Keeping airway open and assisting breathing

Open, clear and maintain airway

What you need

• Suction equipment
• Oropharyngeal airway
• Nasopharyngeal airway
• Oxygen equipment with non-rebreather or ordinary face mask

Open airway

• Do not delay log roll if vomit or debris in mouth — log roll and clear mouth immediately — if proficient use HAINES roll 
• In an unconscious person — clearing blocked airway takes priority over protecting spine
• For unresponsive adult or child — open the airway using the head tilt-chin lift — chin lift preferred in trauma, head tilt may damage spinal cord
• For an infant, open airway — placing head in neutral position and lift jaw (jaw thrust) 

Head tilt/Chin lift

• Place one hand on the forehead. The other hand is used to provide Chin Lift. The head (not the neck) is tilted backwards. Grip chin and gently lift it up — Figure 3.14

Jaw thrust

• Hold jaw at point under both ears, push upward and forward until chin juts out and airway opens — Figure 3.15

Infant in neutral position

• Head may be tilted backwards very slightly with a gentle movement — Figure 3.16

Clear airway

Passive

• If breathing normally and no risk of spinal injury — put unconscious person in recovery position to help protect airway — Figure 3.17. Rest person's head on extended arm to help neck alignment

Finger sweep

If unconscious person vomits or debris in the mouth

• First roll onto side

• Use something tough (eg bite block) between molars if available
• Only do finger sweep if
  
• Person unconscious
• Suction or long-nose or angled forceps not available
• Debris obvious and close to opening of mouth — do not finger sweep if debris not visible
• With gloves on, use 2 fingers to gently clear person’s mouth of dirt, vomit, broken teeth, loose dentures (leave well fitting ones in place)
• Be careful not to push anything further back and block airway

Suction

• Do not touch back of throat — this can make person vomit
• If you have suction equipment — put Yankauer sucker at side of person’s mouth. Suck out any fluid — be careful not to damage teeth, tongue, back of throat

Keep airway open

Attention

• Do not use nasopharyngeal airway if
• Broken nose or cheekbones
• Bruising behind ears, blood and/or clear fluid coming from ears or nose, any signs of skull fracture — consider how person was injured
• Choose type of airway to use
• Oropharyngeal airway — only used for unconscious person
• Nasopharyngeal airway — better for semiconscious person

What you do

Oropharyngeal airway

Choose right sized airway. Should reach from front teeth to angle of jaw — Figure 3.18, or corner of mouth to earlobe

• For adults
• Open mouth and gently push airway in upside down with tip pointing up
• Push airway back along roof of mouth, turn it over to slip the rest of the way over tongue — Figure 3.19
• For small child (under 8 years)
• Use wooden spatula to push tongue down, gently push airway straight in

Nasopharyngeal airway

• Choose right sized airway. Measure from tip of nostril to angle of jaw (or front of ear lobe) — Figure 3.20
• Approximate sizes
• Average height woman/short man — size 6
• Average height man/tall woman — size 7
• Tall person  — size 8

Inserting airway

• If needed put safety pin through flange (or tie piece of long, thin string or tape under flange) to stop airway falling back into nose once in place
• Lubricate airway — can use persons saliva
• Gently push tip of airway straight back into biggest nostril
• Push along base of nose and into back of throat until flange and safety pin rest against nostril — Figure 3.21. Don’t push upward
  
• If resistance — take out and try other nostril

Assisting breathing

Sniffing position — Figure 3.22

• Extends head and flexes neck
• Take care if cervical spine could be damaged
• Cushion from shoulder to occiput (back of head)
• Ear canal level with sternal notch
• Support the head by chin lift or put finger against the chin

Giving oxygen

Attention

• If in shock give high flow oxygen — 15L/min non-rebreather mask
• In other cases only give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD 88–92%
• Take care not to give too much oxygen — may cause harm

Mask

• Use mask for oxygen delivery for all trauma and severely ill people
• Choose right sized mask for person’s face. Person will get less oxygen if mask doesn’t fit well
• Non-rebreather mask with reservoir bag
• Keep adult and paediatric non-rebreather masks in emergency pack
• Give oxygen at 15L/min adult, 10–15L/min child, 10L/min infant. Mask won’t work properly if rate lower
• Reservoir bag must be filled before you put mask on face
• Oxygen mask — simple face mask, Hudson mask
• Give oxygen at 5–10L/min

Remember: Non-rebreather masks need higher flow rates — consider how much oxygen you have, how many people need it, how long it will last

Bag-valve-mask — manual ventilation

Attention

If not used properly bag-valve-mask will not give enough oxygen. If you are not confident about using this equipment — do mouth-to-mask or mouth-to-nose resuscitation at 15 breaths/min

• Bags come in 3 sizes — adult, child, preterm. Clinics need all 3
• Mask must
• Fit firmly around nose, chin, sides
• Not leak when bag squeezed
• Best with 2 operators — second person can get a better fit/seal with mask
• Reservoir bag will only inflate (fill up) with high-flow oxygen. Fill reservoir bag first
• Give oxygen at 12–15L/min for adult, 8L/min for child, 3L/min for infant

What you need

• Helper
• Oropharyngeal or nasopharyngeal airway in place
• Oxygen equipment with tubing connected
• Suction equipment with rigid nozzle (eg Yankauer sucker)
• Correct size mask and bag

What you do

• Clear and open airway
• If person unconscious — put in oropharyngeal or nasopharyngeal airway 
• Select correct sized mask — Adult 4 or 5, child 3, infant 00 or 0/1 or 2

1 operator

• If using oxygen — connect tubing to bag and turn on oxygen at 15L/min adult, 8L/min child, 3L/min infant
• Stand/sit/kneel at top of person’s head
• Put head in sniffing position to open airway
• Hold bag in dominant (main) hand. Put mask over face with other hand
• Keep index finger and thumb on mask. Hold under jaw with last 3 fingers — Figure 3.23

• Try to keep seal all around mask
• Squeeze bag — watch to make sure person’s chest rises with each squeeze. If any problem — check airway, head position, equipment
• Ventilate at 15 breaths/min. Count slowly to get this right (eg 1 — and 2 — and 3 — etc)
• Don’t go too fast, don't overfill lungs

2 operators

• As above, except 1 person uses both hands to hold mask on and keep airway open, and other squeezes bag — Figure 3.24

If further assistance needed AND person unconscious — see Advanced airway management