An open airway is the foundational requirement for survival, representing the “A” in the ABC sequence of trauma care. The airway is the path through which oxygen travels to the lungs, and its blockage can lead to irreversible brain damage within minutes. In an unresponsive person, the most common cause of airway compromise is the tongue falling backward and obstructing the pharynx due to muscle relaxation. Immediate assessment and intervention are necessary to ensure this pathway remains open and prevent rapid deterioration from lack of oxygen.
Rapid Initial Assessment
The first step is to quickly determine if the airway is open and if air is moving effectively, using a concise visual and auditory check. Begin by looking for signs of distress, observing if the chest and abdomen rise and fall symmetrically, as paradoxical “see-saw” movements suggest the person is struggling against an obstruction. Check the skin color; a bluish discoloration, known as cyanosis, especially around the lips, indicates severe oxygen deprivation. Also, quickly scan the mouth for any obvious foreign material, such as vomit, dentures, or food, which may need immediate removal if visible and easily accessible.
Listen closely for any abnormal sounds that indicate air is attempting to pass through a narrowed or fluid-filled space. A gurgling sound suggests the presence of fluid, like blood or secretions, in the airway. Snoring often indicates that the tongue is partially blocking the upper airway, a common occurrence in unconscious individuals. A high-pitched, harsh sound, usually heard on inhalation and called stridor, points to a partial blockage high up in the throat or voice box.
If the person is unresponsive, gently place your ear near their mouth and nose to feel for any movement of air or hear breath sounds. The absence of any breath sounds at the mouth or nose, coupled with signs of severe respiratory effort, is a strong indicator of a complete obstruction. This entire initial assessment should take only a few seconds, guiding the immediate decision on whether to intervene physically. If the person is able to speak clearly, even in short sentences, the airway is considered patent and secure.
Opening the Airway Using Positioning
If the initial assessment reveals a compromised airway, specific manual maneuvers can be used to reposition the jaw and tongue. The most common technique is the Head-Tilt/Chin-Lift, appropriate when a spinal injury is not suspected. To perform this, place one hand on the forehead and apply gentle pressure to tilt the head backward. With the fingertips of the other hand, lift the bony part of the chin upward, which pulls the tongue forward and away from the back of the throat, opening the passage for air.
If trauma is suspected, a spinal injury must be assumed, making the Head-Tilt/Chin-Lift dangerous due to the risk of moving the neck. In this case, the Jaw Thrust Maneuver is the preferred technique, as it opens the airway while keeping the head and neck in a neutral, stable position. To execute the Jaw Thrust, place your fingers behind the angles of the lower jaw (mandible) on both sides. Gently but firmly lift the jaw upward and forward without tilting the head, which moves the lower jaw and tongue forward to clear the obstruction.
Distinguishing Partial Versus Complete Obstruction
Once an airway problem is identified, determining the severity of the blockage is necessary to select the correct course of action. A partial obstruction is characterized by the person still being able to move some air. Signs include noisy breathing, such as wheezing or stridor, and the ability to speak, cry, or cough forcefully, even if the cough sounds choked or weak. In this scenario, the most effective action is to encourage the person to continue coughing forcefully, as this is the body’s natural mechanism for clearing the obstruction.
A complete obstruction occurs when the air passage is blocked almost entirely, preventing effective air movement. The primary sign of a complete obstruction is the inability to speak, cry, or cough at all, or a cough that is completely silent and ineffective. The person may also exhibit the universal sign of choking by grasping their throat, and silent attempts to breathe may be observed. When an obstruction is complete, immediate intervention, such as abdominal thrusts or back blows, is required, as the person is not moving any air and cannot clear the blockage on their own.