Pre-Hospital Airway Management

Airway management is the most critical intervention in pre-hospital care. Hypoxia kills quickly. As a PHLS provider, your primary goal is to recognize airway compromise and establish a patent airway using basic maneuvers and adjuncts before progressing to advanced techniques.

<virtualpatient name="Mr. Othman" age="52" chiefComplaint="Shortness of breath after eating" responses='[{"q":"What exactly happened?","a":"I was eating peanuts and suddenly my throat felt tight."},{"q":"Do you have any allergies?","a":"Yes, to nuts. I forgot my EpiPen at home."},{"q":"Are you on any medications?","a":"Just for blood pressure."}]' />

Anatomy of the Airway

The upper airway consists of the mouth, nose, pharynx, and larynx. The most common cause of airway obstruction in an unconscious patient is the tongue falling back against the posterior pharyngeal wall due to loss of muscle tone.

<biodigital id="respiratory-system" title="Upper Airway Anatomy" caption="Observe the relationship between the tongue, epiglottis, and trachea." />

Recognizing Airway Obstruction

Do not rely solely on pulse oximetry (SpO2) to assess the airway. SpO2 is a late indicator of hypoxia. Instead, use the Look, Listen, Feel approach:

• Look: Agitation (early hypoxia), depressed consciousness (late hypoxia), cyanosis, accessory muscle use, seesaw breathing.
• Listen:
  • Snoring: Tongue obstruction.
  • Gurgling: Fluid (blood, vomit, secretions) in the airway.
  • Stridor: High-pitched sound indicating upper airway narrowing (e.g., anaphylaxis, burns).
  • Silence: Complete obstruction. This is an immediate life threat.
• Feel: Airflow against your cheek.

<redflag> A noisy airway is an obstructed airway. A silent airway in an unconscious patient is a dead patient. Act immediately. </redflag>

Basic Airway Maneuvers

Before using equipment, utilize manual techniques to open the airway.

1. Head-Tilt / Chin-Lift: The standard maneuver for medical patients.
2. Jaw Thrust: The mandatory maneuver for trauma patients with suspected cervical spine injuries. It lifts the tongue away from the posterior pharynx without extending the neck.

Basic Airway Adjuncts

If manual maneuvers are insufficient or cannot be maintained, use basic adjuncts.

Oropharyngeal Airway (OPA)

• Indication: Unconscious patients with NO gag reflex.
• Sizing: Measure from the center of the mouth (incisors) to the angle of the jaw.
• Insertion: Insert upside down, then rotate 180 degrees once past the soft palate.

<goldenrule> Never insert an OPA in a patient with an intact gag reflex. It will induce vomiting, leading to aspiration pneumonitis. </goldenrule>

Nasopharyngeal Airway (NPA)

• Indication: Patients with a reduced level of consciousness who still have an intact gag reflex, or patients with trismus (clenched teeth).
• Sizing: Measure from the tip of the nose to the earlobe.
• Insertion: Lubricate heavily. Insert straight back along the floor of the nasal cavity with the bevel facing the septum.

<redflag> Relative Contraindication: Avoid NPA insertion in suspected basilar skull fractures (e.g., Battle's sign, raccoon eyes, CSF rhinorrhea). </redflag>