10.2 Airway & Breathing Management

Quick Answer: Open the airway now. No trauma: head-tilt/chin-lift. Trauma or unknown mechanism: jaw-thrust (NATA Acute Management of the Cervical Spine–Injured Athlete). OPA if unresponsive without a gag; never force an OPA onto a gagging athlete. NPA if a gag is present and there is no midface or basilar skull fracture—that is the classic contraindication. Two-person bag-valve-mask (BVM) beats one-person BVM. In football, remove the facemask for airway access; do not remove the helmet alone if shoulder pads stay on.

PA8 Domain III task 0303 pairs airway with SCA and other emergencies because an unresponsive athlete without an airway is a failed resuscitation even with a perfect compression rate. Chapter 9 covered scene safety and the primary survey. This section is how you actually move air.

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Open the airway: two maneuvers, one trauma rule

If there is no reason to suspect cervical injury, use head-tilt/chin-lift: one hand on the forehead, two fingers under the bony chin, lift the tongue off the posterior pharynx. Do not crush the soft tissues under the mandible; that closes the airway you are trying to open.

If there is trauma, a helmeted collision, a dive into a pool, or you simply do not know, use a jaw-thrust: fingers behind the angles of the mandible, lift the jaw forward, keep the head in neutral. NATA’s cervical-spine position statement recommends jaw-thrust over head-tilt because head-tilt produces unnecessary cervical motion. Advanced airways in trained hands also tend to move the neck less than repeated poor BVM attempts—but only if they are in your protocol and training.

Inspect the mouth. Suction obvious blood, vomit, or spit. Adult suction on the way out, typically no more than about 15 seconds per pass, then re-oxygenate; prolonged fishing in the pharynx causes hypoxemia and bradycardia. No blind finger sweeps. You push a mouthguard into the glottis that way.

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OPA vs NPA

Adjuncts keep the tongue off the pharynx after you have opened the airway with your hands. They do not replace hands.

Oropharyngeal airway (OPA):

• Size: flange at the corner of the mouth to the angle of the mandible (or earlobe, depending on the device card you were trained on—be consistent and check chest rise).
• Insert with the tip toward the roof and rotate, or use a tongue blade, so you do not drag the tongue backward.
• Contraindication: intact gag reflex. An OPA in a semi-conscious athlete triggers vomiting and aspiration. If they gag, take it out.

Nasopharyngeal airway (NPA):

• Size: nostril to the earlobe or angle of the mandible; too long and you can enter the esophagus or inflame the larynx.
• Lubricate; insert along the floor of the nose with the bevel toward the septum.
• Useful when a gag is present and the mouth is clenched or injured.
• Contraindications: midface fracture, known or suspected basilar skull fracture (Battle sign, raccoon eyes, cerebrospinal fluid rhinorrhea or otorrhea), or severe nasal obstruction. An NPA can enter the cranial vault through a disrupted cribriform plate or a smashed midface. Exam trap: inserting an NPA in a midface fracture.

If neither adjunct is appropriate, you still have two hands, a jaw-thrust, and a mask.

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BVM, oxygen, and supraglottic airways

Two-person BVM is preferred (2025 AHA adult BLS): one rescuer maintains the airway and a two-hand mask seal (often taught as thenar/EC-clamp), the other squeezes the bag over about 1 second just until chest rise. Over-ventilation inflates the stomach, drops venous return, and is a common code-quality failure. For 30:2, those two breaths must be short so compression pauses stay brief.

One-rescuer BVM is a last resort: you cannot seal and squeeze well at the same time. Mouth-to-mask with a one-way valve is acceptable if that is what you have.

Supplemental oxygen belongs on the hypoxic or distressed athlete per protocol—typically high-flow via non-rebreather when the athlete is breathing, or oxygen into the BVM when you are ventilating. Exact liter-flow standing orders are physician- and state-practice-act specific; know your protocol, and do not invent a number on the exam that your EAP never wrote.

Supraglottic airways (laryngeal mask, i-gel, King LT, and similar) can maintain a patent airway when BVM is failing if you are trained, credentialed, and covered by a standing order. They are not a default BOC skill you improvise from a YouTube video on a Friday night. Endotracheal intubation is an ALS/physician skill in almost every athletic setting.

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Helmeted football: airway access, not a full spine lecture

NATA cervical-spine guidance and the 2019 prehospital spine-injured football best-practice documents agree on the airway point this chapter owns:

• Expose the airway. Remove the facemask—even if the athlete is still breathing—before transport when cervical injury is suspected, so you are not fighting hardware when the airway collapses in the ambulance.
• A powered screwdriver plus a backup cutting tool is the usual fastest method; know quick-release clips on the helmets your team actually wears. If the facemask will not come off in a reasonable time, the helmet has to come off.
• Chinstrap can block jaw-thrust and mask seal; it may need to be loosened or cut for airway work.
• Helmet and shoulder pads are a unit. Removing the helmet alone lets the head drop into extension relative to the pads. Leave both on if you cannot remove both. Pack-and-fill is a specialized option when a helmet must come off and pads stay—that lives with the spine chapter. Here: airway access via facemask; do not freelance one-sided equipment removal.
• If the problem is SCA, CAB still wins: you must reach the chest (10.1). Airway and defibrillation are not competing religions; they are sequential jobs on the same patient.

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Tension pneumothorax: recognize, do not freelance a needle

A simple pneumothorax is air in the pleural space. A tension pneumothorax is air under pressure that kinks venous return. Field picture after chest trauma or, rarely, after extreme exertion in a tall thin athlete: progressive dyspnea, unilateral decreased or absent breath sounds, increasing distress, hypotension, jugular venous distention; tracheal deviation away from the injury is a late sign—do not wait for it. Treat with oxygen, rapid EMS, and supportive ventilation. Needle decompression (typically midclavicular 2nd intercostal or mid/anterior axillary 4th/5th, device- and protocol-specific) is not a default AT procedure. Do it only if you are trained and a physician standing order/protocol authorizes it. Inventing a needle because you ‘recognized the diagnosis’ is outside most athletic practice acts.

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Asthma vs anaphylaxis vs VCD vs pulmonary embolism

Four athletes can all say ‘I can’t breathe.’ Your job is a working differential, not a single inhaler for every wheeze.

Asthma (NATA asthma position statement and NATA 2012 sudden-death document): sit the athlete up, give their short-acting β2-agonist (SABA, albuterol)—typically 2 puffs via MDI with a spacer if you have one; onset often 5–15 minutes. Severe attacks may need sequential SABA. Supplemental oxygen. If three administrations do not relieve distress, refer/EMS promptly. Silent chest (no wheeze because air is not moving), accessory-muscle use, inability to lie or speak, falling saturation, confusion, or drowsiness is impending respiratory failure—this is not a ‘take two more puffs and finish the half’ injury. Have a rescue inhaler on the athlete and a spare with you; a nebulizer belongs in the catastrophic kit when your protocol includes it.

Anaphylaxis can mimic asthma. If there are skin findings, hypotension, or a known allergen, epinephrine first (10.3)—not albuterol as the only drug. Albuterol may be an adjunct for wheeze after epinephrine.

VCD/exercise-induced laryngeal obstruction: inspiratory noise, tightness in the throat, often during a race, relatively preserved oxygen, and a history of ‘asthma that never responds.’ Do not keep stacking albuterol as if more β2 agonist will open vocal folds. Remove from intensity, coach slow nasal/pursed breathing, and still rule out anaphylaxis and true asthma if the picture is mixed.

Pulmonary embolism: sudden dyspnea and pleuritic pain without a good asthma story. Support ABCs, oxygen, EMS. There is no sideline clot-busting protocol for ATs.

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Pulse oximetry caveats

A pulse oximeter measures estimated arterial hemoglobin saturation, not ventilation, not oxygen content, and not cardiac output.

• Lag: the number can trail the patient by tens of seconds.
• Poor perfusion, cold, motion, nail polish, and shock make the waveform a toy.
• Carbon monoxide can read falsely high (standard two-wavelength pulse ox cannot distinguish COHb from oxyhemoglobin).
• Anemia can show a ‘normal’ SpO2 with low oxygen-carrying capacity.
• Early PE and early asthma can look numerically fine while the athlete is in trouble.
• A number in the mid-90s does not authorize you to withhold oxygen from a struggling athlete, and a single low number on a cold finger does not by itself diagnose arrest. Treat the patient, use the oximeter as an adjunct, and know that impending failure is a clinical diagnosis (work of breathing, mental status, silent chest), not an SpO2 cutoff you memorize from a consumer watch.