Core skills in emergency medicine: rapidly assess the airway, apply manual manoeuvres, choose the right adjuncts, and deliver effective ventilation to protect your patient while definitive airway care is arranged.

Aim: Maintain airway patency and adequate oxygenation using basic manoeuvres and adjuncts.

You must be able to assess, open and maintain the airway, and recognise when to escalate to advanced airway interventions.

1. Rapid Airway Assessment

Start with a quick, structured assessment. Ask: is the airway patent and is the patient protecting it?

• Look – chest movement, paradoxical breathing, use of accessory muscles.
• Listen – snoring, gurgling, stridor, or no breath sounds.
• Feel – air movement at the mouth and nose.

Consider anatomical, physiological, and obstruction-related factors that may predict a difficult airway or rapid deterioration.

2. Manual Airway Manoeuvres

Head-Tilt / Chin-Lift (HTCL)

First-line in unconscious patients without suspected cervical spine injury.

• One hand on the forehead to gently tilt the head back.
• Fingertips of the other hand under the bony chin, lifting upwards.
• Moves the tongue away from the posterior pharyngeal wall.

Jaw Thrust

Preferred when C-spine injury is suspected.

• Stand at the head, thumbs on the cheeks, fingers behind the angle of the mandible.
• Lift the mandible upwards and forwards.
• Avoid neck movement where possible.

Triple Manoeuvre

Combines head tilt, chin lift, and jaw thrust to maximise airway opening; often requires two hands and may be tiring to maintain.

Suction

Use a Yankauer sucker to remove blood, vomit or secretions to reduce aspiration risk and maintain patency.

3. Positioning

Alignment – “Sniffing” Position

Mild neck flexion with extension at the atlanto-occipital joint aligns the oral, pharyngeal, and laryngeal axes and improves manual ventilation.

Obese or Pregnant Patients – Ramped Position

Elevate head and upper torso so the external auditory meatus aligns with the sternal notch. Improves both oxygenation and airway management.

Stable but Unconscious – Recovery Position

For spontaneously breathing patients who are not intubated: reduces aspiration risk and helps maintain airway patency.

4. Airway Adjuncts

Airway adjuncts prevent soft tissue obstruction and help maintain a patent airway when manual manoeuvres alone are insufficient.

Use an adjunct as soon as you need to maintain an open airway, especially in the obtunded, snoring or intermittently obstructed patient.

Oropharyngeal Airway (OPA)

• Insert in unconscious patients without a gag reflex to prevent the tongue occluding the airway.
• Size from incisors to angle of the mandible.

Nasopharyngeal Airway (NPA)

• Useful in semi-conscious patients with a gag reflex or trismus.
• Size from nostril to tragus.
• Avoid in base-of-skull fractures or significant nasal trauma.

Supraglottic Airway (e.g. LMA, i-gel)

Often taught at basic level; ideal as a bridge when bag–valve–mask ventilation is inadequate or intubation is delayed.

5. Bag–Valve–Mask (BVM) Ventilation

Effective BVM ventilation is a critical emergency skill and can be life-saving, even without advanced airway devices.

Key Principles

• Use the sniffing or ramped position where appropriate.
• Apply a good mask seal (C–E grip) and jaw thrust.
• Prefer a two-person technique: one person holds the mask and airway, the other squeezes the bag.
• Deliver slow, gentle breaths just enough for visible chest rise.
• Avoid over-ventilation to reduce gastric insufflation and aspiration risk.

6. Oxygen Delivery Options

Devices

• Nasal cannulae – mild hypoxia, apnoeic oxygenation.
• Simple face mask – moderate oxygen requirements.
• Non-rebreather mask – high-flow oxygen up to 15 L/min.
• BVM with reservoir – near 100% O₂ if used correctly.

Target saturations as per local guideline. Titrate, but don’t delay oxygen.

7. When Basic Airway Management Is Not Enough

Escalate to senior help and advanced airway techniques (supraglottic devices, endotracheal intubation, surgical airway) when:

• Hypoxia persists despite simple manoeuvres and oxygen.
• Airway patency cannot be maintained with adjuncts and positioning.
• There is ongoing aspiration or risk of complete obstruction.
• Neurological status deteriorates with loss of airway reflexes.

8. Practice Scenario – Teaching Basic Airway Management

Teaching Script (ST4 → F1)

EMAM teaching approach: Understand the Audience → Set–Dialogue–Closure → Communication → Engagement → Feedback.

Step 1 – Understand the Audience

Introduce yourself as the ST4 and clarify the F1’s experience:

“What have you done so far with airway management?”

Then agree learning objectives:

• Assess an airway quickly.
• Open it with basic manoeuvres.
• Use OPA/NPA safely.
• Know the basics of BVM and escalation.

Step 2 – Set: Introduce Structure

“We’ll keep this simple: we’ll look at Assess → Open → Maintain → Escalate. I’ll explain each, then ask you to talk me through and demonstrate on the manikin.”

Step 3 – Dialogue (Main Teaching)

A. Assess

• Explain Look–Listen–Feel and airway protection (GCS, gag reflex).
• Ask: “If a patient is snoring with GCS 6, what does that tell you?”

B. Open

• Head tilt–chin lift when no C-spine concern.
• Jaw thrust if trauma or possible C-spine injury.
• Triple manoeuvre and suction with Yankauer.

C. Maintain

• OPA – unconscious, no gag; size incisors → angle of mandible.
• NPA – gag reflex / trismus; size nostril → tragus; avoid in base-of-skull fracture.
• Sniffing / ramped position; basic principles of two-person BVM.

D. Escalate

• Explain that persistent obstruction or hypoxia requires early senior help and advanced airway planning.

Step 4 – Clarity & Communication

Use simple language tailored to an F1, signpost each section (“First assess… now let’s open the airway…”), and pause to check:

“Does that make sense so far?”

Step 5 – Engagement & Interaction

• Ask the F1 to demonstrate a jaw thrust on the manikin.
• Choose and size an OPA and NPA.
• Explain which adjunct they’d use in a snoring trauma patient.
• Use open questions: “Why would you avoid an OPA here?” to promote reasoning.

Step 6 – Closure & Feedback

Summarise:

“We assess the airway, open with manoeuvres, maintain it with adjuncts and BVM, and escalate early if it’s not working.”

Ask the F1 to recap one key point (e.g. “When do you avoid an NPA?”) then give balanced feedback:

“You sized the OPA well; just revise NPA contraindications. Overall you’d be safe with senior support.”

9. Domains Assessed in This Station

The station checks practical airway knowledge and how well the ST4 teaches and supervises a junior doctor.