Indication:

Upper airway obstruction (partial or complete)

Contraindications (ABSOLUTE/relative):

None

Alternatives

Oropharyngeal airway Nasopharyngeal airway Non-invasive positive pressure ventilation Laryngeal mask airway Intubation

Consent

Consent is not required This is an emergency procedure to save a life

Potential complications

Pain Failure to open airway

Infection Control

Standard precautions PPE: non-sterile gloves

Area

Any

Staff

Procedural Clinican

Positioning

Supine

Head-tilt, Chin-lift

Place one hand on the patient’s forehead and tilt the patients head backwards Lift the mandible at the mentum using index and middle fingertips (avoiding soft tissue compression) Simultaneously apply downward pressure to the patient’s forehead The thumb may be used to grip the chin aiding chin-lift and mouth opening

Jaw thrust

Place index and middle fingertips behind angle of the mandible on each side Place the thenar eminence of each hand over the zygomatic arch Pull mandible anteriorly until lower incisors are anterior to upper incisors The thumb may be used to grip to aid mouth opening

Airway obstruction from fluid or matter

Roll patient onto side, open mouth and turn head downwards to allow material to drain Manual C-spine immobilisation and open mouth if C-spine injury suspected Large-bore (more effective) or Yankauer (reduced trauma) suction of secretions Remove loose dentures but allow well-fitting dentures to remain

Post-procedure care

Definitive airway management if required

Tips

Obese patients require increased head elevation (ramping) to achieve the sniffing position

Discussion

All airway manoeuvres are associated with some movement of the cervical spine. In suspected C-spine injury manual in-line stabilisation of the C-spine should be provided with jaw thrust preferred and chin-lift added only if jaw thrust fails. While we always try to protect the spine, it is important to remember opening the airway takes precedence over spinal or other injuries.

Peer Review

This guideline has been reviewed and approved by the following expert groups: Emergency Care Institute Please direct feedback for this procedure to feedback@emergencyprocedures.org Reviewed November 2023

References

Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 4 – airway. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2016. 7pp. Available from https://resus.org.au/guidelines/ Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019. Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019. Wittels KA. Basic airway management in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 Sept 17. Retrieved March 2019. Available from: https://www.uptodate.com/contents/basic-airway-management-in-adults Guildner CW. Resuscitation - opening the airway. A comparative study of techniques for opening an airway obstructed by the tongue. JACEP. 1976;5(8):588. DOI: 10.1016/s0361-1124(76)80217-1