To Open The Airway, Optimally Position The Head and Neck

The most basic of airway skill is knowing how to open the airway. Sick patients may be breathing spontaneously, but be unable to maintain an open airway, leading to hypoxia. Hypoxia can easily lead to bradycardia and cardiac arrest, especially in children. Mastering basic airway management skills is essential to avoid serious complications.

Opening The Airway Technique

We’re all familiar with the 3 main ways to open the airway.

Head Tilt

Tilting the head back  tends to allow the larynx to rise away from the posterior pharyngeal structures, opening the airway.

illustration of unconscious patient receiving the chin lift maneuver
Tilting the head back, one of the easiest methods of opening an airway, often works without any additional maneuvers.

Jaw Thrust

To use the jaw thrust maneuver , grip the angles of the mandible with both hands to pull the jaw forward. This motion frequently pulls the head into extension. If you’re using cervical precautions because of potential cervical spine injury, pull upward only on the jaw, keep the head and neck stable. Pressing on the bone 1-2 cm above the angle of the jaw and below the ear is painful and may help rouse a sedated patient enough to breathe on their own.

Photo showing jaw lift in a simulated patient
Lifting the jaw by pulling it forward, even with a neutral neck position, will open the airway.

Triple Airway Maneuver

The triple airway maneuver combines the previous techniques. Tilt the head into extension and lift the angles of the jaw. Use your thumbs to pull the mouth open.

Illustration showing the triple airway maneuver
The triple airway maneuver, both tilting the head back and sliding the lower jaw forward is most effective.

While it’s easy to pull the mandible upward by placing your thumb in the patient’s mouth to grip the chin, I don’t recommend it because it’s potentially dangerous — the patient may bite you.

Why Does Tilting The Neck Open The Airway?

The larynx and surrounding structures will move when you move the head and neck and manipalute the surrounding structures. Look at the following Xrays to see why knowledge of the laryngeal anatomy makes it easier for you to open an airway.

Head and Neck Neutral

Look at the lateral Xray with the head in neutral position. The outline of the epiglottis, hyoid bone, thyroid cartilage, and cricoid cartilage are easily identified. The relationship of the larynx immediately in front of the esophagus explains why aspiration can easily occur and is always a risk

Lateral Xray of a the neutral neck showing the larynx
Xray of neck in neutral position. Note how close the trachea and esophagus are. This image shows how the epiglottis works like a trap door to open and close the larynx.

Head and Neck Fully Flexed

Now lets look at a lateral Xray of the neck flexed fully forward. When the head is flexed forward, the structures in the posterior pharynx and the tongue tend to obstruct the airway and close the larynx. You can test this by flexing your head forward as far onto your chest as you can. It becomes much harder to take a breath.

lateral Xray showing that With the head flexed fully forward onto the chest, the airway is almost fully obstructed. Visualization of the larynx wold be impossible.
With the head flexed fully forward onto the chest, the airway is almost fully obstructed. Visualization of the larynx would be impossible.

Head and Neck Fully Extended

Tilt your head back as far as you can. Your airway is now wide open. When we run up a flight of stairs and get out of breath, we tend to tilt our heads back and slightly forward to maximize airway patency and decrease airway resistence. This position is known as the sniffing position.

Now look at at the Xray to see what happens to the airway when the head is tilted backwards.

lateral Xray of the neck in full extension showing how the relationship of the larynx changes with respect to the rest of the neck structures. Extension without placing the patient in the sniffing position will hide the larynx behind the tongue, or a so-called anterior larynx.
Lateral Xray of the neck in full extension showing how the relationship of the larynx changes with respect to the rest of the neck structures.

Don’t Forget Cervical Spine Precautions

Caution: If you are using cervical spine precautions you should NOT tilt the head back. Tilting the head back with possible cervical spine injury could potentially injure the spinal cord. Maintain a neutral position in this situation and rely on jaw thrust.

It helps to know the anatomy and how your manipulations manipulate that anatomy in order to optimize your ability to manage the airway. Think of that anatomy the next time you open the airway.

For more information on opening an airway and on mask ventilation check out:

Airway Emergency: Start With The Basics of Airway Management

May The Force Be With You

Christine E. Whitten MD
author: Anyone Can Intubate: A Step by Step Guide
Pediatric Airway Management: A Step By Step Guide

Click on the images to preview my books at

Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon
Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten

8 thoughts on “To Open The Airway, Optimally Position The Head and Neck”

  1. i have at times been able to easily see epiglottis and corniculate cartilages but Have not been able to see glottis opening. Could this be due to positioning of the bed too low during intubation? I battle with the height that is best and being new to this wonder if I should have my patient higher up for intubation. Any pointers?

    1. While suboptimal height of the bed can make it harder to intubate, I find that failure to have the head and neck in the optimal sniffing position is more commonly the problem. Take a quick look at patient positioning from the side before you start to alert you to potential issues at a time when it is easier to correct them. In addition, when using a curved blade, failure to engage the hyoepiglottic ligament with the tip of the MAC blade is another common reason to not see the vocal cords. Follow the link below to another of my articles on this issue which has video showing the importance of this aspect of the intubation technique. This article also has a list of links to more tips on my site for intubation success.

  2. Wouldn’t this principle also work well to prevent sleep apnea, that is, sleeping with your chin out and head prone to open the airway?

  3. Dr. Whitten, I teach a course in anesthesiology to young doctors in residency. Your resource “The Airway Jedi” is great, especially for learning. I ask for Your permission to use some images and photos in my presentation.
    I am from Russia and I am very sorry about what is happening in Ukraine, but believe me, not all russians are like our president.
    Thank you, Vitalii Shchukin. MD

    1. Thank you for the compliment. You have my permission to use the images and videos with attribution.I too am saddened by what is happening to Ukraine and I am heartened to hear that not all Russians agree with this campaign. I pray for peAce. Good luck with your lectures.

  4. Hello Dr. Whitten, Thanks so much for this info. I am a physical therapist who predominantly treats children and adults with TMJ issues, Headaches, migraines and sleep disordered breathing your images are so helpful to demonstrate why one tends to tip the head back either during the day or at night when they have limited nasal breathing, enlarged tonsils, adenoids, etc and for many poor airway health and the backward positioning of the head leads to day and or morning headaches, neck pain, TMJ issues, etc. May I have your permission to use your above images and will of course give credit to u? I usually write blogs on my website along with do a 2 day educational TMJ and airway course for PTs and Dentists so would use the above images in my powerpoint as well? I sincerely appreciate your consideration here? Please let me know, thanks! Mike

    1. Yes, of course. Sorry for the late reply. Please use the illustrations for your lectures and PowerPoint. I’m so glad they will be helpful to your patients.

  5. Occasionally I wake up with my airway blocked. Sometimes it feels like minutes pass before I cough enough to clear the passage. It happened yesterday while sitting upright and sipping coffee. Thus my search today. Practicing on myself, I experience the clear airway and will try to remember this for the next occurrence.

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