KEY POINTS
- An ‘open airway’ is one where the casualty is talking or breathing easily
- A closed airway is one where there is snoring, gurgling or no breath sounds at all
- Open the airway with a jaw thrust or ‘head tilt, chin lift’
EXPLANATION
An ‘open’ airway is one where air can get from the outside to the lungs. Airways become ‘closed’ when obstructed with blood, vomit or a foreign object, or when a casualty becomes unconscious and the soft tissues of their throat close over.
Kneel down at the level of the casualty. The airway is open if the casualty is talking or if air is moving in and out quietly and easily with each breath. It is closed if there is gurgling, snoring or no sound / air movement at all. In the outdoors, you need to use all your senses to assess the airway: look for chest wall movement, listen for breath sounds, and feel for air coming in and out of the casualty’s mouth with your palm or your cheek.
To open a closed airway, first remove anything obviously obstructing it. Do not put your finger blindly into the casualty’s throat.
Then, perform a ‘head tilt, chin lift’:
- Place one hand on the casualty’s forehead
- Place the other hand on the bony tip of the casualty’s chin
- Gently tilt the head back, while lifting the chin and allowing the mouth to fall open
If that is insufficient, or you don’t want to move the casualty’s neck, then perform a ‘jaw thrust’:
- Place your fingertips at the angle of the jaw
- Rest the base of your thumbs on the casaulty’s cheek bones
- Lift the jaw towards the sky
Both these manoeuvres help pull the soft tissues away from the back of the throat, opening the airway. The jaw thrust is usually the more effective of the two, however it is tiring and the jaw needs to be held constantly in position for the airway to remain open.
Sometimes, both the ‘head tilt, chin lift’ and the ‘jaw thrust’ are required.
Remember that airways are dynamic: they require constant monitoring and adjustment as a casualty’s clinical condition changes.
Opening the Airway in Suspected Spinal Injury
If the casualty may have fallen, been struck by a heavy object, or suffered a high-speed impact, assume the neck could be injured until proven otherwise. In these cases, the standard head tilt, chin lift can cause or worsen spinal cord damage. Use a jaw thrust instead: kneel behind the casualty’s head, place your thumbs on the cheekbones and your index and middle fingers behind the angles of the lower jaw, then lift the jaw forward without tilting the head back. This moves the tongue away from the back of the throat while keeping the neck in a neutral, in-line position.
A second rescuer should hold the casualty’s head still, with one hand on each side, to prevent any sideways movement. If the jaw thrust alone does not open the airway and the casualty is not breathing, you must prioritise the airway over the risk of spinal injury. Add a very small degree of head tilt — just enough to get air moving — while continuing to support the neck manually. Never twist or turn the head to look inside the mouth; instead, have your helper log-roll the whole casualty as a unit if vomit or debris must be cleared.
Airway Adjuncts and Simple Devices
When manual methods keep failing or your hands are needed elsewhere, an airway adjunct can hold the tongue forward. An oropharyngeal airway (OPA) is a curved plastic tube inserted over the tongue. It is only for deeply unconscious casualties with no gag reflex, because in a semi-conscious person it can trigger vomiting. Size it by holding the flange at the corner of the mouth: the tip should reach the angle of the jaw. Insert it upside down, then rotate it 180 degrees as it passes the hard palate, or use a tongue depressor to guide it in the correct orientation.
A nasopharyngeal airway (NPA) is a soft tube passed through the nostril into the back of the throat. It is tolerated by casualties who still have a gag reflex and is useful when the jaw is clenched or the mouth is injured. Lubricate the NPA with water or a water-based jelly, then insert it straight back along the floor of the nose, not upwards. If resistance is met, stop and try the other nostril. In an emergency, both adjuncts are stabilising measures only — they do not replace definitive airway management, and you must still monitor breathing constantly.
Positioning to Maintain an Open Airway
An unconscious casualty who is breathing should be placed in the recovery position as soon as the airway is open. This position lets blood, saliva, or vomit drain from the mouth instead of pooling in the throat. To place a casualty in the recovery position:
- Kneel beside them and remove spectacles and bulky objects from pockets.
- Place the arm nearest you at a right angle to the body, elbow bent, palm up.
- Bring the far arm across the chest and hold the back of the far hand against the near cheek.
- Grasp the far leg above the knee and pull it up, keeping the foot on the ground.
- Pull on the far leg to roll the casualty towards you, then adjust the upper leg so hip and knee are bent at right angles.
- Tilt the head back slightly to keep the airway open and check breathing.
If spinal injury is suspected, do not roll the casualty alone. Use a log-roll with at least two or three rescuers, keeping the head, shoulders, and pelvis aligned. In that case, leave the casualty supine and maintain a jaw thrust continuously while others prepare for evacuation. Recheck the airway and breathing at least every minute, because an unconscious casualty’s position can shift and the tongue can fall back again.
Common Mistakes and Ongoing Monitoring
The most dangerous error is performing a blind finger sweep. You cannot see what is in the throat, and pushing a foreign body deeper or triggering a spasm can turn a partial obstruction into a complete one. Remove only visible objects from the mouth, using forceps or a hooked finger if necessary. Another common mistake is overextending the neck during a head tilt, which can stretch and narrow the airway in small children and cause discomfort or injury in adults. Tilt just until the jaw lifts and air moves.
Do not assume the airway will stay open after one manoeuvre. A casualty’s level of consciousness can fall, secretions can build up, and the tongue can slide back. Continue to look, listen, and feel for breathing every few minutes. If snoring, gurgling, or silence returns, reposition the head or jaw immediately. While waiting for professional help, keep the casualty warm, do not give anything by mouth, and be ready to turn them onto their side if they vomit or if gurgling sounds appear. Document what you did and when, and pass that information to the responding team.