How To Open The Airway

How to open the airway is an essential skill that every health provider should know. Of all the airway skills, it’s the easiest to master and the most likely to save lives in respiratory distress and failure. This article details recognizing airway obstruction, techniques to open the airway, and insertion of oral and nasal airways. Instructional videos plus links to articles on manual ventilation are included.

Recognize Respiratory Compromise

You must be able to recognize airway obstruction. Th signs of airway obstruction inlcude:

Video shows progressive development of the signs of airway obstruction during induction of anesthesia in a child . Opening the airway resolves those signs of obstruction. This is an older video. Note you should always use personal protective gear managing the airway.

If the embedded video does not play follow this link here.

If the patient is apneic, proceed immediately to ventilate with a bag and a mask. On the other hand, if the patient is breathing spontaneously, but is obstructed, try simple arousal. With the head in a relaxed and flexed position, the tongue and soft tissues tend to collapse over the larynx and cause obstruction. Rousing the patient may improve muscle tone and respiratory effort. If stimulating the patient works, monitor the patient closely because he or she may obstruct if they again fall into a deeper plane of sedation.

Open The Airway

If stimulation doesn’t rouse the patient, there are several ways to open the airway of a patient who is breathing spontaneously. The following maneuvers assume no cervical spine injuries. Most common is the head tilt/chin lift maneuver. Tilt the head backward. Place your fingertips under the rim of the mandible and lift upward, keeping pressure on the bone, not the soft tissue. Pressing on the soft tissue potentially obstructs the airway, especially in small children.

Head Tilt

To open the airway, pull the angles of the jaw upward. This action puts tension on the base of the tongue and soft tissues and lifts the epiglottis off the trachea. Further thrust of the jaw opens the mouth and fully opens the airway. We naturally assume this position when sniffing the air, which is why it’s called the sniffing position. 

Steps to open the airway in cross-section
Relieving airway obstruction in cross section. Placing the head on a small pillow and pulling the jaw upward both tend to lift soft tissue away from the posterior pharyngeal wall, opening the airway. Tilting the head backward (c) and thrusting the jaw forward (d) pulls soft tissue off of the larynx, further relieving any obstruction.
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 to open the airway, 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 patient enough to breathe on their own.

Illustration showing jaw thrust to open the airway
The jaw thrust maneuver: place your fingers on the boney mandible behind the angles of the jaw and lifts the jaw upward. This technique is helpful when there is risk of cervical spine injury as it does not move the neck.

Triple Airway Maneuver

The triple airway maneuver opens the airway by combining the previous techniques. Tilt the head into extension and lift the angles of the jaw. Use your thumbs to pull the mouth open. Pulling the angles of the jaw upward puts tension on the base of the tongue and soft tissues, and lifts the epiglottis off the trachea. Further thrust of the jaw opens the mouth and fully opens the airway. This position is called the sniffing position.

The triple airway maneuver tilts the head, lifts the chin, and thrusts the jaw to open the airway.
The triple airway maneuver tilts the head, lifts the chin, and thrusts the jaw.

While it’s easy to pull the mandible upward by placing your thumb in the patient’s mouth to grip the chin, it’s potentially dangerous because the patient may bite you.

Look, listen, and feel for evidence of good ventilation:

  • The chest rises and falls appropriately with breathing
  • You can hear breath sounds
  • There is good movement of air in and out of the mouth and nose
  • A clear oxygen mask fogs with each breath
  • End-tidal CO2 is present

Oral Airways

Oral airways are one of our most important tools to relieve airway obstruction and open the airway. An oral airway, also called an oropharyngeal airway, is a fairly firm, curved piece of plastic. It sits on top of the tongue. Properly placed, the oral airway pulls the tongue forward. Improperly placed it pushes the tongue into the back of the pharynx and further obstructs the airway. 

Disadvantages of Oral Airways

Oral airways should not be used in patients with intact gag reflexes because of the risk of vomiting, aspiration, and laryngospasm. If your patient is coughing, swallowing, or responding when you suction secretions, he or she is unlikely to tolerate an oral airway.

Second, the oral airway must be placed inside the mouth between the patient’s teeth, sometimes a difficult and personally risky task in patients who can protect their airway.

Finally, rigid, plastic oral airways can damage teeth — especially if the teeth are already loose or decayed.

Choosing The Correct Size Oral Airway

The correct size oral airway places the flange immediately outside the teeth or gums and positions the tip near the vallecula.

illustration of correct position of oral airway
The properly sized oral airway sits atop the tongue and pulls it forward. Too large forces the larynx down, too small bunches the tongue: both can worsen airway obstruction.

To estimate the correct size, place the airway next to the patient’s jaw parallel to the mouth and judge where it will lie. The tip should extend from the center of the patient’s mouth to the angle of the lower jaw.

Illustration of how to choose correct size oral airway
Check appropriate size of an oral airway by holding it next to the side of the jaw.

Too small an airway places the tip in the middle of the tongue, bunching the tissue and worsening obstruction. It can obstruct the lingual vein and cause tongue swelling. Too large an airway extends from the mouth and prevents sealing the mask over the face. It can fold the epiglottis down over the glottic opening and worsen obstruction).

Inserting An Oral Airway

There are several ways to insert an oral airway. Always start by opening the mouth as widely as you can. Using either your right or left hand, place your thumb on the lower jaw and your middle finger on the upper jaw. The position is similar to snapping your fingers. By using a pushing rather than a spreading motion, you can open the mouth wider and more forcefully. Make sure that you place your fingers far to the side of the mouth to leave you enough room to insert the oral airway).

You can insert an oral airway either with the curve either down toward the tongue, or up toward the roof of the mouth.

With the curve down, advance the airway around the tongue until the tip is behind the back of the tongue. Wetting the airway with water will allow it to slide more easily if the mouth is dry.

Use of a tongue blade can help. Use your non-dominant hand to place the tongue blade to the rear of the tongue and pull it forward. Slide the oral airway into position with your dominant hand. You can often slide the device down the tongue blade.

Illustration of using a tongue blade to place an oral airway
Using a tongue blade to assist insertion of the oral airway.

Providers sometimes insert an oral airway by turning its curve toward the roof of the mouth. They advance it until its tip lies behind the tongue and then flip it into position. While effective, you must use caution. You can easily damage teeth and the roof of the mouth. If there is a loose front tooth, this maneuver could remove it. You can also injure the roof of the mouth.

Illustration placing oral airway upside down and rotating it into position
If inserting an oral airway upside down and then rotating be very careful of the teeth.
Inserting an oral airway. Note, some video is older. Always use personal protective gear when contamination is possible.

If the embedded video does not play follow this link here.

Nasal Airways

Nasal airways, also called nasopharyngeal airways, nasal canulas or nasal trumpets, are soft, flexible tubes which slide through one side of the nose. This position places the opening of the tube in the posterior pharynx, behind the tongue, and usually though not always, in line with the trachea. The nasal airway opens the airway by bypassing the mouth and routing the majority of airflow though the nose and nasopharynx.

A nasal airway is better tolerated in semiconscious patients because it won’t stimulate the gag reflex as much. However, nasal airways can cause nosebleeds, especially in 3-6 year old children with hypertrophied adenoids.

Choose the correct size airway by measuring the device on the patient: the nasal airway should reach from the patient’s nostril to the earlobe or the angle of the jaw and is usually 2-4 cm longer than the oral airway.  Selecting a nasal airway size based either on nostril opening or comparing it to the size of the little finger is not very accurate because the cartilaginous turbinates inside the nasal passages also play a role and cannot be easily seen).

Illustration how to size a nasal airway
Check the nasal airway size comparing the distance from the nares to the ear

Once inserted, a nasal airway should not be so large that it makes the skin around the nostril blanch from compression. Blanching means the blood supply is compromised and prolonged ischemia can cause permanent injury. This is more likely to occur in the small child than in the adult.

If embedded video does not play then follow the link here.

Nasal Airway Insertion Technique

Liberally coat your nasal airway with lubricating ointment or gel if available. You can also use water. Local anesthetic ointment has the advantage of numbing the nose and making the tube more easily tolerated.

Slide the nasal airway into the nares and gently advance it along the floor of the nose. Don’t try to thread the nasal airway up the nose toward the frontal sinus! Not only will the tube not pass in this direction, you risk a nosebleed.

Inserting a nasal airway. Note that some video is older. Always use personal protective gear when contamination is possible.

The final position places the tip of the nasal airway close, but not into the top of the larynx. Always insert gently and never force one to pass. If you meet an obstruction then carefully twist the tube while slowly pushing it forward

Don’t force it. The turbinates can be fragile and easily fractured and the mucosa is easily torn. Check your angle of insertion and try again. If the nasal airway will not pass, try the other nostril or switch to a smaller tube. Never force a nasal airway during insertion.  If you meet an obstruction try rotating the nasal airway as you advance. 

Adenoidal tissue can plug nasal airways, causing obstruction and potential aspiration of tissue. If it appears plugged, suction the nasal airway to clear it.

The nasal passage sometimes pinches the tube as it turns the corner. The resultant narrowing may make passing a suction catheter down the nasal airway difficult. Moving the tube in or out a small amount will often allow the tube to curve more easily and remove the kink.

Nasal airways are relatively contraindicated in facial trauma when there is risk of skull or midface fracture. If there is such a fracture, there is a small risk of passing the nasal airway through a fractured frontal sinus and into the cranial vault.

is Your Patient Breathing?

At this point if you have been able to open the airway, but the patient is still not breathing adequately, you must assist ventilation. The links below lead to additional articles on opening the airway and ventilating.

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

ADDITIONAL ARTICLES ON AIRWAY MANAGEMENT FOR BEGINNERS AND THEIR INSTRUCTORS

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