Unit 2: Primary Assessment
Airway Management
A blocked airway can quickly become a life-threatening emergency. For EMTs, recognizing airway problems and knowing how to correct them are essential skills. This section of our NREMT study guide covers airway anatomy, airway-opening maneuvers, suctioning, and the use of oropharyngeal and nasopharyngeal airways. You’ll also find five EMT practice questions with detailed answer explanations to reinforce these important concepts.
Airway management involves keeping the passage between the mouth or nose and the lungs open so that air can move freely. An obstructed airway can prevent oxygen from reaching the lungs and quickly lead to respiratory or cardiac arrest.
EMTs must recognize airway problems, open the airway using appropriate techniques, and maintain airway patency throughout patient care.
Upper and Lower Airway Anatomy
The respiratory system includes the upper and lower airways, which allow air to move into and out of the lungs.
The upper airway includes the nose, mouth, pharynx (throat), and larynx (voice box). These structures filter, warm, and direct air toward the lungs.
The lower airway includes the trachea (windpipe), bronchi, bronchioles, and alveoli. The trachea divides into two main bronchi, which branch into smaller airways within the lungs.
The alveoli are tiny air sacs where oxygen enters the bloodstream and carbon dioxide is removed.
Recognizing Airway Obstructions
An airway obstruction may be partial or complete. EMTs must recognize signs of an obstruction and intervene promptly.
Common signs include:
- Snoring: May indicate the tongue is blocking the airway in an unresponsive patient.
- Gurgling: Suggests blood, vomit, or other fluids in the airway.
- Stridor: A high-pitched sound that may indicate upper airway narrowing or obstruction.
- Inability to speak or cough effectively: May indicate a severe foreign body airway obstruction.
- Absent air movement: May indicate a complete obstruction.
An unresponsive patient’s tongue can fall backward and obstruct the airway because the muscles that normally maintain its position have relaxed.
Opening a Patient’s Airway
Two important techniques are used to open an unresponsive patient’s airway.
Head Tilt–Chin Lift
The head tilt–chin lift maneuver is generally used when a cervical spine injury is not suspected.
To perform this maneuver:
- Place one hand on the patient’s forehead and gently tilt the head backward.
- Place the fingertips of your other hand beneath the bony part of the chin.
- Lift the chin upward without pressing on the soft tissues beneath it.
This maneuver helps move the tongue away from the back of the throat.
Jaw-Thrust Maneuver
The jaw-thrust maneuver is preferred when a head or cervical spine injury is suspected.
To perform this maneuver:
- Position yourself at the patient’s head.
- Place your fingers behind the angles of the lower jaw.
- Lift the jaw forward without intentionally tilting the head backward.
The jaw thrust helps open the airway while minimizing movement of the head and neck.
If a jaw thrust does not adequately open the airway, a head tilt–chin lift may be necessary. Maintaining an open airway takes priority when a patient cannot breathe.
Oropharyngeal Airways (OPAs)
An oropharyngeal airway (OPA) is a curved device inserted through the mouth to help prevent the tongue from blocking the upper airway.
An OPA is appropriate for an unresponsive patient who does not have a gag reflex.
Important considerations include:
- Never insert an OPA into a patient with an intact gag reflex.
- Measure the airway from the corner of the mouth to the angle of the lower jaw, near the earlobe.
- Use the correct size to avoid worsening an obstruction or injuring the airway.
- Remove the OPA if the patient begins gagging.
An improperly sized OPA can obstruct the airway instead of keeping it open.
For adults, one insertion technique involves placing the OPA with its tip toward the roof of the mouth, then rotating it 180 degrees as it is advanced.
For infants and young children, use a tongue depressor to insert the OPA without rotating it.
Nasopharyngeal Airways (NPAs)
A nasopharyngeal airway (NPA) is a soft, flexible tube inserted through a nostril to help maintain an open airway.
An NPA may be appropriate for a patient with an altered level of consciousness who has an intact gag reflex and cannot adequately maintain their airway.
Important considerations include:
- Measure from the tip of the nose to the earlobe.
- Apply a water-soluble lubricant before insertion.
- Gently advance the NPA along the floor of the nasal passage.
- Never force the device if resistance is encountered.
An NPA should not be used when a basilar skull fracture is known or suspected. Significant facial trauma may also make NPA insertion unsafe.
Always follow local EMS protocols when selecting and inserting airway adjuncts.
Suctioning the Airway
Suctioning removes blood, vomit, mucus, and other fluids that may obstruct the airway.
A portable or ambulance-mounted suction device is commonly used for this purpose.
The two main types of suction catheters are:
- Rigid suction catheter: Often called a Yankauer or tonsil-tip catheter, used to remove fluids and secretions from the mouth and oropharynx.
- Flexible suction catheter: Used when a smaller or more flexible catheter is needed.
During suctioning, EMTs should:
- Use appropriate personal protective equipment.
- Position the patient and open the airway as needed.
- Insert the suction catheter carefully.
- Apply suction while withdrawing the catheter.
- Reassess the airway and breathing.
Suctioning should be limited to brief attempts to reduce the risk of hypoxia. Provide oxygenation or ventilation support as needed.
Foreign Body Airway Obstructions
Foreign objects, such as food, can partially or completely block the airway.
A patient with a mild obstruction who can cough effectively should be encouraged to continue coughing while being monitored.
For a responsive adult or child with a severe foreign body airway obstruction, current resuscitation guidelines recommend alternating:
- Five back blows, followed by
- Five abdominal thrusts.
Continue until the obstruction is relieved or the patient becomes unresponsive.
For an infant, alternate five back blows with five chest thrusts. Do not perform abdominal thrusts on infants.
If the patient becomes unresponsive, begin CPR and check for a visible obstruction before delivering breaths. Never perform a blind finger sweep.
Key Tip
Choose the airway technique or adjunct based on the patient’s condition. Use a head tilt–chin lift when spinal injury is not suspected, a jaw thrust when it is suspected, an OPA for an unresponsive patient without a gag reflex, and an NPA when appropriate for a patient who retains a gag reflex. Always reassess the airway after an intervention.