Airway, Respiration and Ventilation · 5 min read
Airway Assessment and Basic Management
Assessing the Airway and Breathing
Airway and breathing are checked in the primary assessment right after the general impression and level of responsiveness (in trauma, after controlling exsanguinating hemorrhage). A patient who is talking clearly has an open airway for the moment. In an unresponsive patient, open the airway, look in the mouth, and listen for noisy breathing. Then decide quickly whether breathing is adequate or inadequate — that decision drives every airway intervention.
Look at rate, rhythm, depth (tidal volume) and effort. Watch chest rise on both sides, listen to breath sounds, check skin color and mental status, and add pulse oximetry and, when available, capnography. Mental status is an early and sensitive sign: restlessness and anxiety often appear before the SpO2 drops.
| Finding | Adequate | Inadequate |
|---|---|---|
| Rate | 12–20/min | Below 8–10 or above about 24–30/min |
| Depth | Good, equal chest rise | Shallow or unequal chest rise |
| Effort | Effortless, quiet | Accessory muscles, retractions, tripod |
| Sounds | Clear, equal | Stridor, gurgling, wheezing, diminished |
| Skin | Pink, warm, dry | Pale, cyanotic, cool, clammy |
| Mental status | Alert, speaks full sentences | Anxious, confused, 1–2 word sentences |
Abnormal Breathing Patterns
| Pattern | Description | Usual Cause |
|---|---|---|
| Agonal | Occasional gasps | Cardiac arrest; treat as not breathing |
| Kussmaul | Deep, rapid, regular | Metabolic acidosis (DKA) |
| Cheyne-Stokes | Rising and falling depth with apnea periods | Brain injury, stroke, heart failure |
| Ataxic (Biot's) | Irregular, unpredictable | Severe brain injury |
| Apneustic | Prolonged gasping inhalations | Brainstem injury |
Manual Airway Maneuvers
The first step in opening an airway is a manual maneuver that lifts the tongue off the back of the pharynx. The head-tilt chin-lift is used when there is no suspicion of spinal injury: one hand on the forehead tilts the head back while the fingertips of the other hand lift the bony part of the chin. The jaw thrust is used when spinal injury is suspected: fingers behind the angles of the mandible push the jaw forward while the head stays neutral. If the jaw thrust does not open the airway, use a head-tilt chin-lift — an open airway takes priority over the spine.
Suctioning
Gurgling means fluid in the upper airway: suction immediately. A rigid (Yankauer, tonsil-tip) catheter clears the mouth and oropharynx of large amounts of fluid; a soft (French, whistle-tip) catheter is used in the nose, through an NPA, and in the trachea of an intubated or tracheostomy patient. Measure the catheter from the corner of the mouth to the earlobe, insert without suction, and suction while withdrawing. Preoxygenate before and after, because suctioning removes oxygen as well as fluid.
| Patient | Maximum Time | Notes |
|---|---|---|
| Adult | 15 seconds | Monitor SpO2 and heart rate |
| Child | 10 seconds | Bradycardia from vagal stimulation possible |
| Infant | 5 seconds | Bulb syringe for mouth then nose |
Oropharyngeal and Nasopharyngeal Airways
Airway adjuncts keep the tongue off the back of the throat after the airway has been opened manually; they do not replace head positioning. The oropharyngeal airway (OPA) is only for unresponsive patients with no gag reflex. The nasopharyngeal airway (NPA) is tolerated by patients with a gag reflex, clenched teeth or seizure activity.
| Feature | OPA | NPA |
|---|---|---|
| Indication | Unresponsive, no gag reflex | Altered, gag present, clenched jaw |
| Sizing | Corner of mouth to earlobe or angle of jaw | Tip of nose to earlobe |
| Insertion | Tip to palate, rotate 180° (adult); tongue blade, no rotation (child) | Lubricate; bevel toward septum; right nostril first |
| Contraindication | Gag reflex present | Suspected basilar skull fracture or severe midface trauma (relative) |
| Problems | Vomiting if gag returns; wrong size pushes tongue back | Nosebleed; too long enters esophagus |
Foreign Body Airway Obstruction
A patient with a mild obstruction can cough forcefully, speak and move air; encourage coughing, give oxygen and watch closely. A severe obstruction shows a weak or silent cough, inability to speak, stridor or no air movement, cyanosis and the universal choking sign. Act immediately using the current AHA sequence below.
| Patient | Responsive, Severe Obstruction | Becomes Unresponsive |
|---|---|---|
| Adult | Cycles of 5 back blows then 5 abdominal thrusts | Begin CPR; look in mouth before breaths |
| Child (1 yr to puberty) | Cycles of 5 back blows then 5 abdominal thrusts | Begin CPR; look in mouth before breaths |
| Infant (under 1 yr) | 5 back blows, then 5 chest thrusts (heel of one hand) | Begin CPR; never abdominal thrusts |
| Pregnant or obese | Back blows, then chest thrusts | Begin CPR |
Positioning the Patient
Position helps the airway. A responsive patient in respiratory distress should be allowed to sit upright in the position of comfort (often Fowler's or tripod). An unresponsive patient who is breathing adequately and has no suspected spinal injury goes in the recovery position (on the side) so secretions drain. A patient who needs ventilation must be supine with the head positioned to open the airway. In infants and toddlers, place a towel under the shoulders to offset the large occiput.
| Position | Use For |
|---|---|
| Position of comfort / Fowler's | Responsive patient with dyspnea |
| Recovery (lateral) | Unresponsive, breathing adequately, no spinal concern |
| Supine, airway open | Patient needing BVM ventilation or CPR |
| Sniffing / neutral with shoulder pad | Infant or toddler being ventilated |
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