Airway maintenance and protection

Comatose patients or those with bulbar palsies require careful airway and respiratory management to maintain and protect the airway. The pharynx is the most common site of airway obstruction in comatose patients because of decreased tone in pharyngeal muscles and posterior displacement of soft tissue due to the gravity effects of the supine position. Trauma patients may also have local injury and swelling.

Protective airway reflexes may also be absent in those with a decreased consciousness level or bulbar palsies. The risk of aspiration of gastric contents during passive regurgitation can be minimized by airway protection with an endotracheal tube or tracheostomy. Protective airway reflexes are lost in a predictable manner as the consciousness level decreases; the pharyngeal reflex is lost first, followed by the laryngeal and finally the tracheal reflex.

As a general rule patients with a Glasgow Coma Scale score below 8 require airway control and protection. Postoperative neurosurgical patients may require transfer between departments (e.g. for CT scanning), and it is imperative that the trachea is intubated and ventilation is controlled if the consciousness level is deteriorating or the patient is already comatose.

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