Reducing Pre-Hospital Mortality for Warfighters with Airway Obstructions

At a workshop hosted by the National Academies of Sciences, Engineering, and Medicine, Dr Jon Gandy, Emergency Medicine Specialist, highlighted that in Tactical Combat Casualty Care (TCCC), 87% of combat deaths occur during in the Pre-Hospital environment, with 24% being potentially preventable, with airway obstruction being a leading cause.  The most common cause of upper airway obstruction occurs when the tongue falls back into the pharynx and the musculature in the soft palate relaxes. This results in partial or complete obstruction of the airway, preventing adequate respiration and, thus, reduced oxygenation in the patient. This often occurs due to decreased neurological function, which can occur after traumatic and blast injuries - common in military casualties.  Nasopharyngeal airways (NPAs) (Figure 1) are a mainstay of airway management in the civilian and military Pre-Hospital environment and are also commonly utilized in emergency departments and operating rooms. Despite their importance NPA’s have alarmingly high failure rates as air way obstruction can still occur, and they do not provide airway protection from aspiration, which can lead to life threatening aspiration pneumonia. A leading cause for failure in the DoD is that combatants are issued NPA's as if they are one size fits all, but people of different heights require different lengths to ensure the tongue depresses and that the NPA does not inadvertently obstruct the airway. The current Tactical Combat Casualty Care (TCCC) guidelines (standard of care for battlefield medicine) recommend the use of NPAs in casualties with airway obstruction or impending airway obstruction [9]. NPAs are recommended to be carried by all combatants in their Individual First Aid Kits (IFAK). This reduces the number of supplies that combat medics must carry to ensure medical equipment is available even if a medic is not nearby or able to access the patient. These IFAKs are designed to be very lightweight and only critical medical supplies are included. A 2020 study in the Journal of Special Operations Medicine found that the most frequently carried medical device in medic’s aid bags was an NPA. A distinct advantage of the NPA is that it is relatively noninvasive compared to cricothyroidotomy (an infrequent procedure that involves placement of a tube through an incision in the throat to establish an airway for oxygenation and ventilation), which have high risk of complications and failure rates as high as 33% .