1.1 Upper Airway Anatomy & Assessment
Key Takeaways
- The upper airway consists of the nasal cavity, pharynx (nasopharynx, oropharynx, laryngopharynx), and the larynx.
- The epiglottis is a leaf-shaped cartilage that covers the glottic opening during swallowing to prevent aspiration.
- Airway assessment uses the look, listen, and feel approach to judge adequacy of breathing.
- Adequate breathing shows a regular rate (12-20/min in adults), equal bilateral chest rise, and clear breath sounds.
- Inadequate breathing shows abnormal rate, shallow depth, irregular rhythm, cyanosis, and accessory muscle use.
- Head-tilt/chin-lift is the default maneuver without suspected spinal injury; jaw-thrust is used when cervical spine injury is suspected.
- Snoring, gurgling, stridor, and silence are key airway sounds indicating different obstruction patterns.
The airway is the most critical system for an EMT to understand. Without a patent (open) airway, no other intervention matters — oxygen, ventilation, and circulation all depend on air reaching the lungs. The upper airway warms, filters, and humidifies air before it descends to the lower airway.
Anatomy of the Upper Airway
Nasal Cavity
The nasal cavity is the primary entry point during normal breathing. Bony shelves called turbinates create turbulence that warms, humidifies, and filters inhaled air. The cavity is lined with mucous membranes and cilia (tiny hairs) that trap particles and pathogens. Because this lining is highly vascular, it bleeds easily — relevant when inserting a nasopharyngeal airway or managing epistaxis (nosebleed).
Pharynx
The pharynx (throat) is a muscular tube shared by air and food. It has three regions:
| Region | Location | Function |
|---|---|---|
| Nasopharynx | Behind the nasal cavity | Air passage; contains the adenoids |
| Oropharynx | Behind the mouth | Shared air/food passage; contains the tongue base |
| Laryngopharynx | Below the oropharynx | Divides into the trachea (air) and esophagus (food) |
Epiglottis
The epiglottis is a leaf-shaped flap of elastic cartilage at the base of the tongue. During swallowing it folds over the glottic opening (entrance to the trachea), routing food and liquid into the esophagus and preventing aspiration. When it fails — for example, in a patient with a depressed level of consciousness — aspiration of vomit or secretions becomes a major risk, which is why airway positioning and suction are early priorities.
Larynx
The larynx (voice box) is the transition between upper and lower airway. It houses the vocal cords, which vibrate to produce sound, and is framed by the thyroid cartilage (Adam's apple) and the cricoid cartilage — the only complete (360-degree) cartilage ring in the entire airway. Below the cricoid, all tracheal rings are C-shaped. The cricoid is an important landmark and, in children, the narrowest point of the airway.
Airway Assessment: Look, Listen, Feel
Assessing the airway is the first priority in any patient encounter after scene safety. Use the look, listen, feel approach:
- Look: chest rise and fall, accessory muscle use, nasal flaring, retractions, and skin color (cyanosis).
- Listen: abnormal airway sounds — snoring (tongue/soft tissue obstruction), gurgling (fluid such as blood, vomit, or secretions), stridor (upper airway narrowing/swelling), or wheezing (lower airway constriction).
- Feel: place your cheek or hand near the mouth and nose to feel for moving air.
The key clinical question is not merely "is the patient breathing?" but "is the patient breathing adequately?" A patient can be moving air yet still be in failure if the rate, depth, or effort is insufficient to maintain oxygenation.
Adequate vs. Inadequate Breathing
| Feature | Adequate Breathing | Inadequate Breathing |
|---|---|---|
| Rate | 12-20/min (adult) | Too fast (>24) or too slow (<8-10) |
| Depth | Normal tidal volume (~500 mL) | Shallow or excessively deep |
| Rhythm | Regular | Irregular or agonal |
| Breath sounds | Clear and equal bilaterally | Diminished, absent, or noisy |
| Chest expansion | Symmetric rise and fall | Asymmetric or minimal |
| Skin color | Normal | Pale, cyanotic, or mottled |
| Accessory muscles | Not used | Neck, chest, or abdominal muscle use |
| Mental status | Alert, oriented | Anxious, confused, or declining |
When breathing is inadequate, the EMT escalates from passive oxygen (cannula or non-rebreather) to assisted ventilation with a bag-valve mask — supplemental oxygen alone does not fix inadequate ventilation.
Airway Maneuvers
Head-Tilt/Chin-Lift
The default maneuver when there is no suspected spinal injury:
- Place one hand on the forehead and apply firm, gentle backward pressure to tilt the head back.
- Place the fingertips of the other hand under the bony part of the chin and lift it forward.
- Do not press on the soft tissue under the chin — that can push the tongue up and worsen obstruction.
This maneuver works because the tongue is attached to the lower jaw; lifting the jaw pulls the tongue off the posterior pharyngeal wall, which is the most common cause of obstruction in an unresponsive patient.
Jaw-Thrust Maneuver
Used when cervical spine injury is suspected (falls, motor-vehicle crashes, diving injuries, any significant blunt force above the clavicles):
- Position yourself above the patient's head.
- Place your fingers behind the angles of the mandible on both sides.
- Push the jaw forward (anteriorly) without tilting the head.
- This displaces the tongue forward and opens the airway while maintaining in-line spinal alignment.
If the jaw-thrust alone fails to open the airway in a patient with suspected spinal injury, airway patency still takes priority — a patent airway is essential to life, and the EMT may need to add careful manual positioning while minimizing neck movement.
Recovery Position and Ongoing Airway Protection
For an unresponsive patient who is breathing adequately and has no suspected spinal injury, the recovery (lateral recumbent) position helps protect the airway by allowing secretions, blood, or vomit to drain from the mouth rather than pool in the pharynx. Even in the recovery position, keep suction immediately available — gurgling means fluid is present and must be cleared promptly, because aspiration can rapidly compromise both the airway and oxygenation. Reassess airway patency continuously; an airway that is open one moment can obstruct the next as the patient's mental status or position changes.
Which structure prevents food and liquid from entering the trachea during swallowing?
An EMT finds an unresponsive patient who fell from a ladder. Which airway maneuver should be performed?
A patient is making a snoring sound with each breath. This most likely indicates:
The cricoid cartilage is significant in airway management because it is:
Which finding is a sign of inadequate breathing in an adult?
Which of the following are signs of INADEQUATE breathing in an adult? (Select all that apply)
Select all that apply