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
and
Pediatric Airway Management: A Step By Step Guide

Click on the images to preview my books at amazon.com

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

Pediatric Airway Risks: Inefficient Mechanics of Breathing

Inefficient mechanics of breathing is one major risk factor for infants and young children because it increases work of breathing. In many ways pediatric anatomy and physiology predisposes a child to respiratory distress and respiratory failure.

(Illustrations copyright Whitten, Pediatric Airway Management: A Step By Step Guide)

Mechanics of Normal Breathing

Normal quiet breathing is effortless. The rate is neither too fast nor too slow, however, rate varies greatly depending on age and metabolic rate. The chest rises and falls easily and symmetrically. Air flows into and out of the lungs through the open airway based on changes in air pressure.

Adult Chest Cavity Anatomy Makes Breathing Efficient

Let’s start by reviewing the adult mechanics of breathing. The angulation and rigidity of the ribs during the breathing cycle maximizes efficiency in the adult. The lungs are housed in a skeletal cage formed by the ribs. In order to initiate airflow into the lungs, pressure in the lungs must drop below atmospheric pressure. The body accomplishes this by expanding the airtight chest cavity, thereby decreasing the pressure inside. Two motions are involved:

  • expansion of the rib cage by contraction of intercostal muscles
  • contraction and descent of the diaphragm

The ribs form three functional groupings. The first rib attaches rigidly to the sternum to anchor the rib cage. It hardly moves during respiration.

The 8th through 12th ribs expand mostly laterally during inhalation. This effectively increases intra-abdominal space for organs pushed downward by the diaphragm. The motion is like a bucket handle, swinging up and down toward the side away from the centerline and expanding the width of the chest cavity.

The 2nd to 7th ribs flexibly expand mostly anterior-posterior with a little lateral motion. This motion is like a pump handle — mostly up and down in the front of the chest, expanding the depth of the chest cavity.

Illustration comparing the motions of ribs 8-12 to the motion of ribs 2-7. Each set has unique movements for expanding the rib cage.

a. Ribs 8-12 expand mostly laterally, like a bucket handle. b. Ribs 2-7 expand mostly anteriorly, like a pump handle.

Diaphragmatic Contaction Is The Bellows

The diaphragms are two large dome-shaped sheets of muscle separating the thoracic cavities from the abdominal cavity. As the diaphragms contract with each inhalation, they act like a bellows. During inhalation the bellows descends and flattens, increasing intrathoracic volume and decreasing intrathoracic pressure. This pulls air into the lungs as they inflate.

During exhalation, the diaphragm and intercostals relax. As a result, the diaphragms rise and become dome shaped again, decreasing intrathoracic volume and raising intrathoracic pressure. Lungs deflate. The patient exhales. Unless there is obstruction, exhalation is passive, requiring little energy.

Full contraction of the intercostals and the diaphragm allows for much greater expansion of the chest cavity and produces a larger breath, assuming that air is free to flow into the lungs..

Illustration showing how relaxation and contraction of the diaphragm produces air flow into and out o the lungs by changing air pressure inside the thoracic cavity.

The diaphragm contracts and relaxes during breathing, expanding and contracting the volume of the thoracic cage. The associated air pressure changes inside the thoracic cavity cause the lungs to expand (a) and to deflate (b).

What Factors Affect Ease of Air Flow?

A variety of factors affect how easily that air flows:

  • breathing rate
    • too rapid or too slow a rate impairs air movement
  • inspired tidal volume
    • ventilating close to dead space volume causes CO2 levels to rise
  • airway resistance
    • smaller airways have higher resistance than larger airways
    • increased resistance impairs airflow
  • tissue resistance
    • increased frictional resistance of lung tissues and chest wall increases work of breathing and limits tidal volume
  • elastic recoil
    • with weaker elastic recoil, airways tend to remain partially collapsed on exhalation rather than passively reinflate to baseline
  • compliance
    • poor compliance makes it harder to distend the lungs, limiting air movement and increasing the work of breathing

Changes in any of these parameters can significantly affect adequacy of respiration and how hard it is to take a breath.

Anatomical Features That Increase Pediatric Work of Breathing

When the patient works hard to take a breath, for example against an obstruction, he generates a more negative pressure inside the chest cavity.  The intercostal muscles more fully contract. Retractions, noisy breathing, and a rocking chest wall motion are common. As respiratory failure progresses, the pattern of respiration becomes more and more inefficient and ineffective. Work of breathing increases.

In the patient exhausted to the point of respiratory collapse, or in the patient with respiratory depression due to altered mental status, there may be little effort to breathe. Hypoventilation worsens hypoxia, hypercarbia, and respiratory acidosis. Level of sedation increases, further depressing respiratory drive.

Normal infants and small children have significant anatomic predispositions to serious disruption of their mechanics of breathing if they become sick or injured.

Factors Increasing Infant Work of Breathing

The differences in the mechanics of breathing of small children compared to adults places them at much higher risk of respiratory failure.

Evaluating the degree of respiratory compromise is a judgment call. Mild or potential obstruction may have no signs or symptoms at all. In certain patients such as facial burn victims or patients having a severe allergic reaction, mild airway obstruction can convert to total obstruction quickly as edema forms. Constant reassessment is important so that you may intervene early if necessary — before the airway is lost.

The Infant’s Chest Wall Increases The Work Of Breathing

In the infant or small child, the chest wall is more box-like in shape compared to the adult’s. The ribs are more at right angles to the vertebral column and won’t be angulated like an adult until age 10 years. This makes the pediatric chest wall mechanically less efficient and limits potential lung expansion.

comparison infant vs adult rib angulation

The shape and flexibility of the infant chest, and the shape and immaturity of the diaphragmatic muscle both increase the risk of respiratory failure when the child is ill.

Babies “belly breathe”. To take a deep breath, the infant’s chest therefore expands a little and the abdomen rises a lot as the diaphragm descends, pushing abdominal contents down and out of the way.  Anything that interferes with descent of the diaphragm, such as a stomach or intestines distended with air or liquid, can seriously impair an infant’s breathing.

The infant’s chest wall is also more compliant than an adult’s, with an elastic recoil close to zero because of the lack of rib cage ossification. When the infant takes a breath against resistance, such as with airway obstruction or poor pulmonary compliance from pneumonia, the chest wall actually moves inward as the belly moves outward. The inward movement of the chest wall decreases the amount of air that enters. A rocking chest wall motion is very common in children with even partial airway obstruction.

Illustration showing the components of infant anatomy that make the mechanics of breathing inefficient, increasing risk of respiratory failure.

The inefficient mechanics of infant/toddler breathing increases the risk of respiratory failure.

Because chest wall structure and “belly breathing” limit the ability to increase tidal volume, the baby must rely on respiratory rate increases to compensate for stress. The harder a child tries to breathe, the less efficient and more labored breathing becomes.

You can see video of a toddler with croup and the signs of airway obstruction described above here.

Monitor Your Pediatric Patient Carefully

Watch for signs of airway obstruction.

chart listing the signs of airway obstruction

Infants and toddlers tire easily when they have airway or respiratory compromise. Respiratory distress can easily progress to respiratory failure. Assess your patients carefully and monitor for change. Always ask yourself: “How well is my patient breathing?” Follow the link below for discussions and video of recognizing and treating airway obstruction.

Recognizing Airway Obstruction May Save Your Patient’s Life

Click here see a video clip comparing the signs of airway obstruction in a pediatric patient with a more normal breathing pattern once the obstruction is relieved.

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

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten    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

Click on the covers to preview books at amazon.com

Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose.

The Case

The child was an 18 month old girl whose older brother had been playing with laundry detergent pods. He had offered a pod to his little sister, who promptly put it in her mouth and chewed it, releasing the liquid. Her mother had brought her to the emergency room with respiratory distress. The child had severe stridor and was breathing at 40 times a minute. Oxygen saturation was 92%. She was awake and alert but anxious.

The ED doctor recognized significant airway obstruction and was concerned that the obstruction could worsen if the edema got worse. She immediately called for an anesthesiologist and a Head and Neck surgeon to come to the Emergency Department to evaluate the child. While waiting, she gave 10 mg of IM decadron and treated the child with nebulized racemic epinephrine. She attached a pulse oximeter and left the child sitting on her mother’s lap and otherwise did not disturb the child, trying to avoid making her cry. By the time the anesthesiologist and surgeon arrived the stridor, although still present, sounded better.

The question was what to do now? Continue reading

Airway Emergency: Start With The Basics of Airway Management

We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway emergency: the dreaded “can’t intubate-can’t ventilate” airway emergency scenario.

As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.

One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition. Continue reading

Don’t Be Afraid To Use Percutaneous Jet Ventilation In An Emergency

Needle cricothyrotomy or percutaneous jet ventilation (PCJV) can truly be a life saving procedure. It is a fast, effective way of providing oxygen to a patient with an obstructed airway who does not respond to more conventional means of opening the airway. The “can’t intubate-can’t ventilate” scenario is a good example. PCJV is faster to perform than a surgical airway. It will buy you time to establish a more permanent airway such as an intubation or surgical airway if the patient is hypoxic.

However, percutaneous transtracheal jet ventilation carries some rare though potentially serious risks of worsening airway obstruction and cardiovascular collapse if the catheter is not correctly positioned within the trachea. Fear may prevent us from using it. In addition, most of us have never had to use PCJV in an emergency or even seen it used. Lack of familiarity with the equipment and simple lack of comfort may make us hesitate to try. We may not even think about it in the moment of crisis. So let’s look at some of the ways we can use PCJV safely. Continue reading

Laryngospasm is a Life-Threatening Emergency

Laryngospasm is one of the more frightening events in anesthesia: the protective, reflex, spasmodic closure of the vocal cords that occurs when the vocal cords are stimulated.  When laryngospasm occurs, vocal cord closure can be so forceful that it can prevent all ventilation or even the passage of the endotracheal tube. Life-threatening hypoxia can quickly follow. Other potential complications include post obstructive pulmonary edema, and possibly even cardiac arrest.

Photo of laryngospasm demonstrating closure of the vocal cords and false cords Continue reading