Airway Anatomy — What You're Working With
The airway runs from the nose/mouth → pharynx → larynx → trachea → bronchi → lungs. The epiglottis guards the trachea, snapping shut when you swallow to prevent aspiration. Your entire job with airway management is keeping this pathway open and protected.
- Upper airway: Nose, mouth, pharynx, larynx — where most obstructions occur
- Glottic opening: The vocal cords at the entrance to the trachea — your target when intubating (paramedic skill)
- Trachea: Splits at the carina into left and right mainstem bronchi
- Cricothyroid membrane: Just below the thyroid cartilage — landmark for surgical airway and needle cric
Snoring: tongue blocking the upper airway. Gurgling: fluid in the airway — suction immediately. Stridor: high-pitched, indicates upper airway narrowing (epiglottitis, anaphylaxis, foreign body). Silent: could mean complete obstruction or no air movement — both are emergencies.
Manual Airway Maneuvers
Head-Tilt Chin-Lift
The go-to maneuver for unconscious patients with no suspected spinal injury. Place one hand on the forehead, tilt the head back, and lift the chin with two fingers on the bony part of the jaw (not the soft tissue — you'll compress the airway). This lifts the tongue off the posterior pharynx.
Jaw-Thrust Maneuver
Used when spinal injury is suspected. Place your hands on either side of the face, fingers behind the angle of the jaw, and push the jaw forward without moving the head or neck. This opens the airway without cervical extension. Harder to do, more tiring, but essential for trauma patients.
If jaw-thrust fails to open the airway in a trauma patient and ventilation is inadequate — use head-tilt chin-lift. Airway always takes priority over spinal precautions. A dead patient with a perfect spine is still dead.
Airway Adjuncts
Oropharyngeal Airway (OPA)
- Purpose: Keeps the tongue from blocking the oropharynx in unconscious patients
- Indication: Unconscious, unresponsive, NO gag reflex
- Contraindication: Intact gag reflex — will cause vomiting and aspiration
- Sizing: Measure from the corner of the mouth to the earlobe
- Insertion (adult): Insert upside-down (concave up), rotate 180° as you advance, or insert with a tongue blade without rotation
Nasopharyngeal Airway (NPA)
- Purpose: Opens the nasal airway — can be used in semi-conscious patients
- Indication: When OPA is contraindicated (gag reflex present), clenched jaw, altered but not deeply unconscious
- Contraindication: Suspected basilar skull fracture (raccoon eyes, Battle's sign, CSF from nose/ears)
- Sizing: Measure from the tip of the nose to the earlobe
- Insertion: Lubricate, insert bevel toward the septum, advance gently along the floor of the nasal cavity. Never force it.
Suctioning
Gurgling, vomit, blood, or secretions in the airway must be cleared before or after airway adjunct placement. You cannot ventilate through fluid.
- Rigid (Yankauer) suction: Preferred for oropharynx — cleared secretions, vomit, blood
- Flexible catheter: For smaller airways, NPA, or deeper suctioning
- Duration: No more than 10 seconds per attempt for adults (5 seconds for peds) — suctioning also removes oxygen
- Technique: Insert without suction, apply suction while withdrawing in a circular motion
Bag-Valve Mask (BVM) Ventilation
The BVM is your primary tool for providing positive pressure ventilation when a patient isn't breathing adequately on their own. Used correctly it's highly effective. Used incorrectly it causes gastric distension and aspiration.
- Rate: 1 breath every 5–6 seconds for adults (10–12/min). 1 breath every 3–5 seconds for children.
- Volume: Just enough to produce visible chest rise — roughly 500–600 mL for adults. Don't over-ventilate.
- Seal: EC clamp technique — three fingers under the jaw (E), two fingers and thumb on the mask (C). A poor seal = no ventilation.
- Two-rescuer BVM: Always preferred — one rescuer maintains the mask seal with both hands, the other squeezes the bag.
- Oxygen: Connect to 15 LPM O₂ to deliver nearly 100% FiO₂
Breathing too fast or giving too much volume causes gastric inflation → vomiting → aspiration. It also increases intrathoracic pressure, reducing venous return to the heart and decreasing cardiac output. During CPR this is especially dangerous. Give one breath every 5–6 seconds. Squeeze the bag slowly over 1 second.
Oxygen Delivery Devices
| Device | Flow Rate | FiO₂ Delivered | Use When |
|---|---|---|---|
| Nasal Cannula | 1–6 LPM | 24–44% | Mild hypoxia, awake cooperative patient, COPD (2–4 LPM) |
| Simple Face Mask | 6–10 LPM | 35–55% | Moderate hypoxia, needs higher FiO₂ than NC |
| Non-Rebreather Mask (NRB) | 10–15 LPM | 60–95% | Serious hypoxia, SpO₂ <90%, suspected CO poisoning |
| BVM (with O₂) | 15 LPM | ~100% | Apnea, respiratory failure, inadequate breathing |
The NRB reservoir bag must stay inflated — set flow at 10–15 LPM and ensure the bag doesn't fully collapse on inhalation. If it collapses, increase flow. The one-way valves prevent exhaled air from re-entering the bag, maximizing FiO₂.
When to Initiate Oxygen
Don't give oxygen to everyone by default — hyperoxia has risks. Use these guidelines:
- SpO₂ < 94% — Start supplemental oxygen
- SpO₂ < 90% — Escalate to NRB or BVM
- COPD patients: Target SpO₂ 88–92% — their respiratory drive is hypoxia-dependent
- Suspected CO poisoning: 100% O₂ via NRB regardless of SpO₂ reading (CO makes SpO₂ falsely normal)
- Cardiac arrest: 100% O₂ during resuscitation; titrate post-ROSC to 94–99%