airway management

1. THE AIRWAY AND
BREATHING
EMERGENCIESL E S S O N 7

2. INTRODUCTION
Emergencies with airway or breathing are
common/critical
If assessment shows airway not
open/patient not breathing, act
immediately
Vital organs die in minutes
Illness/injury that impairs airway/breathing
is respiratory emergency

3. RESPIRATORY SYSTEM: PRIMARY
ORGANS<Fig 3-3>

4. STRUCTURES OF THE UPPER AIRWAY

5. BREATHING UNDER CONTROL OF
NERVOUS SYSTEM
When diaphragm contracts/moves down,
thoracic cavity and lungs expand,
decreasing pressure within lungs
Air flows into lungs because pressure is
lower
When diaphragm relaxes/moves up, size of
thoracic cavity reduced and air flows
back out of lungs

6. THE MECHANICS OF BREATHING

7. RESPIRATORY SYSTEM:
PRIMARY FUNCTIONS
Move air in and out of lungs
Oxygen from inhaled air moves into blood
Carbon dioxide from blood moves into air and is
exhaled

8. THE AIRWAY ANATOMY OF
INFANTS/CHILDREN
Airway structures smaller/more easily
obstructed by foreign bodies
Tongue takes up more space than in adults
Trachea more flexible
Don’t hyperextend neck by pushing head back too
far

9. RESPIRATORY PROBLEMS AND
CARDIAC ARREST
Primary cause of cardiac arrest in
infants/children is an uncorrected
respiratory problem.

10. AIRWAY
First thing to check in initial assessment
You may need to open airway, maintain its
patency, or clear it when it is
compromised

11. OPENING THE AIRWAY
Tongue is most common cause of airway
obstruction
Use the head tilt–chin lift to lift tongue
from back of throat and open airway
In a trauma patient, use jaw thrust

12. ASSESSING AIRWAY
Factors that impede flow of air in and out
of lungs affect respiration/can become
life-threatening
An airway obstruction is a physical
blockage that prevents flow of air
Food may lodge in pharynx
An injury to head/neck may cause soft
tissues of upper airway to swell
Any obstruction is a life-threatening
situation

13. SWALLOWING REFLEX
Epiglottis normally prevents substances
from entering trachea with swallowing
reflex
In unresponsive person, this reflex may
not function
In an unresponsive patient lying on the
back, vomit may flow back down throat
blocking/limiting respiration

14. AIRWAY ASSESSMENT
After opening airway, assess that it’s
patent and clear of fluids/solids
Assess airway in unresponsive patients
and responsive patients with injuries or
altered mental status who may not be
able to protect their own airway

15. CHECK AIRWAY FOR PATENCY
Open mouth with gloved hand
Listen for sounds indicating liquid
in airway
Look inside for fluids, solids, or
objects
Clear using finger sweep or
suction

16. CLEARING A COMPROMISED
AIRWAY WITH FINGER SWEEP
Perform finger sweep if fluids/solids seen
in mouth/airway
Roll patient onto one side (left preferred)
Wipe liquids or semi-liquids from mouth
For solid objects, hook index finger, sweep
object to side and out of mouth

17. MAINTAINING OPEN AIRWAY IN
UNRESPONSIVE PATIENTS
When patient is supine, airway must be
kept open with either the head tilt–chin
lift or the jaw thrust
An airway adjunct may be used to help
maintain an open airway
If you must leave the patient’s side, move
patient into recovery position to keep
airway open

18. RECOVERY POSITION
Helps keep airway open
Allows fluid to drain from mouth
Prevents aspiration
If possible, put victim onto left side
Continue to monitor breathing

19. HAINES POSITION
Modified HAINES (High Arm IN Endangered
Spine) position is recommended
because it reduces movement of neck in
case of potential spinal injury
Put patient on left side to reduce chances
of vomiting
Use HAINES position for adults and
children

21. ASSESSING
BREATHING
Look for adequate breathing in adults
Look for presence or absence of
breathing in children and infants

22. ASSESSING
BREATHING
If adult not breathing adequately
(breathing rate < 10 breaths
per minute)
 Begin rescue breaths

23. MOVEMENT OR GASPING
Movement of chest may occur with
obstructed airway as unresponsive
patient makes effort to breathe
You will not hear or feel air movement
Some reflex gasping may be present just
after cardiac arrest

24. ASSESS THE WORK OF BREATHING
Breathing should be effortless
Breathing should be relatively quiet
Observe chest for adequate rise and fall
Look for movement of accessory muscles
to breathe

26. RESPIRATORY EMERGENCIES
Any illness or injury resulting in stopped
breathing or inadequate breathing
Two types
Respiratory arrest
Respiratory distress

27. SIGNS/SYMPTOM
S OF
RESPIRATORY
DISTRESS
Gasping for air
Panting
Breathing
faster/slower than
normal
Making wheezing or
other sounds
Using accessory
muscles in effort
to breathe

28. SIGNS/SYMPTOM
S OF
RESPIRATORY
DISTRESS
(CONTINUED)
Inability to speak a full sentence without
pausing to breathe
Skin may look pale, be cool and moist;
lips/nail beds may be bluish
Dizziness or disorientation
Extreme distress
Sitting and leaning forward, hands on
knees

29. RESPIRATORY
DISTRESS IN
AN INFANT OR
CHILDCrucial to act quickly - may
rapidly progress to arrest
Infant/child may have flaring
nostrils, and more obvious
movements of chest muscles

30. RESPIRATORY
DISTRESS IS A
MEDICAL EMERGENCY
Unless condition
progresses to
inadequate
breathing/respiratory
arrest, ventilation is
not needed
Patient will benefit
from supplemental
oxygen

31. INADEQUATE
BREATHING/RESPIRATORY
ARREST
Respiratory arrest/inadequate breathing is
life-threatening
Respiratory arrest—patient is not
breathing at all
Inadequate breathing—patient is breathing
too slowly/too weakly

32. INADEQUATE
BREATHING/RESPIRATORY
ARREST CONTINUED
Patient will likely have altered mental
status; may have cyanotic appearance
Patient needs ventilations
In an adult who isn’t breathing adequately,
begin to provide ventilations
In a child/infant, look for presence or
absence of breathing; child may be
breathing slowly but still adequately

34. VENTILATION
Patient who is not breathing or whose breathing is inadequate needs
ventilation
If patient’s heart is beating, ventilation provides oxygen for the blood
circulating to vital tissues
If patient has no pulse, ventilation is combined with chest compressions in
CPR
Without special equipment, provide ventilation with your own exhaled air

35. MASKS/BARRIER
DEVICES
Barrier devices recommended
when giving ventilation by
mouth
Pocket masks/face shields offer
personal protection from
patient’s fluids
With either device, keep
patient’s head positioned to
maintain open airway as you
deliver breaths

36. FACE MASKS
Resuscitation mask seals over mouth/nose with port through which you blow air to
give ventilations
One-way valve allows your air through mouthpiece, patient’s exhaled air exits
through different opening.
When using face mask, seal mask well to face while maintaining an open airway
Use bridge of nose as guide for correct placement

37. FACE MASKS
CONTINUED
Seal mask well while
maintaining open airway
How you hold mask
depends on:
Your position by patient
Method to open airway
Whether you have one or two
hands to seal mask

38. POSITION AT
VICTIM’S SIDE
With thumb and index finger seal top and sides of mask to victim’s head
Put thumb of second hand on lower edge of mask
Put remaining fingers of second hand under jaw to lift chin
Press mask down firmly to make seal as you lift chin

39. POSITION AT TOP OF
VICTIM’S HEAD: USING
HEAD TILT – CHIN LIFT
Put thumbs on both
sides of mask
Put remaining fingers
of both hands under
angles of victim’s jaw
As you tilt head back,
press mask down
firmly to make seal as
you lift chin

40. POSITION AT TOP OF
VICTIM’S HEAD: JAW THRUST
Without tilting head
back, position thumbs
on mask with fingers
under angles of jaw
Lift jaw as you press
down with thumbs to
seal mask, without
tilting head back

41. FACE SHIELD
Positioned over mouth as protective barrier
Nose must be pinched closed when giving a
ventilation to prevent air from coming out
Mask is generally preferred to face shield
because air may leak around shield

42. IF NO BARRIER DEVICE IS AVAILABLE
Give ventilations directly from your mouth
to patient’s mouth, nose, or stoma
Risk of disease transmission is very low

43. MOUTH TO MOUTH
Pinch victim’s nose shut
Seal your mouth over victim’s
Breathe into victim’s mouth
Watch chest rise to confirm air is going
in

44. MOUTH TO NOSE
Use victim’s nose if:
Mouth cannot be opened
Mouth is injured
You cannot get a good seal with mouth to
mouth

45. MOUTH TO NOSE
Hold victim’s mouth closed
Seal your mouth over victim’s nose to
breathe in
Open mouth to let air escape

46. MOUTH TO STOMA
Some people breathe through hole in lower
neck – called a stoma
Cup your hand over victim’s nose and
mouth
Seal your mouth over stoma or a round
pediatric face mask
Give rescue breaths as usual

47. MOUTH TO NOSE AND MOUTH
Infants and very small children are given
rescue breaths through mouth and nose
Seal mouth over both mouth and nose
Give gentle breaths
Watch to see chest rise and fall with each
breath

48. TECHNIQUES OF VENTILATION
With patient supine, open airway with head
tilt–chin lift or the jaw thrust
Blow air while watching chest rise to make
sure air is going into lungs
Don’t try to rush or blow too forcefully
Don’t take big breath to exhale more air;
take a normal breath
Give each breath over about 1 second

49. TECHNIQUES OF VENTILATION
CONTINUEDIf breath does not go in, try again to open the airway
If breath still does not go in, there is an airway obstruction
If initial breath goes in, give second breath over 1 second
If your breaths go in, check for pulse (C in ABCs)
If patient has pulse but is not breathing, continue ventilations at a rate of 1
breath every 5-6 seconds in an adult or every 3-5 seconds for a child
Use same steps with face shield, mouth-to-mouth ventilation, or other
techniques with nose or stoma

51. Open the
airway. Look,
listen, and feel
for adequate
breathing for
up to 10
seconds.

52. If not
breathing
adequately,
give 2 breaths
over 1 second
each. Watch
chest rise and
fall.

53. If first breath doesn’t go in, open the airway
and try again. If it still does not go in,
proceed to CPR for choking.

54. If first 2 breaths go in, check for pulse.

55. If pulse but no
breathing, continue
ventilations
Recheck for a pulse
about every 2
minutes

56. ALERT! RESCUE BREATHING
Do not blow harder than needed to make
chest rise
Let chest fall after each breath
Do not blow in too forcefully or for too long
Do not tilt an infant’s head back too far

57. DIFFERENCES IN VENTILATING INFANTS
Gently tilt head back to open airway/check
breathing—do not overextend the neck
If correct size barrier device not available,
cover both mouth/nose with your mouth
to give breaths
Give 1 breath every 3-5 seconds

58. CRICOID PRESSURE (SELLICK
MANEUVER)Prevents air from passing into stomach
 Pressure squeezes esophagus closed
Performed only:
 On unresponsive victims
 Rescuer trained in technique
 By third rescuer
Can be used on adult, child, infant

59. CRICOID PRESSURE
With index finger, locate Adam’s apple
Slide finger down neck, feel just below
indentation (cricoid cartilage)
Apply moderate pressure on cricoid cartilage

60. SPECIAL CIRCUMSTANCES FOR
VENTILATION
Vomiting
Dentures
Facial injuries

61. VOMITING
Air may move into stomach, making vomiting more likely:
airway not sufficiently open
breaths given too quickly
continue to blow in air after lungs have expanded,
chest has risen
Vomiting presents two problems:
Roll unresponsive patient onto side to drain mouth
and clear airway
Vomiting increases risk of aspiration

62. PREVENTING VOMITING
Open airway before giving a breath
Blow steadily over 1 second
Watch chest rise as you give each breath
Stop each breath when chest rises rather
than continuing to blow
Let chest fall between breaths

63. DENTURES
Usually left in place during ventilation
If loose, making it difficult to give breaths,
remove dentures

64. FACIAL INJURIES
If mouth cannot be opened, give
ventilations through the nose:
Hold mouth closed
Seal your mouth over the nose to blow in
Allow mouth to open to let air escape
A patient with injuries may have blood in mouth,
which needs to be cleared before giving ventilations

65. SEVERE AIRWAY
OBSTRUCTION
Victim is getting no air
at all
Victim will soon
become
unresponsive
Heart will soon stop

66. MILD AIRWAY OBSTRUCTION
Victim is still getting some air into
lungs around object
Victim may be able to cough out
object

67. ASSESSING AN AIRWAY
OBSTRUCTION
Most cases in adults occur while eating
Most cases in infants and children occur
while eating/playing
Often someone is present recognizing
choking event while patient responsive

68. MILD OBSTRUCTION
Victim is coughing forcefully
Victim is getting some air
Wheezing or high pitched sounds with breath
Do not interrupt coughing or attempts to
expel object

69. SEVERE OBSTRUCTION
Victim getting little air or none
Victim may look frantic and be clutching at
throat
Victim may have pale or bluish coloring
around mouth and nail beds
Victim may be coughing weakly and
silently or not at all
Victim cannot speak

70. ASSESSING AIRWAY
OBSTRUCTION IN UNRESPONSIVE
PATIENTIf patient’s head is positioned to open
airway but patient is not breathing, give
2 ventilations
If first breath doesn’t go in, try again and
give a second breath
If it still does not go in, assume that there
is obstructed airway

71. CARE FOR FBAO
Depends on whether patient is responsive
or unresponsive; whether the
obstruction is mild or severe
For responsive, choking patient who is
coughing, encourage coughing
For responsive, choking patient who
cannot speak or cough forcefully, give
abdominal thrusts
For unresponsive patient with an FBAO, if
ventilations do not go in, ensure
additional EMS personnel have been
summoned and begin CPR

72. MANAGEMENT OF SEVERE AIRWAY
OBSTRUCTIONS IN RESPONSIVE
PATIENTSAsk for consent, tell patient what you
intend to do, and give abdominal thrusts
With child/someone much shorter than you, kneel
behind patient
If patient is much taller than you, ask patient to
kneel/sit

73. MANAGEMENT OF SEVERE AIRWAY
OBSTRUCTIONS IN RESPONSIVE
PATIENTSAbdominal thrusts can cause internal
injury, patient should be examined by a
healthcare provider
When severe obstruction is not cleared,
patient will become unresponsive within
minutes

74. SEVERE FOREIGN
BODY AIRWAY
OBSTRUCTION
(RESPONSIVE ADULT OR
CHILD)

75. Stand behind victim.
One leg between
victim’s legs.
Head to one side.

76. Make fist with one
hand – thumb side in
to victim’s abdomen

77. Grasp fist with other
hand.
Thrust inward and
upward.

78. For pregnant
victim or victim you
can’t get arms
around, give chest
thrusts.

79. MANAGEMENT OF AIRWAY
OBSTRUCTIONS IN UNRESPONSIVE
PATIENTSMake sure additional EMS personnel have
been called
Provide CPR
Begin by opening airway
When opening patient’s mouth, look first
for an object in mouth
If you see an object in mouth, remove it
with finger sweep
Then give 2 breaths and check for a pulse

80. CPR FOR AIRWAY
OBSTRUCTIONS IN
UNRESPONSIVE PATIENTSChest compressions given in CPR may
expel object
While giving CPR, each time you open
mouth, check to see if object is visible,
and remove it if so

81. FOREIGN BODY AIRWAY
OBSTRUCTIONS IN
INFANTS/CHILDREN
Most child deaths from FBAOs occur under
age 5, mostly in infants
Foreign bodies include:
Toys and other small objects
Pieces of popped balloons
Food such as hot dogs, round candies, nuts, and
grapes

82. FOREIGN BODY AIRWAY
OBSTRUCTIONS IN
INFANTS/CHILDREN
Suspect FBAO in an infant/child with onset of
respiratory distress associated with
coughing, gagging, stridor, or wheezing
If responsive infant can cry/cough, watch
carefully to see if the object comes out

83. RESPONSIVE CHOKING INFANT
WHO CANNOT CRY/COUGH
Ensure that additional EMS personnel have
been summoned
Give alternating back slaps/chest thrusts
to expel object
If Choking Infant Becomes Unresponsive
Give CPR, start with chest compressions
Check for object in mouth, remove any object you
see

84. UNRESPONSIVE INFANT WHEN
ENCOUNTERED
Open airway; check for breathing
If not breathing, give 2 breaths
If first breath doesn’t go in, try again after
repositioning head to open airway
If second breath doesn’t go in, assume an
airway obstruction—provide CPR

85. SEVERE FOREIGN
BODY AIRWAY
OBSTRUCTION
(RESPONSIVE
INFANT)

86. Give up to 5 back slaps between shoulder blades

87. SEVERE FOREIGN BODY AIRWAY
OBSTRUCTION IN RESPONSIVE
INFANT
Check for expelled object
If not present, continue with next step

88. Roll infant face up.

89. Check for expelled object. If not
present, continue with next step.

90. Give 5 chest thrusts. Check mouth
for expelled object.
Repeat back slaps and chest
thrusts as necessary.