4.4 Airway Patency and Positioning

Decide whether air can move now

The Primary Assessment domain includes assessing the patient's airway. Airway patency means the upper airway is open enough for air to pass. EMR airway assessment begins with observation and interaction. Can the patient speak? Are there snoring, gurgling, stridor (high-pitched), crowing, or silent airway cues? Is vomit, blood, secretions, swelling, food, or trauma visible? Is the LOC low enough that airway protection is unreliable?

Speech is a useful clue: a patient who speaks clearly is moving air past the vocal cords at that moment. It does not prove the airway will stay safe, because the patient can vomit, swell, tire, or become less responsive. Airway problems are complete, partial, or impending. Complete obstruction shows as inability to speak or breathe, silent distress, cyanosis, or collapse. Partial obstruction shows as noisy breathing, coughing, gagging, or difficulty speaking. Impending compromise is suggested by decreasing LOC, facial burns, swelling, severe allergic reaction, or repeated vomiting.

Opening the airway: head-tilt chin-lift versus jaw-thrust

The tongue is the most common airway obstruction in an unresponsive patient. Two manual maneuvers open it:

• Head-tilt chin-lift is the first choice for a medical patient with NO suspected spinal injury. Place one hand on the forehead and tilt the head back, then lift the bony part of the chin with the fingertips of the other hand. It lifts the tongue off the back of the throat.
• Jaw-thrust (modified, without head-tilt) is used when spinal injury is suspected (trauma, falls, diving, motor-vehicle crashes). From the head of the patient, place fingers on the angles of the lower jaw and push the mandible forward while keeping the head and neck in a neutral in-line position. It opens the airway without extending the neck.

The critical exam rule: if a jaw-thrust does not open the airway in a trauma patient, a patent airway takes priority over spinal precautions, so carefully add a head-tilt chin-lift. You never trade an open airway for spinal motion restriction.

Suctioning the airway

When gurgling or visible fluid is present, suction. Use a rigid (Yankauer) tip for thick oral secretions, vomit, or blood, inserting only as far as you can see. Suction on the way out, not in, and limit each attempt: 15 seconds maximum for an adult, 10 seconds for a child, and 5 seconds for an infant, because suctioning removes oxygen along with fluid and can stimulate a vagal response (especially in infants). Reoxygenate or ventilate between attempts. Logroll a patient with copious fluid so it drains by gravity if positioning allows.

Airway adjuncts at the EMR scope: OPA and NPA

After a manual maneuver, an EMR may insert a basic airway adjunct to keep the tongue off the posterior pharynx. Two are within EMR scope.

The oropharyngeal airway (OPA) is a curved plastic device that holds the tongue forward. Insert it in adults upside down (tip toward the roof of the mouth) and rotate 180 degrees as it passes the soft palate, or insert it sideways/right-side-up with a tongue blade. The flange should rest at the lips/teeth when correctly sized. The OPA is used only in a patient with NO gag reflex (deeply unresponsive).

It is contraindicated in any patient with an intact gag reflex because it provokes gagging, vomiting, and aspiration; if the patient gags during insertion, remove it. A too-large OPA can press the epiglottis into the airway; a too-small one pushes the tongue back and worsens obstruction.

The nasopharyngeal airway (NPA, or nasal trumpet) is a soft tube passed through a nostril to behind the tongue. Size it from the tip of the nose to the earlobe (some systems use nose to angle of jaw) for length, and pick a diameter that fits the nostril without blanching it. Lubricate with water-soluble gel, bevel toward the septum, and insert straight back (along the floor of the nose), not upward. The NPA is better tolerated in patients with an intact or borderline gag reflex because it is less stimulating than an OPA.

It is contraindicated with suspected skull fracture or significant facial/nasal trauma (basilar skull fracture signs: clear fluid from nose/ears, raccoon eyes, Battle's sign) because the tube can pass intracranially.

An adjunct does not replace a manual maneuver or breathing support. Maintain head position, keep suction ready, and reassess constantly. Vomiting, blood, secretions, and facial trauma all raise risk. Reassess after every intervention because airway status can change in seconds.

Do not confuse airway with breathing: airway asks whether the passage is open; breathing asks whether ventilation and oxygenation are adequate. They are linked but tested separately. A common novice trap is asking a long history while the airway is noisy, or assuming a single cough means the patient is fine; worsening obstruction, fatigue, or inability to speak changes the priority instantly.

Specific takeaways

• Head-tilt chin-lift for medical patients; jaw-thrust when spine is at risk.
• A patent airway outranks spinal precautions if the jaw-thrust fails.
• OPA: corner-of-mouth to earlobe, NO gag reflex only.
• NPA: nose to earlobe, avoid with skull/facial fracture, lubricate.
• Suction 15/10/5 seconds for adult/child/infant, suctioning out.