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

Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide, by Christine E. Whitten MD.

Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary. Continue reading

When Learning Intubation Is Hard

Learning to intubate is easier for some people than for others. Sometimes, no matter how knowledgeable you are about the theory of the intubation technique, the novice can still struggle to bring it all together to pass the endotracheal tube. The anatomy can be confusing. Understanding how to place the laryngoscope blade and manipulate that anatomy can be challenging. And all the while you must be ever vigilant to protect those precious front teeth, avoid hypertension and tachycardia, and breathe for the patient at regular intervals.

I believe there are 4 chief barriers that inhibit learning how to intubate:

  1. Failure to visualize how the outside anatomy links with the inside anatomy makes it hard to predict how deeply to insert the blade.
  2. A mistaken belief that placing the laryngoscope blade itself is all that is needed to align the axes of the airway and reveal the larynx.
  3. Failure to grasp the dynamic nature of the larynx, and the need to actively manipulate it during intubation.
  4. A lack of understanding that intubation is not a sequence of isolated steps, but is instead a complex dance of interacting steps, each setting the stage for the next.

This discussion is going to assume some knowledge of the basic intubation technique. If you’d like to review those basics you can find links for multiple prior in depth discussions at the end of this article. (Illustrations and animation from Anyone Can Intubate, 5th edition, C Whitten MD.) Continue reading

Intubation: Step By Step

Learning intubation technique can be challenging. Fall is the time of year when new students commonly begin to learn how to intubate. My first intubation was one of the first times I literally held someone’s life in my hands. I was nervous. The anesthesiologist teaching me tried to not look too anxious as I awkwardly grabbed my laryngoscope blade, fumbled while opening the patient’s mouth, and cautiously maneuvered the endotracheal tube into the trachea. It felt like time stopped until the tube was in place, after which the three of us (me, my teacher and my patient) all took a deep breath. Since then, over the last almost 37 years, I’ve intubated thousands of people in the U.S. and, as an international volunteer, eight countries.

So I thought it would be helpful at this time of year to discuss a step-by-step approach to intubation with the commonly used curved blade. Intubation, like a dance, is composed of steps that flow naturally from one to the next. The trick to a smooth intubation is to allow each step to blend seamlessly into the next. The text and illustrations below are excerpted from my book Anyone Can Intubate, as well as from my upcoming book on pediatric intubation, which I’m busy writing. Continue reading

Tips To Teaching Intubation

To teach intubation skills on living patients, even those that have practiced on a manikin, can be challenging. With fall comes the new crop of trainees eager to learn how to intubate. There will also be a new group of instructors teaching their first students to intubate. It’s important to anticipate the common errors so we can safeguard our patients. Here I describe the all of the barriers, physical as well as psychological, that interfere with your student’s learning of the intubation technique. I offer tips on how to help your student conquer those barriers, while keeping your patient safe. Continue reading

Assisting Ventilation With Bag-Valve-Mask

As an anesthesiologist, I often run to emergencies where the patient is not breathing adequately and requires intubation. However, before any intubation, a patient in respiratory distress/failure needs ventilation. Providers who have passed ACLS are often able to ventilate an apneic patient well because they have practiced on the manikin. However, I often see that providers have more difficulty trying to assist ventilation of a patient who is still breathing spontaneously.

The typical inexperienced provider will try to provide large, slow breaths just as they were taught in ACLS. Unfortunately these breaths are often out of synch with the patient’s own breathing. Squeezing the bag while the patient is exhaling means that your inflation pressure must not only overcome the diaphragm, but also reverse the passive outflow of air, the elastic recoil of the lungs, and the rebound of the chest wall combined. The vocal cords may be closed. Ventilating out of synch with the patient won’t be as effective. The breath you deliver will take the path of least resistance to enter the stomach or escape from the mask. It often makes the patient cough.

Even worse,  providers will occasionally hesitate to try to assist a patient’s breathing while waiting for the intubation team because they feel they don’t know how. Delay in improving ventilation can place your patient at higher risk of complication. This is unfortunate because in many ways assisting ventilation is even easier than manually ventilating an apneic patient. Let’s see why. Continue reading