What is a potential complication of inserting an oropharyngeal airway that is too small

Oropharyngeal airways are rigid intraoral devices that conform to the tongue and displace it away from the posterior pharyngeal wall, thereby restoring pharyngeal airway patency.

Pharyngeal airways (both oropharyngeal and nasopharyngeal) are a component of preliminary upper airway management for patients with apnea or severe ventilatory failure, which also includes

• Proper patient positioning

• Manual jaw maneuvers

The goal of all of these methods is to relieve upper airway obstruction caused by a relaxed tongue lying on the posterior pharyngeal wall.

Oropharyngeal airways are indicated for unconscious patients in the setting of

• Bag-valve-mask ventilation

• Spontaneously breathing patients with soft tissue obstruction of the upper airway who are deeply obtunded and have no gag reflex

Absolute contraindications

• Consciousness or presence of a gag reflex

Relative contraindications

Insertion of an oropharyngeal airway may not be feasible in some settings, such as

• Oral trauma

• Trismus (restriction of mouth opening including spasm of muscles of mastication)

Nasopharyngeal airways may be used instead.

• Airway obstruction by an improperly sized or improperly inserted oropharyngeal airway

• Gagging and the potential for vomiting and aspiration

• Gloves, mask, and gown

• Towels, sheets, or commercial devices as needed for placing neck and head into sniffing position

• Various sizes of oropharyngeal airways

• Suctioning apparatus and Yankauer catheter; Magill forceps (if needed to remove easily accessible foreign bodies), to clear the pharynx as needed

• Nasogastric tube, to relieve gastric insufflation as needed

• An oropharyngeal airway used concurrently with a nasopharyngeal airway may improve oxygenation and ventilation.

• Aligning the external auditory canal with the sternal notch may help open the upper airway and establishes the best position to view the airway if endotracheal intubation becomes necessary.

• The degree of head elevation that best aligns the ear and sternal notch varies (eg, none in children with a large occiput, a large degree in obese patients).

The sniffing position—only in the absence of cervical spine injury:

• Position the patient supine on the stretcher.

• Align the upper airway for optimal air passage by placing the patient into a proper sniffing position. Proper sniffing position aligns the external auditory canal with the sternal notch. To achieve the sniffing position, folded towels or other materials may need to be placed under the head, neck, or shoulders, so that the neck is flexed on the body and the head is extended on the neck. In obese patients, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck. In children, padding is usually needed behind the shoulders to accommodate the enlarged occiput.

If cervical spine injury is a possibility:

• Position the patient supine or at a slight incline on the stretcher.

• Avoid moving the neck and use only the jaw-thrust maneuver or chin lift without head tilt to manually facilitate opening of the upper airway.

Head and neck positioning to open the airway: Sniffing position

A: The head is flat on the stretcher; the airway is constricted. B: The ear and sternal notch are aligned, with the face parallel to the ceiling (in the sniffing position), opening the airway. Adapted from Levitan RM, Kinkle WC: The airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.

• As necessary, clear the oropharynx of obstructing secretions, vomitus, or foreign material.

• Determine the appropriate size of the oropharyngeal airway. Hold the airway beside the patient’s cheek with the flange at the corner of the mouth. The tip of an appropriately sized airway should just reach the angle of the mandibular ramus.

• Next, begin inserting the airway into the mouth with the tip pointed to the roof of the mouth (ie, concave up).

• To avoid cutting the lips, be careful not to pinch the lips between the teeth and the airway as you insert the airway.

• Rotate the airway 180 degrees as you advance it into the posterior oropharynx. This technique prevents the airway from pushing the tongue backward during insertion and further obstructing the airway.

• When fully inserted, the flange of the device should rest at the patient’s lips.

• Alternatively, use a tongue blade to depress the tongue as you insert the airway with the tip pointed to the floor of the mouth (ie, concave down). Use of the tongue blade prevents the airway from pushing the tongue backward during insertion.

• Ventilate the patient as appropriate.

• Monitor the patient and identify and remediate any impediments to proper ventilation and oxygenation.

• Secure the oropharyngeal airway if it should remain in place (eg, during mechanical ventilation after oral endotracheal intubation).

• Use an oropharyngeal airway only if the patient is unconscious or minimally responsive because it may stimulate gagging, which poses a risk of aspiration. Nasopharyngeal airways are preferred for obtunded patients with intact gag reflexes.

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