2.1 Airway Management
Key Takeaways
- An open airway always precedes ventilation and oxygenation; the head-tilt/chin-lift is used for non-trauma patients while the jaw-thrust is used when spinal injury is suspected.
- An oropharyngeal airway (OPA) is sized from the corner of the mouth to the angle of the jaw and is only used in patients with no gag reflex; a nasopharyngeal airway (NPA) is sized from the nostril to the earlobe.
- Suctioning is limited to 10 seconds in adults (shorter in children) because the suction catheter removes oxygen along with secretions.
- Supraglottic and blind insertion airway devices (BIADs), such as the King LT and i-gel, are within the AEMT scope and are inserted without direct visualization of the vocal cords.
- A foreign body airway obstruction is managed with abdominal thrusts in a responsive adult and with chest compressions plus airway checks once the patient becomes unresponsive.
Why Airway Management Matters
A patient who cannot move air cannot oxygenate, and irreversible brain injury begins within minutes of complete obstruction. On the NREMT Advanced Emergency Medical Technician (AEMT) exam, the Airway, Respiration, and Ventilation domain accounts for 9-13% of scored items, and airway problems appear inside Clinical Judgment and Medical scenarios as well. The exam consistently rewards the candidate who opens and protects the airway before moving on to circulation or medications.
Upper Airway Anatomy
Understanding where obstruction occurs guides the correct intervention.
| Structure | Function | Clinical Relevance |
|---|---|---|
| Tongue | Floor of the mouth | Most common airway obstruction in an unresponsive patient |
| Epiglottis | Cartilage flap over the larynx | Protects the trachea during swallowing; swells in epiglottitis |
| Vallecula | Space between tongue base and epiglottis | Landmark for airway device placement |
| Larynx (vocal cords) | Voice box / glottic opening | Narrowest adult airway point; site of laryngospasm |
| Cricoid cartilage | Complete tracheal ring | Narrowest point in young pediatric patients |
| Trachea / carina | Conducting airway to the bronchi | Carina bifurcation is the cough-reflex trigger point |
Because the tongue is attached to the mandible, any maneuver that displaces the jaw forward also lifts the tongue off the posterior pharynx.
Manual Airway Maneuvers
- Head-Tilt/Chin-Lift — first-line maneuver for a patient with no suspected spinal injury. Tilt the forehead back while lifting the bony chin.
- Jaw-Thrust — used when trauma or spinal injury is suspected. Displace the mandible anteriorly without moving the cervical spine. If the airway cannot be maintained with a jaw-thrust alone, airway patency still takes priority.
- Recovery position — for an unresponsive patient who is breathing adequately with no trauma, to allow drainage of secretions.
Airway Adjuncts: OPA and NPA
Adjuncts hold the tongue away from the posterior pharynx but do not isolate the trachea or replace ventilation.
| Adjunct | Indication | Contraindication | Sizing |
|---|---|---|---|
| Oropharyngeal Airway (OPA) | Unresponsive patient with no gag reflex | Intact gag reflex (risk of vomiting/laryngospasm) | Corner of mouth to angle of jaw / earlobe |
| Nasopharyngeal Airway (NPA) | Responsive or semi-responsive patient who needs airway support and tolerates it | Suspected basilar skull fracture or significant facial/nasal trauma | Tip of nostril to earlobe; lubricate, bevel toward septum |
The NPA is better tolerated in a patient with a gag reflex, such as a postictal seizure patient. Insert it into the larger nostril with the bevel toward the nasal septum.
Suctioning
Suctioning clears blood, vomit, and secretions that adjuncts cannot remove.
- Use a rigid (Yankauer) catheter for thick secretions and vomit in the oropharynx; use a soft (French) catheter for the nasopharynx or down an airway device.
- Suction only while withdrawing the catheter; never insert past what you can visualize in the oropharynx.
- Limit suctioning to 10 seconds in adults, less in children and infants, because suction removes oxygen along with fluid. Pre-oxygenate before and re-oxygenate after.
Supraglottic / Blind Insertion Airway Devices (AEMT Scope)
AEMTs may place supraglottic airways, also called blind insertion airway devices (BIADs), which are advanced over the EMT scope but stop short of endotracheal intubation. Common devices include the King LT, i-gel, and laryngeal mask airway (LMA).
- Inserted without direct visualization of the vocal cords (blind technique).
- Indicated for the apneic or deeply unresponsive patient with no gag reflex when bag-valve-mask ventilation is inadequate.
- After insertion, confirm placement with chest rise, bilateral breath sounds, absent epigastric sounds, and waveform capnography.
- They sit in the hypopharynx and do not provide the definitive aspiration protection of an endotracheal tube, so monitor continuously.
Foreign Body Airway Obstruction (FBAO)
- Mild (partial) obstruction with good air exchange — encourage coughing; do not interfere.
- Severe obstruction, responsive adult/child — deliver abdominal thrusts (chest thrusts for pregnancy or obesity) until the object clears or the patient becomes unresponsive.
- Unresponsive — begin CPR; before each set of ventilations, open the mouth and remove the object only if it is visible. Blind finger sweeps are not performed.
An AEMT is treating an unresponsive 30-year-old who was found in a vehicle collision and has no spinal precautions yet established. Which manual maneuver should be used to open the airway?
Which patient is the best candidate for a nasopharyngeal airway (NPA) rather than an oropharyngeal airway (OPA)?
An AEMT places a supraglottic airway (King LT) in an apneic patient when bag-valve-mask ventilation was inadequate. What is the most reliable way to confirm correct placement?
What is the maximum recommended duration for a single suctioning attempt in an adult patient?