Airway Management Vocabulary
Course Overview and Core Concepts
Chapter 9: Airway Management
Standard: Airway Management, Respiration, and Artificial Ventilation (Airway Management).
Competency: Applies knowledge (fundamental depth, foundational breadth) of general anatomy and physiology to patient assessment and management to ensure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages.
Core Concepts:
Physiology of the airway.
Pathophysiology of the airway.
How to recognize an adequate or an inadequate airway.
How to open an airway.
How to use airway adjuncts.
Principles and techniques of suctioning.
Learning Outcomes:
9.1: Describe the structure and function of the normal airway (differentiate upper vs. lower airway structures; match structures to functions).
9.2: Explain concepts of airway pathophysiology (list causes of upper and lower airway obstruction; list steps to airway assessment in primary assessment; distinguish between signs indicating absent breathing, inadequate airway, and adequate airway; list signs of inadequate airway more likely in children than adults; explain how to determine if airway status may worsen).
9.3: Describe the use of manual maneuvers to open the airway (provide rationales for selecting manual maneuvers best suited for patient scenarios).
9.4: Explain the use of adjunctive equipment to manage an airway (state importance of immediate suction availability; identify adherence to general rules for airway adjuncts; describe features of an oropharyngeal airway; list insertion steps for oropharyngeal airways; identify benefits of nasopharyngeal airways over oropharyngeal airways; list insertion steps for nasopharyngeal airways; describe minimum features required of suction units; match suction components to designed purposes; suggest responses to suctioning complications; recall general rules for suctioning; describe decision-making considerations).
Key Terms: airway, bronchoconstriction, gag reflex, glottic opening, head-tilt chin-lift maneuver, jaw-thrust maneuver, nasopharyngeal airway, oropharyngeal airway, patent airway, stridor, suctioning.
Related Chapters: Chapter 3 (Lifting and Moving Patients), Chapter 6 (Anatomy and Physiology), Chapter 7 (Principles of Pathophysiology), Chapter 10 (Respiration and Artificial Ventilation), Chapter 19 (Respiratory Emergencies).
Chapter 10: Respiration and Artificial Ventilation
Standard: Airway Management, Respiration, and Artificial Ventilation (Respiration, Artificial Ventilation).
Competency: Applies knowledge (fundamental depth, foundational breadth) of general anatomy and physiology to patient assessment and management to ensure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages.
Core Concepts:
Physiology and pathophysiology of the respiratory system.
How to recognize adequate and inadequate breathing.
Principles and techniques of positive pressure ventilation.
Principles and techniques of oxygen administration.
Learning Outcomes:
10.1: Compare the physiology and pathophysiology of breathing (describe mechanical process of breathing; describe alveolar respiration physiology).
10.2: Explain concepts of cardiopulmonary pathophysiology (explain conditions interrupting mechanical breathing, alveolar gas exchange, and cellular circulation exchange).
10.3: Summarize concepts of respiration (recognize consequences of inadequate breathing; distinguish respiratory distress from respiratory failure).
10.4: Describe breathing assessment (sequence of steps; evaluate status based on findings; differentiate supplemental oxygen needs vs. artificial ventilation with supplemental oxygen).
10.5: Summarize positive pressure ventilation concepts (explain complications; general approach and techniques; rapid vs. slow breathing management; match interventions to patient status; identify equipment; list procedural steps; modifications for stoma breathers; automatic transport ventilator / ATV indications).
10.6: Explain supplemental oxygen administration (decision-making considerations; portable and fixed cylinder features; supply evaluation obligations; safety obligations; equipment and supplies; risks of excessive oxygen; preparation steps; scenario-based selection; managing complications; pediatric modifications).
10.7: Explain roles and responsibilities related to advanced airway devices (recognize types of devices; assist in placement procedures; ventilation considerations with advanced airways in place).
Key Terms: alveolar ventilation, artificial ventilation, automatic transport ventilator (ATV), bag-valve mask (BVM), cellular respiration, cyanosis, diffusion, flowmeter, humidifier, hypoxia, nasal cannula, nonrebreather (NRB) mask, oxygen cylinder, pocket face mask, positive pressure ventilation, pressure regulator, pulmonary respiration, respiration, respiratory arrest, respiratory distress, respiratory failure, stoma, tracheostomy mask, ventilation, Venturi mask.
Related Chapters: Chapter 3, Chapter 6, Chapter 7, Chapter 9, Chapter 19, Chapter 20 (Cardiac Emergencies).
Chapter 20: Cardiac Emergencies
Standard: Medicine (Cardiovascular).
Competency: Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.
Core Concepts:
Aspects of acute coronary syndrome (ACS).
Conditions that may lead to a cardiac emergency.
Learning Outcomes:
20.1: Explain cardiovascular anatomy and physiology (blood flow through heart chambers; circulation to body and back).
20.2: Explain acute coronary syndrome (ACS) concepts (recognize signs and symptoms; cardiac compromise concept).
20.3: Outline management for ACS presentations (evaluate signs/symptoms; role of positioning; oxygen administration practice; pharmacology of EMT-administered medications; aspirin responsibilities; nitroglycerin responsibilities; immediate transport criteria; teamwork during transport; advantages of prehospital 12-lead ECGs).
20.4: Illustrate underlying pathophysiology of cardiac conditions (coronary artery disease, angina pectoris, acute myocardial infarction; dysrhythmias; heart failure pathophysiology and presentation; aneurysms; conditions interfering with mechanical work of the heart).
Key Terms: acute coronary syndrome (ACS), acute myocardial infarction (AMI), aneurysm, angina pectoris, bradycardia, cardiac compromise, cardiovascular system, coronary artery disease (CAD), dyspnea, dysrhythmia, embolism, heart failure (HF) / congestive heart failure (CHF), nitroglycerin, occlusion, pedal edema, pulmonary edema, tachycardia, thrombus.
Related Chapters: Chapter 3, Chapter 6, Chapter 10, Chapter 12 (Primary Assessment), Chapter 13 (Vital Signs and Monitoring Devices), Chapter 15 (Secondary Assessment), Chapter 22 (Diabetic Emergencies and Altered Mental Status), Chapter 26 (Abdominal Emergencies), Appendix A (Basic Cardiac Life Support Review).
Epidemiological Statistics:
Cardiovascular disease kills more than people each year in the United States.
In the coming year, approximately people will suffer a heart attack, and roughly of those individuals will die from the event.
Survivors join the ranks of more than people in the United States living with the effects of cardiovascular disease.
Respiratory System Anatomy and Airway Physiology
Overview of Breathing and Pathway:
The average person takes approximately breaths per day to deliver oxygen () and remove carbon dioxide ().
The airway is a continuous channel starting at the mouth and nose and terminating at the gas-exchanging alveolar membranes.
A patent airway is defined as an open and intact airway where airflow is completely unobstructed.
Upper Airway Anatomy & Functions:
Nose: Specifically designed to receive air; warms and humidifies air as it passes through curved nasal passages and paranasal sinuses.
Mouth: Primary entry point of the oral cavity.
Pharynx (Throat): Divided into three anatomic regions:
Nasopharynx: Posterior region where nasal passages join the pharynx (contains pharyngeal tonsil and Eustachian tube opening).
Oropharynx: Middle region where the oral cavity joins the pharynx (contains palatine tonsils, hard palate, soft palate, uvula, tongue, and mandible).
Laryngopharynx (Hypopharynx): Lower region surrounding the entrance to the trachea; provides structure and protects the tracheal opening. Serves as the dividing line between upper and lower airways.
Laryngeal Structure and Boundaries:
Glottic Opening: The entry point into the larynx lined by curtainlike fibers called vocal cords. The vocal cords define the boundary between upper and lower airways and vibrate during air passage to generate voice.
Epiglottis: A large, leaf-like cartilaginous structure positioned directly above the glottic opening; acts as a protective flap that seals off the trachea during swallowing or reflex action (gag reflex).
Thyroid Cartilage: Shield-like cartilage structure protecting the anterior aspect of the larynx; forms the Adam's apple.
Cricoid Cartilage / Ring: A complete circular ring of cartilage forming the lower aspect of the larynx and providing structure to the superior trachea.
Hyoid Bone & Arytenoid Cartilage: Provide upper structural and muscular anchor points surrounding the glottis.
Lower Airway Anatomy & Functions:
Trachea: Windpipe extending below the glottic opening; structurally supported by rings of cartilage to prevent collapse.
The superior ring is the complete cricoid ring ().
The remaining rings extend approximately three-fourths of the way around and are connected posteriorly by smooth muscle.
Carina: The bifurcation point where the trachea divides into the right and left mainstem bronchi.
Bronchial Tree: Mainstem bronchi subdivide into secondary bronchi, tertiary bronchi, and progressively smaller passages termed bronchioles.
Bronchioles: Small air passages supported by cartilage and lined with smooth muscle, allowing them to adjust internal diameter in response to stimuli.
Alveoli: Microscopic air sacs occurring in grape-like clusters at the distal ends of bronchioles; surrounded by pulmonary capillaries. Gas exchange occurs across thin alveolar-capillary membranes.
Bronchioles branch multi-directionally, covering almost all chest regions from collarbones to the diaphragm.
Pediatric Airway Physiology Differences:
Neck muscles are immature, and airway structures are shorter, narrower, and less rigid than adult structures.
Mouth and nose are smaller, making them more easily obstructed by swelling or foreign objects.
Tongue occupies a proportionately larger space in the mouth compared to adults.
Newborns and infants are obligate nose breathers; nasal obstruction severely impairs respiration.
Trachea is narrower, softer, and significantly more flexible.
Cricoid cartilage is less rigid and less developed.
Chest wall is softer and more compliant; pediatric patients depend heavily on the diaphragm for ventilation.
Airway Pathophysiology and Partially Obstructed Airway Sounds
Pathophysiology of Obstruction:
Maintaining a patent airway requires neuromuscular control of more than distinct muscle groups (intact muscle tone).
Neurologic impairment or altered mental status leads to loss of muscle tone, causing airway collapse.
Tongue / Epiglottis Occlusion: In patients with decreased mental status, relaxed lower jaw muscles cause the tongue to drop posteriorly. Because the epiglottis is attached to the base of the tongue, it falls back over the glottic opening, sealing the tracheal entrance.
Position Risk: Unconscious or semiconscious patients lying flat (supine) face severe risk of tongue and epiglottis obstruction.
Causes and Dynamics of Airway Obstruction:
Foreign Objects: Food, small toys, broken teeth, or dental appliances.
Fluids: Blood, vomitus, and excessive mucosal secretions.
Tissue Swelling (Edema): Acute severe allergic reactions (anaphylaxis) cause rapid soft tissue swelling requiring immediate epinephrine injection; burns, blunt trauma, and severe infections (e.g., epiglottitis) also cause upper airway tissue swelling.
Lower Airway Narrowing: Smooth muscle contraction in bronchioles decreases internal diameter (bronchoconstriction or bronchospasm), causing high resistance to airflow (e.g., asthma).
Audible Sounds of Partial Airway Obstruction:
Stridor: High-pitched, whistling sound produced by air forced under pressure through a severely restricted upper airway. Indicates severe passage narrowing and impending total upper airway obstruction (caused by foreign bodies or tissue swelling).
Hoarseness: Voice change or raspiness indicating upper airway narrowing around the vocal cords (e.g., progressive thermal swelling following burn injuries). Development of hoarseness is an ominous clinical sign.
Snoring: Rough sound created by soft tissue vibration in the upper airway; indicates diminished muscle tone and decreased mental status. Signals that manual or mechanical assistance is required to maintain patency.
Gurgling: Sound produced by air passing through liquid obstruction (blood, vomitus, secretions) in the pharynx. Indicates an urgent, immediate requirement for suctioning.
Patient Assessment: Airway Patency and Inadequacy
Core Assessment Questions:
"Is the airway open?"
"Will the airway stay open?"
The Look-Listen-Feel Primary Assessment (Box 9-1):
Speech Evaluation: Asking a patient a simple question evaluates moving air immediately. Normal voice indicates open airway; hoarse, raspy, or absent speech indicates difficulty moving air.
Look:
Visually inspect the mouth and pharynx for foreign bodies, blood, vomitus, or structural trauma.
Inspect for external neck trauma, facial burns, or active oral bleeding.
Observe chest rise and fall during respiration.
Evaluate patient positioning (e.g., sitting bolt upright or assuming the sniffing position).
Listen: Listen for abnormal airflow noises (stridor, snoring, gurgling, wheezing, gasping).
Feel:
Feel for airflow at the mouth and nose using your cheek or hand.
Place hands on the chest wall to feel chest movement.
Sniffing Position:
Posture assumed by patients with partial upper airway obstruction (often infection-induced swelling); characterized by sitting bolt upright with the head pitched forward as if smelling something. Crucial posture to keep the airway open naturally.
Signs of an Inadequate Airway:
Absence of breathing signs or total lack of air movement.
Foreign body obstruction (blood, vomitus, objects, broken teeth).
Absence of felt or heard airflow at nose/mouth, or exchanged air volume below normal limits.
Inability to speak or severe difficulty producing speech.
Hoarse or unusual raspy voice quality.
Chest movements absent, minimal, or asymmetrical (uneven).
Respiratory efforts restricted solely to movement of the abdomen (abdominal breathing).
Diminished or completely absent breath sounds.
Presence of wheezing, stridor, snoring, gurgling, or gasping sounds.
Pediatric Specifics: Muscle retractions above the clavicles, between ribs (intercostal), and below ribs (subcostal); nasal flaring (widening nostrils during inhalation).
Evaluating Airway Stability ("Will it stay open?"):
A patient may present with an open airway that can suddenly collapse as mental status deteriorates or tissue edema progresses.
If manual maneuvers (head-tilt, chin-lift or jaw-thrust) open an airway, removing hands causes immediate closure if muscle tone is absent.
Rapidly progressive edema (e.g., bee sting anaphylaxis, burn trauma) requires immediate advanced intervention before complete occlusion occurs.
Constant reassessment of airway patency is mandatory.
Patient Positioning and Manual Airway Maneuvers
Patient Positioning for Basic Life Support (Scan 9-1):
For airway assessment and management, patients with altered mental status must be positioned supine on a flat surface.
Single-Rescuer Log-Roll Procedure:
Straighten the patient's legs and position the arm closest to the rescuer straight above the patient's head.
Reach across and grasp under the patient's distant armpit.
Cradle the head and neck with one hand while rolling the patient as a unit onto their side.
Roll the patient onto their back and reposition the extended arm.
Trauma Considerations & Spinal Stabilization:
Any movement of a patient with suspected spinal cord trauma can precipitate permanent neurological injury.
Indications of Potential Spinal Injury: High-risk mechanism of injury (fall from ladder/stairs, motor vehicle collision), any visible trauma at or above shoulder level, or bystander accounts of head/neck trauma.
Clinical Priority: Airway and breathing management take absolute priority over complete spinal immobilisation. Provide manual inline cervical stabilization while opening the airway.
Head-Elevated, Sniffing Position:
Optimizes upper airway alignment in supine patients without spinal injury.
Created by placing approximately () of padding beneath the occiput.
Alignment Standard: Achieved when the patient's external auditory meatus (ear) aligns horizontally with the suprasternal notch (top of sternum) viewed laterally.
Pediatric Airway Positioning Considerations:
Children under possess a proportionately larger occiput and flexible trachea.
Placing a small child flat on a backboard flexes the neck forward toward the chest, causing severe tracheal bending and tongue base obstruction.
Pediatric Padding Requirement: Place padding beneath the shoulders of infants and young children to achieve the suprasternal notch alignment; older children may require padding under the occiput similar to adults.
Manual Airway Maneuvers:
Head-Tilt, Chin-Lift Maneuver:
Indication: Unresponsive, non-trauma patient without suspected spinal injury.
Procedure:
Place patient supine; put one hand flat on the forehead.
Place fingertips of the other hand under the bony part of the lower jaw (mandible).
Apply gentle downward pressure to the forehead to tilt the head back.
Lift the chin forward with fingertips until lower teeth almost touch upper teeth.
Retract lower lip with thumb if necessary; never place thumb inside the patient's mouth.
Jaw-Thrust Maneuver:
Indication: Unresponsive patient with suspected head, neck, or spinal trauma, or unknown mechanism of injury.
Purpose: Opens the airway without moving or extending the head or neck.
Procedure:
Maintain head, neck, and spine in inline alignment in a supine position.
Kneel at the top of the patient's head (rest elbows on the ground for stability).
Place hands on both sides of the patient's lower jaw at the mandibular angles below the ears.
Use index/middle fingers to push mandibular angles upward and forward.
Retract lower lip with thumbs if needed to maintain open mouth.
Do NOT tilt, rotate, or extend the head.
Airway Adjuncts: Selection, Sizing, and Insertion
General Rules for Airway Adjunct Usage:
Use an oropharyngeal airway (OPA) only on patients who lack a gag reflex.
Patients with an intact or partial gag reflex will vomit or retch with an OPA; use a nasopharyngeal airway (NPA) instead.
Open the airway manually using head-tilt, chin-lift or jaw-thrust before inserting any adjunct.
Avoid forcing or pushing the tongue back into the pharynx during insertion.
Have suction equipment assembled and powered on prior to adjunct insertion.
Immediately abort insertion if the patient gags or retches; maintain manual positioning.
Continue maintaining manual head position (head-tilt, chin-lift or jaw-thrust) even after an adjunct is seated.
Immediately remove adjuncts if the patient regains consciousness or exhibits a gag reflex (pull straight out along anatomic curve; do not rotate on removal).
Observe personal protective equipment (PPE) protocols: wear gloves, mask, and protective goggles to prevent facial exposure to body fluids.
Oropharyngeal Airway (OPA):
Curved rigid plastic device resting against the lips with a flange; keeps the tongue displaced forward off the pharyngeal wall.
Sizing Method:
Measure from the corner of the patient's mouth to the tip of the earlobe on the same side.
Alternative Method: Measure from the center of the mouth to the angle of the lower jawbone (mandible).
Consequences of Incorrect Sizing:
Too large: Distal tip rests near the esophagus, directing air into the stomach during ventilation.
Too small: Fails to lift the tongue forward, compressing it posteriorly and worsening obstruction.
Adult OPA Insertion Procedure (Scan 9-2):
Ensure correct size by measuring corner of mouth to earlobe.
Open mouth using the crossed-finger technique (cross thumb and index finger, place on upper and lower teeth at corner of mouth, push fingers apart).
Insert airway with distal tip pointing toward the roof of the mouth (hard palate).
Slide device along palate past uvula until resistance is met.
Gently rotate device so distal tip points down into the pharynx.
Position flange flush against patient's lips.
Alternative insertion: Insert tip pointing sideways and rotate down into pharynx (only if approved by local EMS protocol).
Pediatric OPA Insertion Procedure (Scan 9-3):
Pediatric larynx is positioned more anteriorly and superiorly.
Straight Insertion: Insert OPA straight in with tip pointing downward toward the throat (no rotation).
Use a tongue depressor or rigid suction catheter to hold the tongue down and forward during insertion to prevent posterior displacement.
Nasopharyngeal Airway (NPA):
Soft flexible tube inserted through the nasal passage into the pharynx.
Preferred in patients with an intact gag reflex or jaw/oral trauma where mouth opening is impossible.
Suctioning Equipment, Principles, and Techniques
Indications for Suctioning:
Required immediately whenever fluids, blood, vomitus, or liquid secretions are observed in the airway or whenever gurgling is heard.
Prevents pulmonary aspiration of materials which leads to severe chemical pneumonia or mechanical obstruction.
Gravity Drainage Technique:
In non-trauma cases with copious liquid secretions or vomitus, turn the patient onto their side to allow gravity drainage from the mouth prior to or alongside suctioning.
Turn patient away from the rescuer's body to avoid biohazard exposure.
Suction Unit Operational Requirements:
Both mounted (onboard ambulance) and portable suction devices must satisfy standard criteria:
Air intake capacity of at least at the open end of the collecting tube.
Generate a vacuum pressure of no less than when the suction tube is clamped.
Suction System Components:
Tubing: Thick-walled, non-kinking, wide-bore tubing that will not collapse under high vacuum pressure.
Rigid Pharyngeal Tip (Yankauer / Tonsil-Tip): Curved, rigid plastic suction tip providing control in the oral cavity; larger bore than flexible catheters.
Flexible Catheters: Soft plastic tubes sized on the French scale (higher French number = larger diameter; e.g., a catheter is larger than an catheter). Used for NPAs, endotracheal tubes, or nasopharyngeal clearance.
Collection Container: Unbreakable, disposable container.
Sterile Water Source: Container of clean/sterile water kept alongside suction units to flush thick debris and unblock clogged tubing.
Suctioning Rules and Complications:
Vagus Nerve Stimulation: Contacting the posterior pharyngeal wall with suction tips (especially rigid Yankauer tips) stimulates the vagus nerve, inducing profound bradycardia (slowing of heart rate).
Limit rigid suctioning duration to a few seconds at a time.
Maintain continuous visual inspection of the rigid tip inside the mouth; never insert beyond visual range.
If thick, copious vomitus clogs standard tips, disconnect tip and suction directly using wide-bore tubing.
Pediatric Suctioning Considerations:
Infants are extremely vulnerable to vagal stimulation and secondary severe bradycardia from hypopharyngeal contact.
Keep suction duration minimal and avoid striking the back of the hypopharynx.
Bulb Syringe Suctioning: Manual rubber bulb syringe used in infants and small children to clear mucus from nostrils or clear newborns in emergency childbirth settings.