Airway: Simple airway manoeuvres and facemask ventilation

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Airway manoeuvres all have one aim – open the airway so that air/oxygen/vapours can be delivered to the lungs. Simple manoeuvres are life saving: understanding the anatomy, what each manoeuvre achieves and what to do if the manoeuvres fail will be the key to success in airway management – it’s your special skill as an airway trained practitioner!!

Head tilt, chin lift and jaw thrust

The head tilt, chin lift and jaw thrust are simple, quick manoeuvres that are life saving in dealing with an obstructed airway initially. It is worth taking the time to understand these movements and what their value is in opening an airway.

Golden rule: Whatever manoeuvre you perform, always check airway patency each time you make a change! Eg. head tilt, chin lift then check for ETCO2/breathing (chest rise/misting/breath sounds).

Here is a demonstration of how to do this:

The video has no audio πŸ™‚
The video has no audio πŸ™‚
To show you what you achieve with the head tilt, here’s a fluoroscopic video of the airway opening up the moment you tilt the head back and lift the soft tissues up with a chin lift.
Similar thing for an MRI!

Oropharyngeal and nasopharyngeal airways

The video is audio-free. Size the airway from the incisor tooth to the angle of the mandible. Once you pick the appropriate sized oropharyngeal airway, insert it the opposite way round because if you do it the standard way round you might end up pushing the tongue back and worsening the airway obstruction. Once the guedel reaches the soft palate at the back of the mouth, turn the airway 180 degrees and check airway potency with a face mask.
This video is also audio free. Size the airway from the nostril to the tragus of the ear or the angle of the jaw. Once the appropriate size is chosen, put lubricant over the tip (check you’ve not blocked it up with lubricant though!) and gently insert backward with a slight twisting movement. You should not have to apply significant force, otherwise you can cause nose bleeding. You should not put nasopharyngeal airways into patients with head injuries as there is a risk of going through an existing base of skull injury and making a connection between the back of the nose and the CSF and brain – introducing infection from the nostril up to the brain and also introducing leak of CSF or blood out of the cranium through the nose (thus affecting intracranial pressure).

Good face mask ventilation technique

In the video above, the trainer demonstrates bag valve mask ventilation with one and 2 hands. For successful bag mask ventilation, you need to be able to keep the airway open whilst at the same time squeezing a bag to fill the patient’s lungs with air/oxygen/vapour mix.

One handed or 2 handed?

Anaesthetists frequently can do one handed bag mask ventilation for elective patients with fewer risk factors – one hand holds the mask in place and the other squeezes the bag.

For any emergency department, intensive care, pre-hospital, emergency list or even any elective patient with any risk factor, it is advisable to perform 2 handed face mask ventilation to improve the seal with the mask and keep the airway open at the same time.

Whichever technique you choose, the most important part of this is to check that the technique is working and recognising quickly if you need to adapt or change it.


Which brings us to troubleshooting.

Keys to success with face mask ventilation: A good seal with the mask and a patent airway.

Poor seal with face mask

What is a poor seal?

When the mask is on the patient’s face, you ideally want 100% of the air, oxygen, vapour mix that you’re giving them to go into their lungs, but because you don’t have a direct connection to the lungs that you might have with an endotracheal tube, so you have to get the gas mix into the mouth, down the oropharynx and in past the vocal cords into the trachea to the lungs.

The first problem is getting the gas mix into the mouth – face masks are standard sizes but not everyone’s faces are made to fit these standard sizes. This might lead to the gas mix leaking out the side of the face mask before it even gets into the mouth, in other words, a poor seal.

Why does it happen?

Generally: Poor positioning of the patient and the practitioner
1) Can’t place the facemask directly on skin – beard, NG tube
2) Can’t fit mask over mid face (mask too large or too small) – facial trauma, broken nose, craniofacial defects
3) Can’t fit mask over bottom of face or chin (mask too large or too small) – large jaw eg acromegaly or high BMI, receding jaw, patients with dentures especially after the dentures are removed

What can you do?

  • Use 2 handed techniques if you’re using 1 handed techniques and getting a bad seal
  • Tape over the beard with tegaderm – plastic + plastic is a better seal
  • Gently pushing the soft tissue inward into the mask before adding a jaw thrust to help with the seal
  • Adding adjuncts in to help (eg. oropharyngeal and nasopharyngeal airways) a higher % of the gas to enter the patient’s mouth rather than leaking out the side
  • Using high flow nasal oxygen (Optiflow) to oxygenate (assuming the nasopharynx onward is patent)
  • Moving on to another step – see below
Keeping the airway patent

Some patients have a large amount of soft tissue or very tight soft tissue after radiation therapy, or sometimes have some other obstruction in the mouth, throat, larynx eg. foreign body, tumour, large tonsils that makes it difficult for the gas mix to enter the airway despite having a good seal over the face.

This can really tire your hands out as you’re having to lift the patient’s face very hard up into the mask and at the same time keep the mask pressed firmly onto the patient’s face.

What can you do?

  • Use 2 handed techniques if you’re using 1 handed techniques and getting a bad seal
  • Using a higher flow might help improve the mass flow of gas mix into the trachea past the soft tissue
  • Add adjuncts in to help (eg. oropharyngeal and nasopharyngeal airways) a higher % of the gas to enter the airway

A suggested troubleshooting plan for unanticipated difficult face mask oxygenation/ventilation is presented in the video below:

If you think there are risk factors for difficult ventilation, plan ahead and make sure you and your team are aware of what difficulties you might face and what your plan is. You need the appropriate people, equipment, and drugs ready for any of the above plans, and it is better to be over prepared than underprepared. It takes time to draw up medications and to set up for Optiflow so it is always better to take an addition 5-10 minutes getting everything ready before you put the patient to sleep than to try to ask the ODP, ward nurse or theatre staff to do it midway through induction because you can’t leave the patient.

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