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Airway Management for the Sports Physician

Part 1: Basic Techniques

Robert L. Norris, MD; Jeffery Peterson, MD


This is the first of two articles on airway management for sports physicians. The second article, on advanced techniques, appears in our November 2001 issue.

In Brief: Airway emergencies are, fortunately, rare in sports medicine, but when they occur, they must be addressed quickly and effectively. Various techniques can be applied by a trained team physician to optimize oxygenation and ventilation for an acutely ill or injured athlete. Initial management of airway emergencies on the field can be guided using a simple algorithm. Basic maneuvers include methods to clear airways, place ventilation devices, and assist with breathing. More advanced techniques include placing various endotracheal tube devices and performing surgical techniques; these will be discussed in a subsequent article.

No emergency in sports medicine, short of a complete cardiopulmonary arrest, is more immediately life-threatening than loss of an adequate airway. Compromise of an athlete's airway may arise from several causes, including sudden loss of consciousness, trauma, anaphylaxis, and aspiration of gastric contents, blood, or foreign bodies.

The response to any acutely ill or injured patient must be met using a systematic approach, with the airway being the first priority. The injured athlete who can speak in a normal voice has a patent airway and adequate respiratory drive, at least for the time being. If the airway or respiratory status appears inadequate, measures to intervene must be instituted immediately. Simple techniques such as opening the airway, suctioning, positioning the mandible, and inserting an oral airway may be the only steps necessary to ensure adequate ventilation and life-sustaining oxygenation. At other times, however, more advanced techniques are required.

Basic and more advanced techniques can be used on the field to treat acute airway emergencies in athletes. While it is beyond the scope of this article to completely prepare sports physicians to treat airway emergencies, this review should encourage personnel to re-evaluate their training and preparation. One critical task is routine and frequent checks of available airway equipment (and emergency equipment as well) to ensure that it functions properly.

Types of Airway Emergencies in Sports

Sudden collapse of an athlete may stem from many factors, including heat exhaustion, heatstroke, cardiac dysrhythmia, seizure, anaphylaxis, and status asthmaticus. The most common cause of airway restriction in the unconscious athlete is loss of tongue muscle tone that allows it to fall back and obstruct the upper airway. Any coexistent blood or emesis compounds the problem but can be remedied (see below). In a severe anaphylactic reaction, laryngeal edema, bronchospasm, and shock can rapidly create a serious airway emergency.

Trauma interfering with the athlete's airway can be either direct or indirect. Direct trauma may cause soft-tissue injury, facial fractures, fracture of the larynx, or disruption of the laryngotracheal junction. Such severe injuries are rare but may be seen in contact sports such as football, hockey, lacrosse, and full-contact martial arts.

Laryngotracheal injuries are also a concern when off-road motorcycle or all-terrain vehicle riders collide with a chain or rope strung across their route. Direct laryngeal trauma, especially when associated with fracture of the thyroid cartilage, produces submucosal hemorrhage and rapidly progressing edema. This can result in life-threatening airway compromise in patients who may otherwise have little external evidence of injury. Expanding hematomas from vascular disruptions in the neck may cause obstruction by mechanical compression of the trachea.

Fractures of the maxilla or mandible also can lead to airway dysfunction. Bilateral, anterior mandibular fractures can result in loss of the anterior support of the tongue, allowing it to fall back and occlude the airway. Maxillary trauma (eg, Le Fort fractures) can result in rapid soft-tissue swelling and hemorrhage that can obstruct the airway.

Indirect trauma that may affect the airway and breathing includes cervical spine injuries, head injuries, and chest trauma. Central nervous system trauma can result in loss of respiratory drive or neuromuscular function of the respiratory muscles. Chest trauma can produce chest-wall injuries (rib or sternal fractures) as well as pulmonary contusions and pneumothoraces.

Airway Assessment

Airway assessment and management can be accomplished by following a step-by-step treatment algorithm (figure 1).

[Figure 1]

History. The first step in managing a patient is to assess the situation. Acute airway history-taking must necessarily be brief. The precipitating events and any pertinent medical history should be obtained when possible.

Examination. The seriously ill or injured athlete should be assessed with the "ABC" approach (airway, breathing, and circulation). The physician should evaluate skin color, distress, stridor, ability to phonate, movement of air through the mouth and nose, tracheal deviation, motion of the chest wall, breath sounds, use of accessory muscles of respiration, sternal and supraclavicular retractions, and diaphragmatic breathing.

Basic Techniques of Airway Interventions

Neck positioning and opening the airway. Proper positioning is essential in the stricken athlete to maintain an adequate airway. If any possibility of a cervical spine injury exists, the patient's neck and back should be kept in a neutral position to guard against inducing or exacerbating cord damage. The best means of maintaining a neutral cervical spine position is to have an assistant use the hands and arms to stabilize the victim's head, neck, and shoulders (figure 2). This is not a "traction" maneuver—care must be exercised to avoid distracting an unstable injury.

[Figure 2]

With the neck stabilized, the airway should be opened as necessary. This can be accomplished by opening the mouth and using a cross-finger or "scissoring" technique. Any foreign material should be swept out of the mouth; the mouth and airway can also be suctioned mechanically. The tongue is elevated out of the airway in the unconscious victim by using a chin lift or jaw thrust maneuver (figure 3: not shown).

Assisting ventilation. If the athlete is not breathing, ventilatory assistance must be started immediately. A bag-valve-mask (BVM) device should be used if available, preferably with 100% supplemental oxygen. If no resuscitation bag is available, mouth-to-pocket mask ventilation or mouth-to-mouth ventilation can be administered.

For maximal effectiveness, BVM ventilation often requires two rescuers. The first maintains a secure seal of the mask to the victim's face using the thumbs and index fingers of each hand over the mask with the long, ring, and little fingers along the mandible while simultaneously applying a jaw thrust maneuver to open the airway. The second rescuer squeezes the bag, using one or two hands as necessary to administer an adequate tidal volume. If a third rescuer is available, he or she should apply firm pressure over the cricoid cartilage (Sellick maneuver). This pressure is transmitted posteriorly through the cricoid cartilage (the only complete ring of the upper airway), closes off the esophagus, and reduces risk of passive aspiration. If the victim begins to vomit, however, pressure must be released to avoid esophageal rupture.

Oropharyngeal and Nasopharyngeal Airways

An oropharyngeal or nasopharyngeal airway can greatly facilitate ventilations by keeping the tongue from obstructing air flow in the posterior oropharynx. The oropharyngeal airway (figure 4) should only be used in fully unconscious patients as it may otherwise stimulate the gag reflex and induce vomiting. A nasopharyngeal airway (figure 5: not shown) is usually better tolerated in the semiconscious or conscious patient.

[Figure 4]

Laryngeal mask airway. The laryngeal mask airway (LMA) is an excellent alternative to the BVM. The device consists of an inflatable mask that is passed blindly into the upper aerodigestive tract. Once seated, the cuff of the mask is inflated with air (figure 6).

[Figure 6]

The patient is ventilated with a bag-valve device attached to the proximal 15-mm adapter of the LMA tube. Ventilations tend to be more effective with the LMA than with the BVM because a secure facial seal is not needed. An LMA is particularly helpful when one tries to ventilate an athlete who has a full beard. Facial hair can make it very difficult to maintain an adequate seal with a face mask. Since the cuff of the LMA rests above the vocal cords, however, there is still a risk of aspiration of gastric contents when this device is used (1).

The LMA comes in graded sizes (neonate through large adult), and prehospital care providers can be quickly taught to use the device with a greater than 90% success rate (2,3). Mannequin training can be obtained by contacting a regional representative for LMA North America (800-788-7999).

Esophageal tracheal double lumen airway (Combitube). The Combitube (Kendall Healthcare Products, Mansfield, Massachusetts) is designed to facilitate airway management when patients cannot be endotracheally intubated by direct laryngoscopy (eg, patient-related factors or operator inexperience). The device comes in two sizes, one for use in patients taller than 5 ft and the other for patients between 4 and 5.5 ft. There is no pediatric model.

The device consists of a double lumen tube (with two proximal 15-mm resuscitation bag adapters, one blue and one white) and two separate cuffs (a 100-mL, proximal pharyngeal cuff and a 15-mL, distal cuff; figure 7).

[Figure 7]

After checking cuff integrity and lubricating the device, the rescuer blindly passes the tube into the oropharynx with the help of a simultaneous chin-lift maneuver. Proper depth of insertion is achieved when the victim's maxillary incisors are aligned between two black marks on the shaft of the tube. In 98% to 99% of placements, the distal portion of the tube enters the esophagus (4). In this position, when both cuffs are inflated, the patient is ventilated using a resuscitation bag attached to the blue port (see figure 7). The distal cuff occludes the esophagus, and oxygen is delivered at the glottic opening through openings between the two cuffs.

In the rare situation in which the distal portion of the tube enters the trachea, the tube is used as an endotracheal tube (ETT), with the distal cuff occluding the proximal trachea. Ventilations in this case are administered through the white port. If the patient cannot be ventilated via either port, it is likely that the pharyngeal cuff is occluding the airway. To correct this situation, the 100-mL cuff should be deflated, the tube pulled back 2 cm, the cuff re-inflated, and the patient's breath sounds reassessed. The patient must be deeply unconscious (ie, without a gag reflex) for this tube to be used.

Contraindications to its use include patient's height less than 5 ft for the standard model, less than 4 ft or greater than 5.5 ft for the small adult model, or a history of caustic ingestion or esophageal disease. The Combitube device has a high rate of success in oxygenating and ventilating patients if the rescuer has had some formal airway management training (didactic instruction, videotape viewing, and mannequin work) (5).

Remaining Trained and Vigilant

Airway assessment is of utmost importance in the initial evaluation of the acutely ill or injured athlete. The sports medicine physician can best prepare for these emergencies by ensuring, in advance, that appropriate emergency airway equipment is available and operating properly, and by being familiar with some of these techniques—and the ones to be covered in part 2 of this article, which will appear in a subsequent issue.

For those with little airway experience, additional training can be obtained through the Advanced Cardiac Life Support Course, the Advanced Trauma Life Support Course, and the Pediatric Advanced Life Support Course. More intensive training can be obtained through courses and teaching videos (eg, the National Emergency Airway Management Course, phone: 800-458-4779), manufacturers of kits, and anesthesiologists. Having the proper medical equipment available and knowing the techniques to use when an airway emergency occurs at an athletic venue can literally mean the difference between life and death.


  1. Reed AP: Current concepts in airway management for cardiopulmonary resuscitation. Mayo Clin Proc 1995;70(12):1172-1184
  2. Pennant JH, Walker MB: Comparison of the endotracheal tube and laryngeal mask airway by paramedical personnel. Anesth Analg 1992;74(4):531-534
  3. Stewart RD, Paris PM, Winter PM, et al: Field endotracheal intubation by paramedical personnel: success rates and complications. Chest 1984;85(3):341-345
  4. Wissler RN: The esophageal-tracheal Combitube. Anesthesiol Rev 1993;20(4):147-152
  5. Blostein PA, Koestner AJ, Hoak S: Failed rapid sequence intubation in trauma patients: esophageal tracheal Combitube is a useful adjunct. J Trauma 1998;44(3):534-537

Dr Norris is an associate professor of surgery and emergency medicine and chief of the division of emergency medicine at Stanford University Medical Center in Stanford, California. Dr Peterson is a resident physician in the Stanford/Kaiser Emergency Medicine Residency Program in Stanford, California. Address correspondence to Robert L. Norris, MD, 701 Welch Rd, Suite C, Palo Alto, CA 94304; e-mail to [email protected].