3 Airway, Respiration, and Ventilation

Exam context

The current NREMT EMT examination specifications organize content into five domains: Scene Size-up and Safety, Primary Assessment, Secondary Assessment, Patient Treatment and Transport, and Operations. Airway and breathing care is assessed within these domains rather than as a separate EMT examination domain. The National EMS Education Standards identify airway management, respiration, and ventilation as core EMT competencies for patients of all ages.

How breathing works

Air passes through the mouth or nose, pharynx, larynx, trachea, bronchi, and smaller airways to the alveoli. The alveoli are surrounded by capillaries: oxygen moves into the blood there, while carbon dioxide moves out. The diaphragm and other respiratory muscles expand the chest to draw air in; normal exhalation is mostly passive.

Keep ventilation, oxygenation, and respiration distinct. A patient may have adequate oxygen readings but still ventilate poorly, or have adequate air movement but poor oxygenation. Supplemental oxygen does not replace ventilation when breaths are inadequate.

Infants and young children have smaller airways that obstruct more easily and rely more on the diaphragm. Their respiratory problems can worsen quickly, so use age-appropriate equipment and techniques.

Assessing respiratory status

Assess and treat immediate threats during the primary assessment. Do not delay essential airway care to obtain a detailed history.

Observe, listen, and feel for the following:

• Mental status and speech: Determine whether the patient can answer in full sentences. Confusion, drowsiness, or inability to speak may signal deterioration.

• Airway patency: Look for obstruction, secretions, vomit, blood, swelling, or trauma. Listen for snoring, gurgling, stridor, or hoarseness.

• Breathing: Note rate, depth, regularity, chest rise, symmetry, effort, and accessory-muscle use. Listen to both sides of the chest when appropriate.

• Skin and circulation: Assess color, temperature, and moisture; check pulse and perfusion.

• Measurements: Obtain pulse oximetry when available and appropriate, but interpret it with the whole assessment. Poor perfusion, motion, nail products, or carbon monoxide exposure can make the reading misleading. A reassuring number does not rule out distress.

Look for trends and signs of fatigue. A fast rate, retractions, tripod positioning, and an anxious appearance can indicate distress. Slowing or irregular breathing, reduced effort, worsening mental status, or a previously loud wheeze becoming very quiet can indicate impending respiratory failure. Cyanosis is a late and serious sign.

Ask about onset, triggers, medical history, medications, allergies, and associated symptoms. Reassess after every intervention and during transport.

Opening and protecting the airway

1. Open the airway. Use a head-tilt/chin-lift when trauma is not suspected. If head, neck, or spinal injury is possible, use a jaw-thrust while minimizing movement. If that does not open the airway, airway and ventilation needs take priority.

2. Remove visible obstruction. Suction fluids or secretions when needed. Use the suction device safely and only as long as necessary; reassess between attempts. Remove only objects that are visible and reachable. Do not perform a blind finger sweep.

3. Use an airway adjunct when indicated and permitted. An oropharyngeal airway (OPA) is for an unresponsive patient without a gag reflex. A nasopharyngeal airway (NPA) may be appropriate for a patient with an intact gag reflex, but avoid it with significant facial trauma or suspected basilar skull injury. Select the correct size and follow training and local protocol.

4. Position and monitor. When injuries do not prevent it, allow a conscious patient to assume a position that eases breathing. For an unresponsive patient who is breathing adequately and has no contraindication, use a position that helps protect the airway and monitor continuously.

Supporting oxygenation and ventilation

Choose support based on the patient’s condition, device availability, training, and local protocol. A nasal cannula or mask can provide supplemental oxygen to a patient who is breathing adequately but needs oxygen support. Use a bag-valve-mask (BVM) when breathing is absent or inadequate. A BVM can be difficult for one rescuer to seal and operate effectively, so use a two-person technique when available.

For BVM ventilation, open the airway, create a firm mask seal, and give only enough volume to produce visible chest rise. Reassess chest movement and the patient’s condition. Excessively rapid or forceful breaths can inflate the stomach, increase aspiration risk, and reduce blood return to the heart. If the chest does not rise, reposition the airway, improve the mask seal, check for obstruction, and try again.

For an adult with a pulse in respiratory arrest, the 2025 AHA guideline says it is reasonable to give one ventilation every six seconds, with each breath producing visible chest rise. Pediatric ventilation rates differ; follow current pediatric BLS guidance, training, and protocol. If there is no definite pulse or the patient is in cardiac arrest, start CPR and use the applicable BLS algorithm rather than treating the patient as having isolated respiratory arrest.

Recognizing common respiratory emergencies

Respiratory emergencies require support matched to the presentation, close reassessment, and timely transport or additional resources.

• Asthma or COPD exacerbation: Wheezing, prolonged exhalation, cough, or increased work of breathing may occur; severe obstruction may produce little air movement. Position the patient for comfort, support oxygenation and ventilation as needed, assist with prescribed medication when authorized, and reassess closely. Worsening fatigue or altered mental status is an emergency.

• Pulmonary edema or heart failure: Clues include severe breathlessness, crackles, possible frothy sputum, and sometimes a history of heart disease. Support breathing and oxygenation, position the patient upright if tolerated, arrange prompt transport, and follow local protocol.

• Anaphylaxis: Rapid onset after exposure may cause breathing difficulty or airway swelling; skin findings may or may not be present. Support the airway and breathing, assist with the patient’s prescribed epinephrine auto-injector when authorized, and promptly request additional resources.

• Foreign-body airway obstruction: Sudden difficulty speaking, coughing, or breathing may indicate obstruction; severe obstruction may prevent effective coughing or speech. Encourage an effective cough for mild obstruction. For severe obstruction, follow current age-specific BLS guidance. The 2025 AHA guidance recommends cycles of five back blows and five abdominal thrusts for adults and children, and five back blows alternating with five chest thrusts for infants. If the patient becomes unresponsive, begin CPR and follow the BLS algorithm; remove an object only if visible.

• Opioid-related respiratory depression: Very slow or absent breathing, decreased responsiveness, and possible pinpoint pupils are clues. Open the airway and ventilate effectively. Provide naloxone when authorized and indicated, but do not delay ventilation or resuscitation. Reassess because breathing problems may persist or return.

• Croup, epiglottitis, or other upper-airway swelling: Stridor, hoarseness, drooling, difficulty swallowing, or a characteristic barking cough may occur. Keep the patient calm, avoid unnecessary airway procedures, support oxygenation, and transport promptly. Do not inspect or manipulate an airway when epiglottitis is suspected.

• Chest injury, pneumothorax, or pulmonary embolism: Breathlessness with chest pain, trauma findings, unequal chest movement, or sudden unexplained symptoms may be present. Support the airway, oxygenation, and ventilation as needed; monitor for rapid deterioration and transport promptly.

• Drowning or submersion injury: Respiratory distress or arrest may follow submersion, and hypoxia may be the primary problem. Ensure scene safety, provide effective ventilation and CPR when indicated, and transport for evaluation even if the patient initially improves. AHA guidance emphasizes providing breaths as soon as feasible in drowning-related arrest.

A decision pattern for breathing difficulty

When a scenario presents breathing difficulty, ask in order: Is the airway open? Is breathing adequate? Is the patient oxygenating and ventilating effectively? Is the condition worsening?

Correct immediate threats first, choose the least invasive effective support within EMT scope, reassess the response, and arrange appropriate transport or additional resources. Follow local protocols and current BLS guidance.

Putting the priorities together

Airway patency, ventilation, and oxygenation are related but distinct. Assess breathing through effort, depth, rate, chest rise, mental status, and overall appearance—not by a single number. Open and clear the airway, use adjuncts appropriately, provide oxygen when indicated, and ventilate patients whose breathing is inadequate. Watch closely for fatigue and deterioration, apply age-specific BLS guidance, and reassess after every intervention.