Overview
Airway management is the highest priority in emergency medicine and the most heavily tested topic on the NREMT-Basic exam. This guide covers the anatomy of the respiratory system, techniques for opening and maintaining the airway, adjunct devices, oxygen delivery, and ventilation methods. Mastering these concepts is essential — a compromised airway is immediately life-threatening.
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Airway Anatomy & Physiology
The Respiratory Pathway
Air travels through a precise sequence of structures from entry to gas exchange:
Nose/Mouth → Pharynx → Larynx → Trachea → Bronchi → Bronchioles → Alveoli
> Remember: Gas exchange (O₂ in, CO₂ out) occurs only at the alveoli.
Key Structures & Functions
| Structure | Function / Clinical Relevance |
|---|---|
| Epiglottis | Leaf-shaped flap; covers the trachea during swallowing to prevent aspiration |
| Carina | Bifurcation point of trachea into left/right mainstem bronchi; located at the sternal angle (angle of Louis) |
| Alveoli | Site of gas exchange; surrounded by pulmonary capillaries |
| Trachea | Conduit for air; soft and easily obstructed in children |
Pediatric Airway Differences
Children present unique challenges compared to adults:
• Narrower, shorter, more anterior airway
• Proportionally larger tongue — increases obstruction risk
• Floppy epiglottis — harder to visualize
• Softer trachea — collapses more easily
• Small diameter = even minor swelling causes significant obstruction
Normal Respiratory Rates
| Patient | Normal Rate |
|---|---|
| Adult | 12–20 breaths/min |
| Child | 15–30 breaths/min |
| Infant | 25–50 breaths/min |
Breathing Patterns to Know
• Agonal breathing: Occasional, irregular, gasping breaths in dying patients — NOT effective ventilation
- Action: Treat as respiratory arrest → begin positive-pressure ventilation immediately
Key Terms
• Pharynx – Throat; divided into nasopharynx, oropharynx, and hypopharynx
• Larynx – Voice box; contains the vocal cords and epiglottis
• Carina – Ridge at tracheal bifurcation
• Tidal Volume – Amount of air moved in one normal breath (~500–600 mL in adults)
• FiO₂ – Fraction of inspired oxygen
⚠️ Watch Out For
• Agonal breathing is NOT breathing — do not count it as adequate respiration; treat as arrest
• If air is inadvertently forced into the right mainstem bronchus (more vertical angle), only the right lung ventilates — listen bilaterally to confirm equal breath sounds
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Airway Opening Techniques
Manual Maneuvers
#### Head-Tilt–Chin-Lift
• Use: Unresponsive patients with no suspected spinal injury
• Technique: One hand on forehead tilting head back; fingers of other hand under the bony part of the chin (not soft tissue) lifting upward
#### Jaw-Thrust Maneuver
• Use: Patients with suspected spinal injury — preferred choice
• Technique: Place hands on both sides of the head; use fingers behind the angle of the jaw to thrust the jaw forward without moving the neck
• Why: Opens the airway without neck extension, minimizing spinal movement
Most Common Cause of Airway Obstruction
> Tongue relaxation in an unconscious patient — the tongue falls posteriorly and occludes the pharynx
Foreign-Body Airway Obstruction (FBAO)
#### Conscious Adult — Severe Obstruction
• Deliver abdominal thrusts (Heimlich maneuver)
• Hand position: Fist just above the navel, well below the xiphoid process, thumb side against abdomen
• Deliver firm inward and upward thrusts until object is expelled or patient becomes unresponsive
#### Unresponsive Adult — Severe Obstruction
1. Lower patient to the ground
2. Begin CPR starting with chest compressions
3. Before each ventilation — look in the mouth for the object
4. Remove the object only if visible (no blind finger sweeps)
⚠️ Watch Out For
• Never perform blind finger sweeps — may push the object deeper
• For conscious infants: use 5 back blows + 5 chest thrusts (NOT abdominal thrusts)
• Jaw-thrust is preferred for spinal precautions, but head-tilt–chin-lift may be used if jaw-thrust fails to open the airway
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Airway Adjuncts
Oropharyngeal Airway (OPA)
#### Sizing
• Measure from the center (or corner) of the mouth to the earlobe, OR
• From the corner of the mouth to the angle of the jaw
#### Indications
• Unconscious patient without a gag reflex
#### Contraindications
• Conscious or semiconscious patient with an intact gag reflex → risk of vomiting and aspiration
#### Insertion Technique
| Patient | Technique |
|---|---|
| Adult | Insert upside down (tip toward roof of mouth); rotate 180° as it passes the soft palate |
| Child/Infant | Insert right-side up using a tongue depressor to avoid palate injury |
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Nasopharyngeal Airway (NPA)
#### Sizing
• Measure from the tip of the nose to the earlobe
• Confirm the diameter fits the patient's nostril
#### Indications (Preferred Over OPA When)
• Patient has an intact or active gag reflex
• Trismus (clenched teeth)
• Oral trauma preventing OPA insertion
#### Contraindications
• Suspected basilar skull fracture: Signs include:
- Battle's sign (bruising behind ears)
- Raccoon eyes (periorbital bruising)
- CSF drainage from ears or nose
- Risk: NPA could enter the cranial vault
Key Terms
• OPA (Oropharyngeal Airway) – Curved plastic device maintaining tongue-off-posterior-pharynx position
• NPA (Nasopharyngeal Airway) – Soft rubber/plastic tube inserted through the nostril
• Trismus – Involuntary clenching of the jaw
• Battle's Sign – Mastoid bruising; sign of basilar skull fracture
• Raccoon Eyes – Periorbital bruising; sign of basilar skull fracture
⚠️ Watch Out For
• Using an OPA in a patient with a gag reflex → vomiting → aspiration → death
• An OPA that is too large can obstruct the airway; too small will not properly open it
• Always insert NPA with lubricant and directed toward the septum (not upward into the skull)
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Suctioning
Key Rules for Suctioning
| Parameter | Guideline |
|---|---|
| Duration per pass | No more than 15 seconds for adults (10 sec for children; 5 sec for infants) |
| Before suctioning | Hyperoxygenate with high-flow O₂ |
| After suctioning | Reoxygenate immediately after each pass |
Catheter Selection
| Situation | Catheter Type |
|---|---|
| Thick secretions / vomitus in oropharynx | Rigid (Yankauer / tonsil-tip) catheter |
| Deeper, narrower suctioning (NPA/ET tube) | Soft (flexible) suction catheter |
⚠️ Watch Out For
• Suctioning too long → hypoxia (hence the 15-second limit)
• Always hyperoxygenate before AND after suctioning
• Stimulating the posterior pharynx can cause vagal stimulation → bradycardia, especially in children
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Oxygen Delivery Devices
Device Comparison Chart
| Device | Flow Rate | Approximate FiO₂ | Notes |
|---|---|---|---|
| Nasal Cannula | 1–6 L/min | 24–44% | ~4% increase per liter above 21% room air |
| Simple Face Mask | 6–10 L/min | 35–60% | Minimum 6 L/min to flush CO₂ |
| Nonrebreather Mask (NRB) | 10–15 L/min | ~90% | Reservoir bag must be fully inflated before use |
| BVM with O₂ | 15 L/min | ~100% | Used for positive-pressure ventilation |
Oxygen Cylinder Safety
#### Cracking the Valve
• Purpose: Briefly open and close the cylinder valve to clear dust and debris from the valve outlet before attaching the regulator
• Prevents contamination of equipment
#### Cylinder Replacement Threshold
• Replace or refill when pressure drops to 200 psi or below
• Use the formula to calculate remaining time: Duration (min) = (Pressure − 200) × Tank constant ÷ Flow rate
Key Terms
• FiO₂ – Fraction of inspired oxygen (expressed as percentage or decimal)
• Reservoir Bag – Collects oxygen between breaths on an NRB mask; must be inflated before application
• PSI (Pounds per Square Inch) – Unit of pressure for oxygen cylinders
⚠️ Watch Out For
• A nonrebreather mask that delivers low FiO₂ may mean the reservoir bag is not pre-inflated or the flow rate is too low
• Never use a nasal cannula for a critically ill or hypoxic patient — use NRB or BVM
• Minimum 6 L/min on a simple face mask or CO₂ will accumulate in the mask
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Ventilation Techniques
BVM (Bag-Valve-Mask) Ventilation
#### Ventilation Parameters for Adults
| Parameter | Value |
|---|---|
| Tidal Volume | ~500–600 mL (enough for visible chest rise) |
| Rate — Apneic adult with pulse | 10–12 breaths/min (1 breath every 5–6 seconds) |
| Rate — Intubated adult during CPR | 10 breaths/min (1 breath every 6 seconds), delivered asynchronously |
#### E-C Clamp Technique (Single Rescuer)
A critical skill for maintaining mask seal with one hand:
• "E" fingers (fingers 3, 4, 5): Hook under the jaw, lifting the chin upward
• "C" fingers (thumb + index finger): Form a C-shape over the mask, pressing it firmly to the face
• Simultaneously maintains head-tilt and mask seal
> Two-rescuer BVM is always preferred — one holds the mask, one squeezes the bag.
Confirming Adequate Ventilation
In order of reliability:
1. Bilateral, symmetric chest rise — primary and most reliable field confirmation
2. Auscultate equal breath sounds bilaterally
3. Pulse oximetry (SpO₂) monitoring
4. Waveform capnography (if available, gold standard)
Gastric Distension
• Cause: Excessive ventilation volume or rate
• Sign: Rising abdomen
• Complications:
- Regurgitation → aspiration
- Impairs diaphragm movement → reduces ventilation effectiveness
Cricoid Pressure (Sellick Maneuver)
• Purpose: Compress the esophagus between the cricoid cartilage and the cervical spine to reduce risk of regurgitation and aspiration during ventilation
• Apply only upon request of the team leader; do not apply during active vomiting
Key Terms
• BVM (Bag-Valve-Mask) – Device delivering positive-pressure ventilation with near 100% O₂
• Tidal Volume – Volume of air delivered per breath
• Asynchronous Ventilation – Delivering breaths independently of compressions (during CPR with advanced airway)
• Sellick Maneuver – Cricoid pressure to occlude the esophagus
• SpO₂ – Oxygen saturation measured by pulse oximetry
⚠️ Watch Out For
• Over-ventilation (too fast/too much volume) is a common and dangerous error — causes gastric distension, aspiration, and can reduce cardiac output during CPR
• During CPR without an advanced airway: 30:2 ratio (pause compressions for breaths)
• During CPR with an advanced airway: Do NOT pause compressions — ventilate asynchronously at 1 breath every 6 seconds
• Visible chest rise = correct volume; if the chest doesn't rise, reassess the airway first
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Quick Review Checklist
Use this checklist to confirm mastery before your NREMT exam:
Anatomy & Physiology
• [ ] Can recite the complete airway pathway from nose to alveoli
• [ ] Know the function of the epiglottis and location of the carina
• [ ] Understand why pediatric airways are more challenging
• [ ] Recognize agonal breathing and know the correct response
• [ ] Know normal respiratory rates for adults
Airway Opening
• [ ] Know when to use jaw-thrust vs. head-tilt–chin-lift
• [ ] Know the most common cause of airway obstruction in unconscious patients
• [ ] Can describe Heimlich maneuver hand positioning
• [ ] Know FBAO management for conscious vs. unresponsive patients
Airway Adjuncts
• [ ] Know how to size both OPA and NPA
• [ ] Know contraindications for OPA (intact gag reflex)
• [ ] Know contraindications for NPA (basilar skull fracture)
• [ ] Know adult vs. pediatric OPA insertion technique difference
• [ ] Know the signs of basilar skull fracture (Battle's sign, raccoon eyes, CSF drainage)
Suctioning
• [ ] Know the 15-second maximum suction duration for adults
• [ ] Know to hyperoxygenate before AND after suctioning
• [ ] Know when to use Yankauer (rigid) vs. soft catheter
Oxygen Delivery
• [ ] Know flow rates and FiO₂ for NRB mask, nasal cannula, and simple face mask
• [ ] Know to pre-inflate the NRB reservoir bag
• [ ] Know why you crack the cylinder valve
• [ ] Know the cylinder replacement threshold (200 psi)
Ventilation
• [ ] Know adult BVM tidal volume (~500–600 mL) and rate (10–12/min)
• [ ] Can describe the E-C clamp technique
• [ ] Know how to confirm adequate ventilation (chest rise first)
• [ ] Know signs and dangers of gastric distension
• [ ] Know the ventilation rate during CPR with an advanced airway (1 breath/6 sec, asynchronous)
• [ ] Know the purpose of the Sellick maneuver
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> Final Exam Tip: When in doubt on the NREMT, airway comes first. Before treating anything else, ensure the airway is open, the patient is breathing adequately, and oxygenation is maintained. Every scenario begins with airway assessment.