Maintaining an open airway is the most immediate life-saving priority in any emergency situation. The airway, the passage for air from the nose and mouth to the lungs, can be compromised in moments, leading to oxygen deprivation. Since the brain can suffer irreversible damage in as little as four to six minutes without oxygen, the rapid and accurate assessment and opening of the airway is a time-sensitive skill. Understanding how to recognize a problem and initiate management techniques is fundamental to basic life support.
Recognizing Signs of Airway Distress
The initial assessment of a person in distress begins with observation for visual and auditory cues signaling a compromised airway. A person who is conscious and speaking in full sentences generally has a clear airway, but any deviation warrants immediate attention. Obvious signs of severe respiratory distress include a panicked or agitated appearance as the person struggles to breathe.
Visual signs often involve the skin turning pale, gray, or blue (cyanosis), a late indicator of low blood oxygen levels, particularly around the lips and nail beds. You may observe “retractions,” where the chest visibly sinks in below the neck or between the ribs as the person attempts to pull air in. Ineffective or paradoxical breathing, where the chest and abdomen move in opposite directions, signals a severe obstruction.
Auditory cues are often the most telling indicators of a partial blockage. Stridor, a high-pitched, harsh sound heard on inspiration, suggests a narrowing in the upper airway. Snoring or gurgling sounds indicate the tongue or fluids (vomit or blood) are partially blocking the passage. A complete obstruction is characterized by silence, as no air is moving, which is the most dangerous sign.
Performing the Primary Airway Assessment
Once a potential problem is recognized, the primary assessment involves checking for air movement using the “Look, Listen, and Feel” technique. This step should take no more than ten seconds to perform. You should look for the rise and fall of the chest and abdomen, which indicates effective breathing.
Next, you listen for the sound of air moving in and out of the mouth and nose. Simultaneously, you should feel for the rush of air against your cheek or ear. If the person is unconscious and not breathing normally, the most common cause of airway obstruction is the tongue relaxing and falling back against the pharynx.
To open the airway in a person without a suspected neck injury, the Head-tilt/Chin-lift maneuver is performed. This involves placing one hand on the forehead and gently tilting the head backward. The fingers of the other hand are placed under the bony part of the chin to lift it upward. This action aligns the oral and pharyngeal axes, moving the tongue away from the back of the throat.
Identifying and Managing Common Obstructions
Airway obstruction generally results from either a loss of muscle tone, as seen in unconsciousness, or from a foreign body blocking the passage. The Head-tilt/Chin-lift technique effectively manages the former by physically moving the jaw and tongue. Foreign body obstruction, or choking, requires a different approach, depending on the severity of the blockage.
A person with a partial obstruction can still cough forcefully, speak, or cry, and should be encouraged to continue coughing to expel the object. Intervention is necessary when the obstruction is severe, indicated by an inability to speak, a silent cough, or the universal sign of choking (clutching the throat). For a conscious adult with a severe obstruction, a combination of five back blows followed by five abdominal thrusts, known as the Heimlich maneuver, is performed.
To administer abdominal thrusts, stand behind the person, wrap your arms around their waist, and place a clenched fist just above the navel, grasping it with your other hand. Deliver five quick, inward and upward thrusts to create an artificial cough that forces air out of the lungs to dislodge the object. This sequence of five back blows and five abdominal thrusts should be repeated until the object is expelled or the person becomes unresponsive. If the person becomes unconscious, they should be lowered to the ground and basic life support, starting with chest compressions, initiated.
Modifying Assessment for Trauma and Pediatric Patients
Patient populations with potential spinal trauma or young children require modifications to standard airway maneuvers. If spinal injury is suspected, such as from a motor vehicle accident or a fall, the Head-tilt/Chin-lift maneuver must be avoided because tilting the head can exacerbate a spinal cord injury.
In trauma cases, the Jaw-thrust maneuver is used, which opens the airway while maintaining the head and neck in a neutral, in-line position. The rescuer places fingers under the angles of the lower jaw and lifts the jaw forward with firm, upward pressure. This action pulls the tongue and soft palate forward, clearing the obstruction while minimizing cervical spine movement.
Pediatric patients, particularly infants, have anatomical differences that necessitate modified techniques. Infants have disproportionately larger heads and tongues, and their larynx is positioned higher and more anteriorly than in adults. For an infant under one year old who is choking, abdominal thrusts are not used due to the risk of internal organ damage. Instead, the rescuer delivers a sequence of five back blows while the infant is facedown on the forearm, followed by five chest thrusts using two fingers over the breastbone while the infant is faced up.