(See also Respiratory Arrest Overview of Respiratory Arrest Respiratory arrest and cardiac arrest are distinct, but inevitably if untreated, one leads to the other. (See also Respiratory Failure, Dyspnea, and Hypoxia.) Interruption of pulmonary gas exchange... read more and Airway Establishment and Control Airway Establishment and Control Airway management consists of Clearing the upper airway Maintaining an open air passage with a mechanical device Sometimes assisting respirations (See also Overview of Respiratory Arrest.) read more .)
These methods require active ongoing attendance by the operator and are an integral part of bag-valve-mask ventilation How To Do Bag-Valve-Mask (BVM) Ventilation Bag-valve-mask (BVM) ventilation is the standard method for rapidly providing rescue ventilation to patients with apnea or severe ventilatory failure. (See also Airway Establishment and Control... read more (BVM).
Positioning of the patient in a proper sniffing position Head and neck positioning to open the airway: Sniffing position 
, when possible, is a prerequisite to these manual methods as well as to the invasive methods of airway management (ie, supraglottic Laryngeal Mask Airways (LMA) If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more and tracheal Other Devices If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more artificial airways).
These methods should be supplemented with use of oropharyngeal How To Insert an Oropharyngeal Airway Oropharyngeal airways are rigid intraoral devices that conform to the tongue and displace it away from the posterior pharyngeal wall, thereby restoring pharyngeal airway patency. (See also Airway... read more or nasopharyngeal airways How To Insert a Nasopharyngeal Airway Nasopharyngeal airways are flexible tubes with one end flared (hence their synonym: nasal trumpets) and the other end beveled that are inserted, beveled end first, through the nares into the... read more .
The addition of continuous positive airway pressure Noninvasive positive pressure ventilation (NIPPV) Mechanical ventilation can be Noninvasive, involving various types of face masks Invasive, involving endotracheal intubation Selection and use of appropriate techniques require an understanding... read more may achieve airway patency when these manual methods alone fail.
Indications
Treatment of suspected upper airway obstruction in obtunded or unresponsive patients
Part of initial emergency treatment for apnea or impending respiratory arrest
Improvement of airway patency during BVM ventilation and sometimes during spontaneous breathing
Confirmation of apnea
Contraindications
Absolute contraindications
There is no medical contraindication to providing rescue breathing; however, a patient may have a legal contraindication (do-not-resuscitate order Do-Not-Resuscitate (DNR) Orders and Portable Medical Orders The do-not-resuscitate (DNR) order placed in a patient’s medical record by a clinician informs the medical staff that cardiopulmonary resuscitation (CPR) should not be done in the event of cardiac... read more or specific advance directive Advance Directives Advance directives are legal documents that extend a person's control over health care decisions in the event that the person becomes incapacitated. They are called advance directives because... read more in force).
Relative contraindications
Suspected or actual cervical spine injury
Tilting the head or otherwise moving the neck is contraindicated in a patient with a possible cervical spine injury, but maintaining an airway and ventilation is a greater priority. In the setting of a possible cervical spine injury, the jaw-thrust maneuver, in which the neck is held in a neutral position, is preferred over the head tilt–chin lift maneuver.
Complications
Complications are uncommon and include
Spinal cord injury if the cervical spine has an unstable bony or ligamentous injury
Exacerbation of mandibular injury
Equipment
Gloves, mask, gown (ie, universal precautions)
Towels, sheets, or commercial devices (ramps) for elevating neck and head into optimal positioning
Suctioning apparatus and Yankauer catheter; Magill forceps (if needed to remove easily accessible foreign bodies and patient has no gag reflex), to clear the pharynx as needed
Additional Considerations
Suction should be used if necessary to clear the upper airway.
Relevant Anatomy
Aligning the external auditory canal with the sternal notch may help open the upper airway and establishes the best position to view the airway if endotracheal intubation becomes necessary.
The degree of head elevation that best aligns the ear and sternal notch varies (eg, none in children with a large occiput, a large degree in obese patients).
Positioning
The sniffing position—only in the absence of cervical spine injury
Position the patient supine on the stretcher.
Align the upper airway for optimal air passage by placing the patient into a proper sniffing position. Proper sniffing position aligns the external auditory canal with the sternal notch. To achieve the sniffing position, folded towels or other materials may need to be placed under the head, neck, or shoulders, so that the neck is flexed on the body and the head is extended on the neck. In obese patients, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck. In children, padding is usually needed behind the shoulders to accommodate the enlarged occiput.
Head and neck positioning to open the airway: Sniffing position
A: The head is flat on the stretcher; the airway is constricted. B: The ear and sternal notch are aligned, with the face parallel to the ceiling (in the sniffing position), opening the airway. Adapted from Levitan RM, Kinkle WC: The Airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.  |
If cervical spine injury is a possibility
Position the patient supine or at a slight incline on the stretcher.
Avoid moving the neck and do the jaw-thrust maneuver first (before trying the head tilt–chin lift if needed to open the airway).
Step-by-Step Description of Procedure
Head tilt–chin lift
Tilt the patient’s head back by pushing down on the forehead.
Place the tips of your index and middle fingers under the chin and pull up on the mandible (not on the soft tissues). This lifts the tongue away from the posterior pharynx and improves airway patency.
Be sure to pull up only on the bony parts of the mandible. Pressure to the soft tissues of the neck may obstruct the airway.
Jaw thrust
Stand at the head of the stretcher and place your palms on the patient’s temples and your fingers under the mandibular rami.
In patients with possible cervical spine injury, avoid extending the neck.
Lift the mandible upward with your fingers, at least until the lower incisors are higher than the upper incisors. This maneuver lifts the tongue along with the mandible, thus relieving upper airway obstruction.
Be sure to pull or push up only on the bony parts of the mandible. Pressure to the soft tissues of the neck may obstruct the airway.
Jaw thrust
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Aftercare
Maintain these positions as long as necessary.
More Information
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Berg RA, Hemphill R, Abella BS, et al: Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122:S685-S705, 2010.
