When a person becomes unconscious, their muscles relax, and the most common cause of airway blockage is the tongue falling back to obstruct the throat. Before rescue breaths can be effective during cardiopulmonary resuscitation (CPR), a clear passage for air must be established. Opening the airway is the first step after checking for responsiveness and calling for emergency services. This action repositions the soft tissues of the mouth and throat, moving the tongue away from the back of the pharynx to allow air to pass freely into the lungs.
The Primary Method: Head-Tilt, Chin-Lift
The standard technique for opening the airway in an unresponsive adult or child, when there is no indication of a neck or spinal injury, is the Head-Tilt, Chin-Lift maneuver. The goal is to lift the jawbone and reposition the head, which mechanically pulls the tongue forward and away from the back of the throat.
To perform this, the rescuer should place the heel of one hand on the person’s forehead and apply gentle, firm pressure to tilt the head backward. Simultaneously, the fingers of the other hand are placed underneath the bony part of the chin. It is important to lift the chin upward and forward, avoiding pressure on the soft tissue under the chin, which could inadvertently compress the airway. This combination of tilting the head and lifting the chin achieves the necessary alignment to straighten the passage for air.
The head tilt extends the neck, aligning the oral and pharyngeal axes to create a straight pathway. This correct alignment is maintained while the rescuer checks for breathing or delivers rescue breaths as part of the CPR cycle. If the chest does not rise during a rescue breath, the rescuer should immediately repeat the Head-Tilt, Chin-Lift maneuver to ensure proper airway positioning before attempting the second breath.
Airway Opening When Spinal Injury is Suspected
In scenarios involving a potential fall, motor vehicle accident, or any significant trauma, there is a risk of cervical spine injury. In these cases, the standard Head-Tilt, Chin-Lift maneuver is avoided because tilting the head could cause movement in the neck vertebrae, potentially leading to further damage to the spinal cord. The alternative technique used to open the airway while minimizing neck movement is the Jaw-Thrust Maneuver.
The Jaw-Thrust Maneuver requires the rescuer to stabilize the head and neck in a neutral position throughout the procedure. The rescuer should position themselves at the person’s head and place their fingers under the angles of the lower jaw (mandible). The thumbs are often placed on the cheekbones to assist with stabilization.
The key action is to thrust the jaw forward and upward with the fingers without tilting or turning the head. This motion slides the lower jaw forward, physically displacing the tongue and other soft tissues from the back of the throat to open the airway. This technique is more physically difficult to perform and maintain, especially for a single rescuer who must also deliver rescue breaths.
Positioning Differences for Infants and Children
The anatomy of infants and young children requires a modification of the Head-Tilt, Chin-Lift technique. Because a baby’s head is proportionally larger and neck structures are softer and more flexible than an adult’s, overextension of the neck can actually close their small, pliable airway. Therefore, a deep head tilt is avoided for pediatric patients.
For an infant (under one year of age), the head should be placed in a neutral position. For a child, a slightly past-neutral position is used, often referred to as the “sniffing position,” which mimics the posture someone assumes when trying to sniff the air. The difference in technique is important because the goal is to align the trachea without compressing it.
For both age groups, the chin is still lifted gently to move the tongue, but the degree of head movement is significantly less than what is required for an adult. In an infant, the head tilt is extremely gentle and minimal to prevent the soft windpipe from kinking shut.