Suction and Basic Airway Adjuncts

Suctioning: Clearing Fluids Fast

When the airway contains blood, vomit, or secretions — heard as gurgling — the EMR uses suction to clear it so air can move and aspiration is prevented. The cardinal rule is the time limit: suction for no more than 15 seconds per attempt in an adult, because the suction catheter removes oxygen along with fluid and the patient is not being ventilated during suctioning. In children, limit to about 10 seconds, and in infants about 5 seconds, because they desaturate faster.

Key technique points the exam rewards:

• Measure the rigid (Yankauer) catheter from the corner of the mouth to the earlobe so you do not insert it too deeply.
• Suction only on the way out — insert without suction, then apply suction while withdrawing.
• Reoxygenate between attempts; if the airway is still not clear, ventilate/oxygenate, then suction again.
• For large volumes of vomit the EMR cannot keep up with, log-roll or turn the patient to let it drain by gravity.

A frequent distractor is suctioning continuously until the airway looks perfect — that produces dangerous hypoxia. Brief bursts with reoxygenation in between is the tested standard.

Oropharyngeal Airway (OPA)

The oropharyngeal airway (OPA) is a curved plastic device that holds the tongue away from the back of the throat. It is reserved for patients with NO gag reflex — typically deeply unresponsive patients — because inserting it in someone with an intact gag reflex causes vomiting, gagging, or laryngospasm.

Sizing: measure from the corner of the mouth to the angle (tip) of the jaw, or from the center of the mouth to the earlobe. A too-long OPA can press on the epiglottis and obstruct; a too-short OPA fails to hold the tongue. Insertion in an adult: insert with the tip pointing toward the roof of the mouth, then rotate 180 degrees as it passes over the tongue. (In children, insert it right-side-up with a tongue depressor rather than rotating.)

If the patient gags, coughs, or pushes the OPA out, remove it — that means the gag reflex has returned and the OPA is no longer appropriate.

Nasopharyngeal Airway (NPA)

The nasopharyngeal airway (NPA) is a soft, flexible tube passed through a nostril into the posterior pharynx. Because it bypasses the back of the tongue without touching it directly, it is better tolerated by patients who still have a gag reflex — for example, a patient with an altered mental status who is not deeply unconscious. Sizing: measure from the tip of the nose (nostril) to the earlobe, and choose a diameter that fits the nostril.

Insertion: lubricate the NPA with water-soluble gel, and insert it into the right nostril with the bevel toward the septum, advancing gently straight back (not upward). Avoid the NPA in patients with suspected skull-base fracture or significant facial/head trauma (signs like clear fluid from the nose/ears or raccoon eyes), because the tube could theoretically pass into the cranial vault.

Worked scenario

A patient who took an opioid overdose is responsive only to pain (AVPU = 'P'), breathing shallowly, with an intact gag reflex. An OPA would make him gag and vomit, so the better adjunct is an NPA, sized nostril-to-earlobe, while you assist ventilations with a BVM and oxygen and prepare for naloxone per protocol. Remember the universal rule: open the airway manually first, then add the adjunct — the OPA or NPA supplements positioning, it does not replace it. After placement, confirm the chest rises with ventilation and reassess continuously.

Choking: Foreign-Body Airway Obstruction (FBAO)

A solid object — food, a toy, dentures — can obstruct the airway. The EMR must distinguish a mild (partial) from a severe (complete) obstruction. With a mild obstruction the patient can still cough forcefully, speak, or wheeze; the correct action is to encourage continued coughing and stay ready, NOT to slap the back, because the patient's own cough is the most effective force. With a severe obstruction the patient cannot speak, cough, or breathe, may clutch the throat (the universal choking sign), and turns cyanotic.

For a conscious adult or child with severe obstruction, current (2025 AHA) guidance is to alternate 5 back blows (between the shoulder blades) with 5 abdominal thrusts (the Heimlich maneuver), repeating until the object clears or the patient becomes unresponsive. For an infant under 1 year, abdominal thrusts are NOT used because of injury risk; instead alternate 5 back blows with 5 chest thrusts. For a pregnant or very obese patient, chest thrusts replace abdominal thrusts.

If the choking patient becomes unresponsive, the EMR lowers them safely to the ground, calls for help/AED, and begins CPR, looking in the mouth for a visible object each time before giving breaths and removing it only if seen — blind finger sweeps are not done because they can push the object deeper.