something similar to what is said in the lead paragraph just so the reader understands what it is in the event that they did not get that far down in the lead paragraph. But I also understand if you didn’t want it to be repetitive!
• If you could just expand the “non-invasive” link that links out to the minimally invasive page
• For clarity, if you could add, “Basic airway management can be divided into treatment and prevention of an obstruction in the airway.” Just to improve flow into the next sentence.

Treatment

• You could consider adding a little bit to improve flow and context: “Treatment includes different maneuvers that aim to remove the foreign body that is obstructing the airway. This type of obstruction most often occurs when someone is eating or drinking.”
• I got a little lost on my first read of this sentence so I would just add a few words to clarify. “Abdominal thrusts can also be performed on oneself with the help of certain objects, such as by leaning over a chair.”
• Could you maybe add a picture for the children <1 being in head-down position? I could see that being super useful for readers!
• You could just cut off the sentence at “However, many modern protocols recommend against the use of the finger sweep.” Since it’ll get too long otherwise!
• Great citations and presentation of different protocols!

Prevention This was great – it is a complicated topic so I think you did an awesome job organizing and simplifying!

• There are a few words that may be difficult for a layperson to understand (i.e. flexion and extension in the healt-tilt/chin-lift section). I’m not sure if it is worth expanding on those or including a photo that more clearly depicts the angles of extension and flexion? But I’ll leave this up to you since there is already a page on the healt-tilt/chin-lift, so there may not be a point in reinventing the wheel here!
• Same goes with jaw-thrust maneuver – maybe just adding a better clarifying photo regarding anatomy and finger placement and keeping the linked page will be enough! But the overall wording is clear and makes sense.
• Could you clarify what a dependent position is or if this is allowed, maybe you could ask readers to refer to the photo?
• Just a few additional words to help improve flow since this is the first time in this article a collar is mentioned: “When there is a possibility of cervical injury, collars are used to help hold the head in-line. Most of these airway maneuvers are associated with some movement of the cervical spine. Even though cervical collars can cause problems maintaining an airway and maintaining a blood pressure….”

Again, awesome job overall. All of my comments are minor so feel free to take them as you see fit!

Amlunatesan (talk) 19:59, 13 December 2016 (UTC)

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