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HLT-EMT39-04 · Lesson 4 · 30 clock hours · lab

Basic Airway Maneuvers and Manual Airway Adjuncts

Objective. Students will perform head-tilt chin-lift, jaw thrust, and correct insertion of oropharyngeal and nasopharyngeal airways on manikins, selecting the appropriate technique for trauma and non-trauma patients.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Why Airway Comes First

In emergency medicine, no intervention matters more than a patent airway. Without oxygen reaching the lungs, brain injury begins within minutes. Every EMT and paramedic must be able to open, maintain, and protect an airway using hands alone and with basic adjuncts before reaching for any advanced device. This lab focuses on the foundational manual techniques and the two most common basic airway adjuncts: the oropharyngeal airway (OPA) and the nasopharyngeal airway (NPA).

Manual Airway Techniques

Head-Tilt Chin-Lift

The head-tilt chin-lift is the standard technique for opening the airway of an unresponsive patient with no suspected spinal injury. Place one hand on the patient's forehead and apply firm, backward pressure to extend the neck. Simultaneously place the fingertips of your other hand under the bony part of the chin and lift upward. This moves the tongue away from the posterior pharynx and opens the airway. Do not press on the soft tissue under the chin, as this can compress the airway instead of opening it.

Jaw Thrust

When spinal injury is suspected — including any significant mechanism of trauma — use the jaw thrust instead. Kneel at the top of the patient's head, place your fingers behind the angles of the mandible (the jaw), and push the jaw forward while keeping the head and neck as still as possible. This technique opens the airway without extending the cervical spine. It requires more effort and is harder to maintain during prolonged ventilation, but patient safety demands its use in trauma scenarios. If a jaw thrust fails to open the airway and ventilation is impossible, it is acceptable to reposition to a head-tilt chin-lift — an open airway takes priority.

Oropharyngeal Airway (OPA)

The OPA is a rigid, curved device inserted through the mouth to hold the tongue away from the posterior pharynx. It is appropriate only for patients who have no gag reflex. Inserting an OPA in a patient with an intact gag reflex can cause vomiting and aspiration.

Sizing: Measure from the corner of the patient's mouth to the earlobe, or from the center of the mouth to the angle of the jaw. The correctly sized OPA reaches from the lips to the angle of the jaw.

Insertion — adult (rotation method): Open the mouth and insert the OPA with the tip pointing toward the roof of the mouth (curved end up). As the device passes the soft palate, rotate it 180 degrees so the curve follows the natural curve of the tongue. Confirm placement by visualizing the flange resting at the lips and observing chest rise during ventilation.

Insertion — pediatric/infant (tongue-blade method): In children, the rotation method can damage soft tissues and is generally avoided. Use a tongue blade or laryngoscope blade to depress the tongue, then insert the OPA in its anatomically correct position (curved end down, following the tongue) from the start. A tongue blade protects the delicate tissue of a child's airway.

Confirming placement: After insertion, provide bag-valve-mask (BVM) ventilation and watch for bilateral chest rise. The flange should rest outside the teeth or gums.

Nasopharyngeal Airway (NPA)

The NPA is a soft, flexible rubber or plastic tube inserted through a nostril to create a channel between the nare and the nasopharynx. It is better tolerated than the OPA in patients who have a partial level of consciousness or a gag reflex. It can be used in patients who are not fully unresponsive.

Sizing: Measure from the tip of the nose to the earlobe. Select a diameter that approximates the patient's smallest finger or the nostril opening.

Contraindications: Do not insert an NPA when there is suspected basilar skull fracture (signs include Battle's sign, raccoon eyes, or clear fluid from nose or ears). Also use caution with known or suspected nasal fractures and facial trauma in the area.

Insertion: Lubricate the NPA generously with water-soluble lubricant. Insert into the larger or more patent nostril with the bevel facing toward the nasal septum (midline). Advance gently with a slight rotating motion, following the floor of the nasal cavity — not upward toward the skull. Never force the device. If resistance is met, try the other nostril. The flange should rest at the nostril opening.

Confirm placement by ventilating with a BVM and observing chest rise.

Safety Points

Key terms10

Oropharyngeal Airway (OPA)A rigid, curved adjunct inserted through the mouth to displace the tongue from the posterior pharynx; used only in patients without a gag reflex.
Nasopharyngeal Airway (NPA)A soft, flexible tube inserted through a nostril to maintain a patent airway channel; tolerated by patients with an intact or partial gag reflex.
Head-Tilt Chin-LiftA manual airway maneuver in which one hand tilts the forehead back while the fingers of the other hand lift the chin; contraindicated when spinal injury is suspected.
Jaw ThrustA manual airway maneuver that opens the airway by pushing the mandible forward without extending the neck; the preferred technique for trauma patients with possible spinal injury.
Gag ReflexA protective pharyngeal reflex that triggers retching when the posterior pharynx is stimulated; its presence contraindicates OPA insertion.
Rotation MethodAn OPA insertion technique for adults in which the device is introduced tip-up and rotated 180 degrees as it passes the soft palate.
Tongue-Blade MethodAn OPA insertion technique used in pediatric patients in which a tongue blade depresses the tongue while the OPA is introduced in its correct anatomical orientation without rotation.
Basilar Skull FractureA fracture of the base of the skull that is a contraindication to NPA insertion due to the risk of the tube entering the cranial vault; signs include Battle's sign, raccoon eyes, and cerebrospinal fluid from the nose or ears.
Patent AirwayAn airway that is open and unobstructed, allowing adequate air movement to and from the lungs.
Water-Soluble LubricantA gel-based lubricant used to ease NPA insertion and reduce mucosal trauma; petroleum-based products are avoided because they can damage airway tissue and equipment.

Worked examples4

1. You are sizing an OPA for an adult male manikin. The distance from the corner of the mouth to the earlobe measures 9 cm. Your OPA kit contains sizes labeled 80 mm, 90 mm, 100 mm, and 110 mm. Which size do you select?
  1. Convert your measurement to the same units as the OPA labels: 9 cm = 90 mm.
  2. Match the measurement to the closest available OPA size in your kit: 90 mm.
  3. Confirm the selection by holding the OPA against the patient's face — the flange should rest at the corner of the mouth and the tip should reach the earlobe.
Answer: Select the 90 mm OPA. It matches the corner-of-mouth to earlobe measurement directly.
2. You are sizing an NPA for a patient. You measure from the tip of the nose to the earlobe and get 12 cm. Available NPAs are labeled 6 mm, 7 mm, 8 mm, and 9 mm (these labels refer to internal diameter). You also visually assess the nostril. The patient's nostril approximates a 7 mm diameter tube. Which NPA do you select and why?
  1. The nose-to-earlobe measurement (12 cm) tells you the correct length — confirm the chosen tube is approximately that length when held against the face.
  2. Diameter is selected by matching the patient's nostril size or the width of the smallest finger: the assessment suggests 7 mm.
  3. Cross-check: a 7 mm NPA is appropriate for an average adult. An 8 or 9 mm tube may cause trauma to this nostril.
  4. Select the 7 mm NPA, lubricate it, and insert with the bevel toward the septum.
Answer: Select the 7 mm NPA. The diameter matches the nostril assessment, and the length is confirmed by the nose-to-earlobe measurement.
3. During a pediatric simulation, you measure an OPA from the center of the mouth to the angle of the jaw on an infant manikin and get 4 cm (40 mm). Your pediatric OPA kit has sizes 50 mm, 60 mm, 70 mm, and 80 mm. You realize none matches exactly. What is your next step?
  1. Recognize that 40 mm falls below the smallest available size (50 mm) in this kit.
  2. Re-measure using the corner-of-mouth to earlobe landmark to confirm: if still approximately 40 mm, the kit may not contain an appropriate size for this infant.
  3. Do not insert an oversized OPA — a 50 mm OPA on a 40 mm measurement could push past the larynx and cause obstruction.
  4. Maintain the airway manually with a jaw thrust or head-tilt chin-lift and prepare to reassess or obtain the correct size equipment.
Answer: Do not insert any of the available OPAs. The smallest size exceeds the patient's measurement. Maintain the airway manually and obtain the correct size.
4. After inserting an OPA using the rotation method on an adult manikin, your partner ventilates with a BVM but sees no chest rise. The OPA flange is at the lips. List the steps to troubleshoot in order.
  1. Step 1 — Recheck the manual airway position: ensure the head-tilt chin-lift is adequate; a poorly positioned head negates any adjunct.
  2. Step 2 — Confirm the mask seal: re-seat the BVM mask, use the E-C clamp technique, and squeeze the bag with enough volume to produce visible chest rise.
  3. Step 3 — Check OPA size: if the OPA is too small it may not adequately lift the tongue; if too large it could be pushing on the larynx.
  4. Step 4 — Inspect the oral cavity: look for vomit, blood, or a foreign body obstructing the airway; suction if needed.
  5. Step 5 — If still no chest rise, remove the OPA, perform direct airway assessment, and consider re-sizing or escalating to a higher-level airway intervention.
Answer: Troubleshoot in sequence: recheck head position, recheck mask seal, verify OPA size, inspect and suction the airway, then reassess or escalate if ventilation remains inadequate.

The math in this lesson1

Learners convert a 9 cm mouth-to-earlobe measurement to 90 mm to select the matching OPA size.
N-Q.1
Brush up in the math halls at newSchoolWorks.com:
In class: Paired practice on adult, pediatric, and infant airway manikins: partners alternate performing head-tilt chin-lift and jaw thrust, then switching while the evaluating partner uses the NREMT psychomotor skill sheet for basic airway adjuncts. · OPA sizing and insertion lab: students measure OPA size using the corner-of-mouth to earlobe method on manikins of varying sizes, insert the airway using both the rotation method and tongue-blade method, and confirm correct placement visually. · NPA sizing and insertion lab: students lubricate and insert appropriately sized NPAs into manikin nasal passages, noting bevel orientation, and evaluate airway opening by observing simulated chest rise with BVM ventilation; students also identify contraindications by reviewing three written case vignettes.
Materials: Adult, pediatric, and infant airway manikins, OPA sets (multiple sizes), NPA sets (multiple sizes), water-soluble lubricant, tongue blades, gloves, NREMT psychomotor skill sheets, lab evaluation checklists
Check: NREMT-format psychomotor evaluation for OPA insertion performed by instructor; student must complete all critical criteria with zero critical failures; pass requires no critical errors on the official skill sheet.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Airway, Respiration, and Ventilation
1. A trauma patient is found unresponsive after a high-speed motor vehicle collision. Which airway maneuver should you use first?
Airway, Respiration, and Ventilation
2. You are preparing to insert an OPA in an adult patient. Using the corner-of-mouth to earlobe method, you measure 10 cm. Which OPA size is most appropriate?
Airway, Respiration, and Ventilation
3. Which of the following patients is the BEST candidate for NPA insertion?
Airway, Respiration, and Ventilation
4. When inserting an OPA in an infant, the preferred method differs from the adult rotation technique. What is the correct pediatric approach?
Airway, Respiration, and Ventilation
5. You attempt NPA insertion and meet firm resistance after advancing the tube about halfway. What is the correct action?
Airway, Respiration, and Ventilation
6. After inserting an OPA, your partner delivers BVM ventilations and bilateral chest rise is observed. The patient then begins to gag. What is the priority action?
Airway, Respiration, and Ventilation
7. A patient is found unconscious after a fall from a second-story window. You note clear fluid draining from one nostril and bruising appearing behind both ears. Which airway adjunct is contraindicated?
EMS Operations / Certification Requirements
8. On the NREMT psychomotor skill evaluation for basic airway adjuncts, a critical criteria failure means:
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