Airway management, oxygen therapy and ventilation

Manage now— do this, in order

• Order of priority: a patent airway over oxygen, oxygen over ventilation, and ventilation over any drug.
• Open the airway mechanically: head tilt and chin lift, or jaw thrust where cervical spine injury is possible; suction the visible pharynx under direct vision — never pass a catheter blindly beyond the pharynx; add an oropharyngeal airway sized incisors-to-angle-of-jaw (remove it if the patient gags) or a nasopharyngeal airway where the gag is intact (not if base-of-skull fracture is possible); recovery position for the unconscious breathing patient, and position infants under one year with the head neutral.
• Bag-valve-mask ventilation with high-flow oxygen and an adjunct until an experienced operator arrives — two-person technique, squeezing slowly over one second just until the chest rises, at 10 breaths/min in adults and 12–20 in infants and young children.
• Oxygen is a drug with a device, a flow rate and a target: in the critically ill start with 15 L/min via a reservoir mask and titrate down — targets 94–98% for most acutely unwell adults, 88–92% for those at risk of hypercapnic failure, 94% or above in children; reassess five minutes after every change, and obtain a blood gas within 30 minutes in anyone managed in the lower band. Never withhold oxygen from a hypoxaemic patient for fear of CO₂ retention.Not available at your setup — Arterial blood gas.
• Stridor is managed differently: do not lie the patient flat, do not force a mask onto a frightened patient, do not inspect the throat with a tongue depressor. Give nebulised adrenaline 1:1000 — 5 mL (5 mg) in adults, 0.5 mL/kg (max 5 mL) in children — the effect wears off within 1–2 hours, so observe afterwards; in croup dexamethasone 0.15 mg/kg orally or IV; where anaphylaxis is possible, IM adrenaline 500 micrograms (300 at 6–12 years, 150 under 6), repeated after 5 minutes.
• Non-invasive ventilation: CPAP does not clear carbon dioxide — for type II failure use bi-level, starting IPAP 12–15 cmH₂O and EPAP 4–5 cmH₂O, increasing IPAP towards 20–25; for pulmonary oedema or type I failure start CPAP 5 cmH₂O and increase to 10–12. If the blood pressure falls, reduce the pressure and give a 250–500 mL crystalloid bolus. Reassess at 15 and 30 minutes and, decisively, at one hour with a repeat gas — failure to respond must trigger a decision regarding intubation.Doctor / NurseNot available at your setup — Mechanical ventilator, Arterial blood gas.
• Intubate on clinical assessment, not on waiting for a number: severe distress despite maximal therapy, exhaustion, GCS 8 or less, PaCO₂ rising above 8 kPa (60 mmHg), PaO₂ below 8 kPa despite oxygen, or failure of NIV. Prepare properly: pre-oxygenate with 100% oxygen for at least three minutes, anticipate hypotension — optimise volume and start inotropes if necessary before attempting; ketamine 1–2 mg/kg IV preserves blood pressure; halve or quarter propofol in shock, hypovolaemia or old age; avoid suxamethonium where hyperkalaemia is likely.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• Confirm with capnography — absence of a waveform in a perfusing patient means oesophageal intubation requiring immediate removal and re-oxygenation; the tip should lie 2–4 cm above the carina. Then ventilate protectively: tidal volume 4–8 mL/kg ideal body weight (ideally 6), plateau pressure not exceeding 30 cmH₂O, PEEP 5–8 cmH₂O, permissive hypercapnia provided pH stays above 7.2.Doctor / NurseNot available at your setup — Mechanical ventilator.
• A life-threatening obstruction that cannot be bypassed with a tracheal tube is relieved by cricothyroidotomy — safer, quicker and easier than a formal tracheostomy; hesitation is fatal.Doctor / Nurse