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Airway Management: From Manual Techniques to Tubes

November 1, 2026

Impaired airway patency is one of the fastest-killing conditions during trauma or acute illness. In an unconscious victim, the muscles of the tongue relax and can fall back, completely blocking airflow to the larynx and lungs. The ability to quickly identify this issue and take the necessary steps can save the victim's life before medical personnel arrive.

Causes and Identification of Airway Obstruction

A relaxed tongue is the most common cause of airway obstruction in an unconscious state. Airway patency can also be compromised by blood, vomitus, tooth fragments, foreign bodies, or tissue swelling caused by trauma and burns. If the victim is unconscious, the first step is to assess whether they are breathing.

Wheezing, gurgling, stridor, or a total absence of breath sounds while the chest is moving indicates that the airway is partially or fully obstructed. If you notice these signs, call 112 immediately and begin emergency intervention. According to the basic life support and AED guidelines, airway opening is performed immediately after evaluating consciousness.

Manual Methods for Opening the Airway

Without specialized equipment, the airway can be opened using manual techniques. The choice of technique depends on whether a neck or spinal injury is suspected.

Head-tilt / Chin-lift: This is the standard method used when there is no risk of spinal trauma. One hand is placed on the victim's forehead to gently tilt the head back. The fingertips of two fingers on the other hand grip the bony part of the lower jaw to lift the chin upward. This action pulls the base of the tongue away from the posterior pharyngeal wall.
Jaw-thrust (without head tilt): Used when a spinal injury is suspected (e.g., following a fall from height or a motor vehicle accident). The responder kneels behind the victim's head, places fingers at the angles of the lower jaw, and lifts the jaw upward and forward without tilting the head back.

Nasopharyngeal Airway (NPA): What Is It and When to Use It?

Manual methods require the continuous presence and hands-on effort of the responder. Furthermore, during patient transport, maintaining an open airway manually can be difficult. In such scenarios, a NasoSafe nasopharyngeal airway or an adjustable RUSCH adjustable nasopharyngeal airway is used.

A nasopharyngeal airway is a soft, flexible rubber or plastic tube inserted through a nasal passage to the posterior pharyngeal wall. It creates an open channel for air to pass by the base of the tongue and soft palate. This device is well-tolerated even by partially conscious patients because it rarely triggers a gag reflex, unlike oropharyngeal airways. Nasopharyngeal airways should not be used if there are clear signs of a basilar skull fracture or massive midface trauma.

Procedure for Inserting a Nasopharyngeal Airway

Safe and correct tube insertion requires proper preparation. The steps for insertion are as follows:

Sizing: The tube length is measured from the tip of the victim's nose to the earlobe.
Preparation and Lubrication: The exterior of the tube is coated with a water-based lubricant—often included in the package with the airway.
Insertion: The responder gently lifts the tip of the nose. The tube is inserted into the right nostril (if undamaged) with the bevel facing the nasal septum. The tube is pushed straight back, perpendicular to the face, rather than upward toward the bridge of the nose.
Completing the Procedure: The tube is advanced gently without force until the external flange rests against the nostril. If resistance is met, try rotating the tube slightly or inserting it into the other nostril.

Other Airway Devices and Their Limitations

Healthcare professionals and paramedics use more advanced devices to secure the airway. For example, an I-GEL supraglottic airway allows rapid laryngeal sealing without cuff inflation, while suctioning can be performed using a TyTek Medical disposable portable suction device.

Additionally, tactical medicine includes invasive procedures such as cricothyroidotomy—a surgical airway opening through the cricothyroid membrane when all other methods fail. This procedure is performed only in cases of total upper airway obstruction and requires specialized training, appropriate qualifications, and dedicated equipment. Performing surgical incisions without proper training is dangerous.

Recovery Position (Side-Lying Position)

If an unconscious victim is breathing spontaneously and has no severe injuries requiring a supine position, placing them in the recovery position is recommended. This position prevents the tongue from obstructing the airway, and in the event of vomiting, fluid drains out of the mouth, reducing the risk of aspiration into the lungs.

Maintaining an open airway in patients lying on their side remains safer, but continuous monitoring of their breathing is essential until the emergency medical service team arrives. If the victim stops breathing, roll them onto their back and begin CPR.

Comparison of Airway Management Methods

Method / Device	Indications	Advantages	Limitations / Risks
Head-tilt / Chin-lift	Unconscious patient without suspected spinal injury	Requires no equipment, fast	Unsuitable if neck injury is suspected
Jaw-thrust	Unconscious patient with suspected spinal injury	Spine-safe	Requires practice and two hands
Nasopharyngeal Airway (NPA)	Unconscious or semiconscious patient	Tolerated without gagging, maintains air passage	Contraindicated in facial / basilar skull trauma
Recovery Position	Unconscious, spontaneously breathing patient	Prevents aspiration of fluids	Unsuitable in cases of unmanaged massive bleeding