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.
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.
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.
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
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.
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.
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
and
Pediatric Airway Management: A Step By Step Guide
Click on the images to preview my books at amazon.com
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?
Thanks!
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.
https://airwayjedi.com/2018/10/22/the-mac-blade-the-vallecula-and-the-hyoepiglottic-ligament/
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?
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
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.
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 treatingtmj.com 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
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.