03 Airway Management and Respiratory Care

Priorities in airway and respiratory care

Airway and breathing problems can cause altered mental status, cardiac arrest, and death within a short time. EMT care follows a priority sequence:

1. Recognize the problem and assess responsiveness.

2. Open and clear the airway.

3. Determine whether breathing is adequate.

4. Support oxygenation when needed.

5. Support ventilation when breathing is inadequate.

6. Reassess after every intervention.

7. Request additional resources and transport promptly when indicated.

The immediate goal is to correct the most serious life threat while staying within local protocol and scope of practice. Equipment, oxygen targets, medication assistance, and advanced airway procedures may vary by jurisdiction.

Takeaway: Treat airway and breathing threats immediately, then continue reassessment because a patient can deteriorate rapidly.

Airway anatomy and the physiology of breathing

The upper airway includes the nose, mouth, pharynx, and larynx. The lower airway begins below the larynx and includes the trachea, bronchi, bronchioles, and alveoli.

Important functions include:

• The nose and mouth warm, humidify, and filter incoming air.

• The pharynx serves as a shared passageway for air and food.

• The epiglottis helps direct food away from the larynx during swallowing.

• The larynx and vocal cords protect the lower airway and produce sound.

• The trachea and bronchi conduct air toward the lungs.

• Bronchioles regulate airflow through smaller conducting passages.

• Alveoli are air sacs where oxygen and carbon dioxide exchange occurs.

• The diaphragm and intercostal muscles create the pressure changes needed for breathing.

Several related terms describe different processes. Ventilation is air movement into and out of the lungs. Oxygenation is transfer of oxygen from the alveoli into the blood. External respiration is gas exchange between alveoli and pulmonary capillaries, while internal respiration is gas exchange between systemic capillaries and body tissues. Cellular respiration is the use of oxygen by cells to produce energy.

A clear airway does not guarantee adequate breathing. A patient with severe asthma may have an open airway but poor air movement, while a patient with opioid-related respiratory depression may have an unobstructed airway but breathe too slowly or shallowly.

Takeaway: Always distinguish airway patency, ventilation, and oxygenation; correcting one does not necessarily correct the others.

Assessment and airway-opening techniques

During the primary assessment, determine whether the patient can speak, whether air is moving, and whether breathing is adequate. Assess:

• Ability to speak in full sentences

• Rate, depth, and regularity of respirations

• Chest rise and work of breathing

• Accessory-muscle use, nasal flaring, retractions, or tripod positioning

• Breath sounds such as snoring, gurgling, stridor, wheezing, or silence

• Skin color, diaphoresis, mental status, and oxygen saturation when available

• Blood, vomitus, secretions, swelling, or foreign material

Use the head-tilt–chin-lift when trauma is not suspected. Tilt the head by placing one hand on the forehead and lift the bony portion of the chin with the other hand. Avoid pressing deeply into the soft tissue beneath the chin.

When cervical-spine injury is suspected, use the jaw-thrust maneuver. Move the mandible forward without extending the neck. If the maneuver does not adequately open the airway, establishing an adequate airway takes priority while spinal precautions are maintained as much as possible.

An oropharyngeal airway (OPA) is appropriate for an unresponsive patient without a gag reflex. An nasopharyngeal airway (NPA) may be useful for a patient who is not fully responsive but retains a gag reflex or cannot tolerate an OPA. Avoid or use an NPA cautiously with severe facial trauma, suspected basilar skull fracture, major nasal obstruction, or another local-protocol contraindication. Never force an airway adjunct against resistance.

Takeaway: Choose the opening maneuver and adjunct based on trauma concerns, responsiveness, and gag reflex, then verify that the airway and breathing actually improve.

Clearing obstruction and managing foreign bodies

Fluids, vomitus, blood, and secretions can block airflow and prevent oxygen or ventilations from reaching the lungs. Position the patient so fluids can drain when possible, use personal protective equipment, and test the suction unit before use.

Use a rigid tonsil-tip catheter for the mouth of an unresponsive patient when appropriate. Insert it without suction when possible, apply suction while withdrawing, and move the tip from side to side. Do not insert a rigid catheter beyond the base of the tongue. Traditional EMT guidance limits adult suctioning to approximately 15 seconds and recommends shorter intervals for infants and children; reoxygenate and ventilate between attempts as needed.

Suctioning does not reliably remove solid objects and must not delay other lifesaving care. If suctioning causes bradycardia, worsening cyanosis, or deterioration, stop and provide oxygenation or ventilation. Reassess because secretions may return.

For a responsive patient with an effective cough, encourage continued coughing and observe closely. Severe foreign-body airway obstruction is suggested by an ineffective or absent cough, inability to speak, cyanosis, altered mental status, or apnea. For a responsive adult with severe obstruction, perform repeated cycles of five back blows followed by five abdominal thrusts. Use chest thrusts instead of abdominal thrusts in late pregnancy or when the rescuer cannot encircle the abdomen. If the patient becomes unresponsive, begin CPR with compressions and look for a visible object before attempting ventilations; never perform blind finger sweeps.

Takeaway: Clear fluids promptly, use brief suction attempts, and treat severe obstruction according to the patient’s responsiveness and the current local protocol.

Oxygen therapy and choosing a delivery device

Administer oxygen according to patient condition, reassessment, and local protocol rather than automatically giving it to every patient. Indications may include respiratory distress, hypoxemia, shock, major trauma, altered mental status associated with poor oxygenation, or another protocol-supported condition.

Common delivery options include:

• A nasal cannula for a breathing patient who needs a modest increase in inspired oxygen and can tolerate the device

• A nonrebreather mask for a spontaneously breathing patient who needs a high concentration of oxygen; inflate the reservoir before placement

• A bag-valve mask with supplemental oxygen for an apneic or inadequately breathing patient

• An oxygen-powered ventilation device only when permitted by local protocol and safe to apply

A pulse oximeter can support assessment but has limitations. Motion, poor perfusion, cold skin, carbon monoxide exposure, nail products, and other factors can produce misleading values. Treat the patient’s overall condition rather than responding to a number in isolation.

Oxygenation support is different from ventilation support. Oxygen can increase the concentration of available oxygen, but it does not provide adequate air movement for a patient who is apneic or breathing too shallowly.

Takeaway: Match the oxygen device to the patient’s breathing ability and clinical condition, and use ventilation when oxygen alone cannot move air.

Positive-pressure ventilation with a BVM

Provide positive-pressure ventilation when the patient is apneic or breathing inadequately. Signs include slow or irregular respirations, shallow chest movement, poor tidal volume, exhaustion, altered mental status, cyanosis, or declining oxygen saturation despite oxygen administration.

To use a bag-valve mask (BVM) effectively:

1. Open and maintain the airway.

2. Select the correct mask size and position it over the nose and mouth.

3. Insert an airway adjunct when indicated.

4. Create a tight mask seal while maintaining the airway position.

5. Deliver each breath over approximately one second, using only enough volume to produce visible chest rise.

6. Avoid excessive rate, pressure, and volume.

7. Reassess chest rise, skin signs, pulse, mental status, and oxygenation.

A two-person technique is usually more effective because one rescuer maintains the airway and mask seal while the other squeezes the bag. If the chest does not rise, reassess head position, mask seal, airway adjunct placement, and obstruction; suction or reposition as needed. Do not simply squeeze harder or ventilate faster. Hyperventilation can increase intrathoracic pressure, reduce venous return, decrease cardiac output, and cause gastric inflation.

A patient with a pulse who is not breathing or not breathing effectively requires assisted ventilation for oxygen delivery and carbon dioxide removal.

Takeaway: Effective BVM ventilation depends on airway positioning, a good seal, controlled breaths, visible chest rise, and frequent reassessment.

Recognizing respiratory deterioration

Respiratory distress means the patient is still compensating. Findings can include rapid breathing, increased work of breathing, wheezing, anxiety, tripod positioning, and the ability to speak only in short phrases.

Respiratory failure occurs when compensation is failing. Red flags include decreasing respiratory rate, shallow or irregular breathing, exhaustion, altered mental status, cyanosis, inability to speak, diminished or absent breath sounds, and poor chest rise. A patient who becomes quieter or less anxious may be worsening because fatigue can reduce air movement.

Common patterns include:

• Asthma: wheezing, prolonged exhalation, chest tightness, and increased work of breathing. A silent chest in a severely ill patient may indicate critically reduced airflow.

• Chronic obstructive pulmonary disease: dyspnea, prolonged expiration, wheezing, and diminished breath sounds. Do not withhold oxygen from a hypoxemic patient; titrate and reassess according to protocol.

• Pulmonary edema: severe dyspnea, crackles, orthopnea, pink or frothy sputum, and anxiety. Keep the patient upright when tolerated and provide oxygen or positive-pressure support according to protocol.

• Pneumothorax: sudden dyspnea, unilateral decreased breath sounds, pleuritic chest pain, and possible trauma. Treat respiratory compromise immediately and request advanced care.

• Opioid-related respiratory depression: depressed mental status with slow, shallow, or absent respirations. Open the airway, provide ventilations, and administer naloxone only as authorized.

• Anaphylaxis: respiratory distress from bronchospasm, upper-airway swelling, or both. Look for wheezing, stridor, hives, facial or tongue swelling, and hypotension; provide immediate supportive care and assist with emergency medications within scope.

Takeaway: Increasing effort can signal distress, but decreasing effort in an exhausted patient can signal impending or established failure.

Integrated decision sequence and reassessment

Use this sequence for a patient with a breathing problem:

1. Ensure scene safety and use standard precautions.

2. Assess responsiveness and request additional resources early.

3. Open the airway with the appropriate maneuver.

4. Clear visible fluids and perform suctioning as needed.

5. Decide whether breathing is adequate.

6. If breathing is adequate but oxygenation is poor, administer oxygen and monitor continuously.

7. If breathing is inadequate, provide positive-pressure ventilation with a BVM and use an airway adjunct when indicated.

8. Treat the likely cause within scope, such as assisting with a prescribed inhaler or administering a protocol-approved medication.

9. Reassess after every intervention and prepare for rapid transport or escalation of care.

Apply the most immediate intervention first. For example, an apneic patient with a pulse needs ventilation rather than a nasal cannula, and an unresponsive trauma patient with gurgling respirations needs suction while spinal precautions are maintained.

Takeaway: The best intervention is the one that corrects the most serious current threat, followed by repeated reassessment and escalation when the patient does not improve.