Airway Management

Every breath follows the same physical path, and airway management is entirely about keeping that path open

Air enters through the nose or mouth, travels through the throat and down the windpipe, and reaches the lungs, where the actual exchange of gases takes place. The nose does something the mouth does not: as air passes through its curved internal passages, the nose warms and humidifies it. The whole path is divided into two regions with a specific dividing line. The upper airway runs from the mouth and nose down to the vocal cords, and the lower airway is everything below that.

The epiglottis is a single small structure doing a genuinely critical job

Right where the throat meets the windpipe sits the epiglottis, a flap that flips downward every time you swallow, sealing off the airway so that food and liquid go toward the esophagus instead of the lungs. Just below it is the glottic opening, at the level of the vocal cords, which marks the actual boundary between the upper and lower airway. This one structure explains a great deal of airway pathology. Swelling here, injury here, or failure of the mechanism itself, as in a patient with a depressed level of consciousness who can no longer protect their own airway, is why airway problems are addressed before almost anything else in patient care.

In an unresponsive patient the tongue is the most common obstruction, and it is an obstruction you can fix with your hands

The tongue is anchored to the lower jaw. When a patient loses consciousness, the muscles that hold the jaw forward relax, the jaw falls back toward the spine, and the tongue falls back with it against the posterior wall of the throat. Nothing is stuck in the airway and nothing is swollen; the airway has simply folded shut. This is the single most common cause of airway obstruction in an unresponsive patient, and the reason the first thing you do for such a patient costs nothing and takes two seconds.

Both manual maneuvers work by the same mechanism: they move the lower jaw forward, and the tongue, being attached to it, comes forward off the back of the throat. Neither one opens anything. They un-fold something.

Head-tilt/chin-lift is the default; jaw-thrust is the one you use when the spine is in question

The head-tilt/chin-lift is the standard maneuver for a patient with no suspected spinal injury. One hand on the forehead tilts the head back; the fingertips of the other hand under the bony part of the chin lift it upward. Keep your fingers on bone. Pressing into the soft tissue under the chin pushes the base of the tongue up into the airway, which is the opposite of what you are trying to do.

The jaw-thrust is the maneuver for a patient in whom you suspect a spinal injury, because it opens the airway without moving the neck. You position yourself at the patient's head, place your fingers behind the angles of the jaw on both sides, and displace the jaw forward while keeping the head in a neutral, in-line position. It is harder to hold and it ties up both of your hands, which is why it is not the default.

There is an order of priority worth being explicit about, because scenarios are written to test it. A patient with a suspected spinal injury who has no airway gets the jaw-thrust first. If the jaw-thrust does not open the airway, you use the maneuver that does. An open airway is the higher priority, because a protected spine in a patient who is not breathing is not a good outcome.

A child's airway is not a small adult airway, and the differences change what you do

Several differences matter at the bedside. A child's tongue is proportionally larger relative to the mouth, so tongue obstruction is more likely and more complete. The airway structures themselves are smaller and softer, so a given amount of swelling narrows the airway far more, and so the trachea can be collapsed by pressure from outside. The back of an infant's head is proportionally large, so when an infant is laid flat on a hard surface the head is pushed forward into flexion and the airway closes.

The practical consequence is that the neutral position for an infant or small child is not the same as for an adult. You may need a folded towel under the shoulders to bring the airway back into line, and over-extending the neck, tilting the head back as far as it will go, will kink a soft trachea shut rather than open it.

An adjunct holds the tongue off the back of the throat so your hands do not have to

A manual maneuver works only while you are doing it. The moment you let go to do something else, the jaw falls back and the airway closes again. An airway adjunct is a device that holds the tongue away from the posterior pharynx mechanically, so the airway stays open without a rescuer permanently committed to holding it.

Neither adjunct is a definitive airway. Neither one seals the trachea, and neither protects the lungs from vomit. A patient with an adjunct in place can still aspirate, and you still need suction within reach.

The oropharyngeal airway: no gag reflex, sized from the corner of the mouth to the earlobe

The oropharyngeal airway (OPA) is a rigid curved plastic device that sits in the mouth with its tip in the posterior pharynx. Its one absolute requirement is that the patient has no gag reflex. In a patient who retains a gag, an OPA will provoke gagging and vomiting, and in a patient who cannot protect their airway that vomit goes into the lungs. If the patient tolerates it, the adjunct was appropriate; if the patient gags on it, remove it.

Sizing: measure from the corner of the patient's mouth to the tip of the earlobe, or from the center of the mouth to the angle of the jaw. Both landmarks are taught and both give a workable length. Size matters in both directions: an OPA that is too long can push the epiglottis down over the glottic opening and obstruct the airway you were trying to open, and one that is too short leaves the tongue exactly where it was.

Insertion, adult: open the mouth, insert the airway with the tip pointed toward the roof of the mouth, and as it reaches the back of the mouth rotate it 180 degrees so the curve follows the curve of the tongue. The flange should rest against the lips.

Insertion, pediatric: do not use the rotation technique. A child's palate is soft and the rotation tears it. Insert the airway right side up, following the curve of the tongue, using a tongue depressor to hold the tongue down and out of the way.

The nasopharyngeal airway: tolerated by a patient with a gag, sized nose to earlobe

The nasopharyngeal airway (NPA) is a soft flexible tube that passes through the nostril into the posterior pharynx. Its advantage is the one the OPA lacks: most patients with an intact gag reflex will tolerate it. That makes it the adjunct for the patient whose level of consciousness is depressed but not absent, the semi-conscious patient who keeps losing their airway but gags on anything in their mouth.

Sizing: length is measured from the tip of the nose to the tip of the earlobe. Diameter should be the largest that fits the nostril without blanching it, roughly the diameter of the patient's own little finger.

Insertion: lubricate the tube generously with a water-soluble lubricant. Position the bevel toward the septum, the wall dividing the nostrils, and advance the tube straight back, along the floor of the nasal cavity, not upward. The nasal passage runs backward, not up toward the eyes; advancing upward drives the tube into the roof of the nasal cavity and causes bleeding. If you meet resistance, do not force it. Withdraw and try the other nostril.

The contraindication to know: an NPA is avoided in a patient with signs of a basilar skull fracture or significant mid-face trauma — raccoon eyes, Battle's sign, fluid from the nose or ears. The concern is a tube passing through a fracture at the base of the skull rather than into the pharynx.

Suctioning removes what you can hear; it is a time-limited procedure because it removes oxygen too

Suction clears blood, vomit, and secretions from the airway. The reason it is limited in time is that a suction catheter in the pharynx removes air along with fluid, and for the duration of the procedure the patient is neither breathing nor being ventilated. Suctioning a hypoxic patient makes them more hypoxic before it makes them better, so you pre-oxygenate when you can, suction for a defined interval, and ventilate again.

The limit taught for an adult is no more than about 15 seconds per attempt, and shorter in a child or infant — about 10 seconds or less, with a lower suction pressure. Some texts teach 10 seconds for an adult rather than 15; local protocol governs the number you are held to. The principle behind whichever number your system uses does not vary: suction, then ventilate, then suction again, rather than staying in the airway until it is perfectly clear.

The technique details are the ones that separate suctioning that helps from suctioning that injures

Measure the catheter before you insert it: from the corner of the mouth to the angle of the jaw or earlobe, the same landmark as an OPA. Insert it without suction applied, to the measured depth only, and apply suction while withdrawing in a sweeping motion. Suctioning on the way in pulls the soft tissue of the pharynx into the catheter tip and removes oxygen for the whole insertion rather than the withdrawal. Never insert past the point you can see.

The rigid (Yankauer) catheter is the one for thick secretions and vomit in the mouth of an adult, because its bore is wide enough not to clog. A soft (French) catheter is for the nose, for a stoma, or for going through an adjunct. If vomit is thick enough to clog even a rigid catheter, log-roll the patient onto their side and let gravity do it.

Stimulating the back of the throat can trigger a vagal response and slow the heart rate, which matters most in infants and children. If the heart rate falls during suctioning, stop and ventilate.

Four sounds, four different problems, four different responses

An airway in trouble usually announces itself, and the sound tells you where the problem is and what to do about it. This is high-yield because each sound has a distinct and non-interchangeable response.

Snoring is the tongue against the posterior pharynx — a partially obstructed upper airway in a patient with depressed consciousness. The response is positional: a manual maneuver, then an adjunct. Suction does nothing for it.

Gurgling is fluid in the airway — blood, vomit, or secretions. The response is suction. Repositioning does nothing for it.

Stridor is a high-pitched sound, heard on inspiration, produced by narrowing at or above the level of the larynx: swelling from anaphylaxis or burns, infection, or a foreign body. It is an upper-airway emergency, and it is the sound that should make you think about rapid transport rather than another adjunct, because nothing in an EMT's hands opens a swollen larynx.

Wheezing is a whistling sound from narrowed lower airways, classically on expiration, and it points to bronchoconstriction — asthma, COPD, and also the lower-airway component of anaphylaxis. It is treated pharmacologically, not mechanically.

And the sound that is not a sound: a patient making obvious respiratory effort with no air movement at all has a complete obstruction. Silence with effort is worse than any noise on this list.

Mild or severe is the only question, and the answer is how much air is moving

A foreign body in the airway produces one of two problems, and telling them apart decides everything that follows. The deciding evidence is air movement, not whether the patient looks distressed.

A mild obstruction leaves enough of the airway open for effective air exchange. The patient can cough forcefully, can speak, and can move air you can hear. Do not intervene. A forceful cough generates more airflow, and more sudden pressure, than any thrust a rescuer can deliver by hand, and the patient is already doing the most effective thing available. Stay with them, encourage the coughing, and watch. Reaching in with thrusts or a finger on a patient who is still clearing the airway themselves can drive the object further in and convert a mild obstruction into a severe one.

A severe obstruction means air exchange has become inadequate. The cough is weak or absent, the patient cannot speak, there is high-pitched stridor or no sound at all, and cyanosis follows. Many patients clutch the throat — the universal choking sign. Note the trap here: a patient with a weak, ineffective cough is still technically coughing, and still counts as severe. The question is never whether something is happening but whether enough air is moving to sustain the patient.

Silence with visible effort is the worst finding in the whole chapter: the patient is trying to breathe and nothing is moving.

The 2025 sequence: five back blows first, at every age

The 2025 AHA guidelines settled on one shape for the maneuver across every age group: five back blows, then five thrusts, repeated. Only the second half changes with age.

Table 9.1The 2025 sequence: five back blows first, at every age

For a responsive adult or child, position yourself behind the patient, place a fist thumb-side in just above the navel and below the xiphoid, grasp it with the other hand, and deliver each thrust inward and upward as a distinct movement rather than a squeeze. For an infant, support the head and jaw, lay the infant face down along your forearm with the head lower than the chest for the back blows, then turn the infant as a unit and deliver chest thrusts on the lower sternum.

Abdominal thrusts are never used on an infant. An infant's liver is proportionally large and sits low, largely below the protection of the rib cage, and an abdominal thrust can tear it.

What changed in 2025, and why it changed

Two pieces of this are new, and both are the kind of detail a question is built on.

Back blows were added to the adult and child sequences. An adult used to receive abdominal thrusts alone, and a child the same. A cohort study of 709 people with a foreign body airway obstruction found that back blows relieved more obstructions, and caused fewer injuries, than abdominal thrusts did. The AHA also wanted one sequence a rescuer could remember under stress rather than three, and infants were already receiving back blows first — so the adult and child sequences moved to match, rather than the other way round.

Infant chest thrusts are delivered with the heel of one hand. They used to be delivered with two fingers, the same landmark as infant compressions. Two fingers turned out not to reach a useful depth reliably, and the technique was dropped from infant chest compressions for the same reason. Note the AHA's own care with the words: these are chest thrusts, not chest compressions, because nothing about rate or recoil applies — you are trying to expel an object, not perfuse a brain.

When the patient goes unresponsive, it stops being a choking call

Once the patient loses consciousness, the maneuver changes completely. Lower them to the ground and begin CPR, starting with chest compressions. Compressions generate higher airway pressures than an abdominal thrust does, so they are both the resuscitation and the best remaining attempt at clearing the object.

The one modification is that before each set of rescue breaths you look in the mouth, and remove an object only if you can actually see it. If the chest does not rise on the first breath, reposition the head and try once more before returning to compressions. Do not stop to check for a pulse between cycles the way you would in an ordinary arrest.

Blind finger sweeps are not done, at any age. A finger you cannot see with can push a partially dislodged object back past the vocal cords, and in a child or infant the airway structures are small and soft enough to injure on the way.

After it clears, and the obstructions this does not fix

A patient whose obstruction is relieved still goes to the hospital. Abdominal thrusts can injure the liver, spleen or stomach; a fragment of the object may remain; and aspiration of what did go down shows up hours later as pneumonia. Reassess the airway and breathing, give oxygen if it is indicated, and transport.

Finally, know what this sequence is for. Back blows and thrusts relieve a mechanical obstruction sitting in the airway. They do nothing at all for an airway narrowed by swollen tissue — anaphylaxis, an inhalation burn, epiglottitis, angioedema. Those patients are also stridorous and also in trouble, but nothing in an EMT's hands opens a swollen larynx, and the answer is oxygen, minimal agitation, and rapid transport toward a provider who can secure the airway. Thrusting on them wastes the time they have.

The bag-valve mask is the skill most often performed badly, and the failure is almost always the seal

A bag-valve mask (BVM) delivers positive-pressure ventilation to a patient who is not breathing adequately on their own. The adult bag holds roughly 1,200 to 1,600 mL. Connected to oxygen at 15 L/min with a reservoir attached, it delivers close to 100 percent oxygen; without oxygen connected it delivers room air, about 21 percent, which is still worth doing while someone sets up the tank.

The device fails in a specific and predictable way. Squeezing the bag is easy; maintaining a seal on the face with one hand while holding the jaw forward with the same hand is hard, and when the seal leaks the volume goes into the room instead of the patient. This is why two-rescuer BVM is preferred whenever a second pair of hands exists: one rescuer uses both hands to hold the mask and the jaw, the other squeezes the bag. It is not a matter of preference or staffing convenience. Two-rescuer technique delivers measurably more volume.

The mechanics: E-C clamp, chest rise, one second, and no faster than the rate calls for

For a single rescuer, the E-C clamp is the hand position: thumb and index finger form a C over the mask pressing it to the face, while the remaining three fingers form an E along the bony ridge of the jaw, lifting the jaw up into the mask rather than pressing the mask down into the face. Lifting the jaw into the mask both seals and opens; pressing the mask down pushes the jaw back and closes the airway.

Position the mask with the narrow end over the bridge of the nose and the wide end in the groove between the lower lip and the chin. Squeeze over about one second, and squeeze only until the chest visibly rises. Visible chest rise is the endpoint, not a full squeeze of the bag.

Rate, for a patient who has a pulse but is not breathing adequately: about 1 breath every 6 seconds (10 per minute) in an adult, and 1 every 2 to 3 seconds (20 to 30 per minute) in an infant or child. During CPR with an advanced airway in place, ventilations run about 10 per minute without pausing compressions. Note that older references teach 10 to 12 per minute for an adult; the current AHA figure is 10.

Too much ventilation is its own injury, and the troubleshooting order is fixed

Ventilating too fast or with too much volume is actively harmful, not merely wasteful. Excess pressure opens the esophagus and forces air into the stomach. Gastric distention pushes the diaphragm up, reducing the volume the lungs can hold, and it makes vomiting and aspiration far more likely. Beyond that, sustained positive pressure in the chest raises intrathoracic pressure and reduces the blood returning to the heart, which lowers cardiac output at the exact moment the patient can least afford it.

When the chest does not rise, work through the causes in this order, because the common ones come first: re-seal the mask (the most common failure by a wide margin), reposition the head and jaw, suction if there is fluid, and check for an obstruction. Squeezing harder is not on the list. If the seal is leaking, more force makes a louder leak.