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Securing the airway and assuring adequate ventilation are the first priorities in the resuscitation of any acutely ill or injured patient.1 Without a patent airway and adequate gas exchange other resuscitative measures will almost universally be futile. Thus, attention to the airway must precede or occur simultaneously with any other type of management. The exception is the initial defibrillation in cardiac arrest due to ventricular fibrillation, if it can be performed immediately. (Figure 10–1.)

Figure 10–1.

Management of the compromised airway. I-LMA, intubating laryngeal mask airway; LMA, laryngeal mask airway; PTTJV, percutaneous transtracheal jet ventilation; RSI, rapid sequence induction.

Assess the Airway

First, determine the patient’s level of consciousness and note the presence of respirations and grade respiratory effort. In patients with known or suspected cervical spine (C-spine) injury, all assessments and maneuvers should be undertaken with the C-spine immobilized in a neutral position to prevent cord injury. Consider placing a nasal cannula to facilitate apneic oxygenation (see “High-Flow Oxygen” section) if potential for intubation.

A. Apneic, Unconscious Patients

If the C-spine is not injured, place the head in the sniffing position with the chin lift maneuver to open the airway (Figure 10–2). For patients with potential C-spine injuries, a jaw-thrust maneuver should be used. Clear the airway of obstructions, using a rigid suction catheter to remove any blood, vomitus, or secretions from the oropharynx. Remove any large obstructing foreign bodies from the oropharynx manually or with Magill forceps (see Chapter 9). Do not perform a blind finger sweep of the oropharynx if foreign body suspected.

Figure 10–2.

In the sniffing position, the head is slightly extended and the neck is flexed on the shoulders. This aligns the axis of the airway with the mouth and pharynx, facilitating direct visualization of the cords during intubation. It is particularly important in young children and infants, in whom the larynx is considerably more anterior. Placing a pad underneath the occiput will lift the head and align the ear with the sternal notch, facilitating optimal positioning for intubation. This position cannot be used when there is cervical spine injury.

If the patient remains apneic, assist ventilation using a bag-valve-mask device (eg, Ambu bag) or mouth-to-mouth breathing (see Chapter 9). If adequate personnel and equipment are available, immediately perform endotracheal intubation.


This chapter is a revision of the chapter by Justin Knowles, MD and Allison Raines, MD, from the 7th edition.

B. Patients with Respiratory Effort

Administer high-flow oxygen. Clear and position the airway as described above. Identify evidence of upper airway ...

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