Airway Management: The Foundation of Emergency Care
Airway management is the single most critical skill for any EMT. Without a patent airway, no other intervention matters. The NREMT devotes 18% of the EMT exam to airway, respiration, and ventilation topics, and airway questions appear across all content areas when patient scenarios involve respiratory compromise.
Airway Assessment
Begin every patient contact with a rapid airway assessment. Look for signs of airway obstruction: stridor, gurgling, snoring, or silence in a patient who should be breathing. Assess the patient's ability to speak. A patient who can speak in full sentences has a patent airway and adequate ventilation. A patient who can only speak in short phrases or single words may have partial obstruction or respiratory distress.
Check for foreign bodies, blood, vomitus, or secretions in the mouth. Look for swelling of the tongue, lips, or throat that may indicate anaphylaxis or thermal injury. Assess for facial trauma or burns that could compromise the airway.
Manual Airway Maneuvers
Head-Tilt Chin-Lift
The head-tilt chin-lift is the primary airway maneuver for patients without suspected spinal injury. Place one hand on the patient's forehead and apply gentle backward pressure while lifting the chin upward with the fingers of your other hand. This moves the tongue away from the posterior pharynx and opens the airway.
Jaw-Thrust Maneuver
Use the jaw-thrust when spinal injury is suspected. Place your fingers behind the angles of the mandible and push the jaw forward without tilting the head. This opens the airway while maintaining cervical spine alignment. The jaw-thrust is more difficult to maintain than the head-tilt chin-lift but is essential for trauma patients.
Airway Adjuncts
Oropharyngeal Airway (OPA)
The OPA is indicated for unconscious patients without a gag reflex. It holds the tongue away from the posterior pharynx and provides a channel for air flow and suctioning. Size by measuring from the corner of the mouth to the angle of the jaw. Insert upside down and rotate 180 degrees, or use a tongue depressor to insert directly. If the patient gags, remove immediately and consider a nasopharyngeal airway instead.
Nasopharyngeal Airway (NPA)
The NPA is indicated for patients with an intact gag reflex who need airway assistance. Size by measuring from the tip of the nose to the earlobe. Lubricate with water-soluble lubricant and insert into the larger nostril with the bevel facing the septum. Contraindicated in suspected basilar skull fracture (signs include Battle's sign, raccoon eyes, CSF leakage from ears or nose).
Oxygen Delivery Systems
Choose the oxygen delivery system based on the patient's condition and oxygen requirements:
- Nasal cannula: 1-6 LPM, delivers 24-44% FiO2. Use for patients with mild hypoxia who are breathing adequately
- Non-rebreather mask: 10-15 LPM, delivers 60-90% FiO2. Use for patients with significant hypoxia. Always ensure the reservoir bag is inflated before placing on the patient
- Bag-valve-mask (BVM): 15 LPM with reservoir, delivers nearly 100% FiO2. Use for patients who need assisted ventilation or are not breathing adequately
Suctioning
Suction before ventilation whenever possible. Use a rigid catheter (Yankauer) for the oropharynx and a flexible catheter for the nasopharynx and endotracheal tubes. Limit suctioning to 15 seconds in adults, 10 seconds in children, and 5 seconds in infants. Preoxygenate before suctioning and reoxygenate after. Position the patient on their side (recovery position) when possible to allow gravity drainage.
BVM Ventilation
The BVM is the most challenging airway skill for EMTs. Proper technique requires maintaining a seal while delivering adequate tidal volume. Use the C-E grip: form a C with your thumb and index finger on the mask and an E with your remaining fingers along the mandible. Ventilate over 1 second until you see visible chest rise. Avoid hyperventilation, which increases gastric distension and aspiration risk while decreasing venous return and cardiac output.