Airway, Respiration, and Ventilation
Open it, clear it, and know when to breathe for them
Nothing on this exam, and nothing in the field, kills faster than a failed airway. The NREMT weights this domain heavily and loves to test one specific judgment over and over: is this patient breathing adequately, or do I need to breathe for them. Get that decision right and half the airway questions fall over.
Anatomy the exam cares about
In an unresponsive patient, the most common airway obstruction is the tongue falling against the back of the throat, which is why positioning fixes so many airways. The epiglottis guards the trachea during swallowing. Pediatric airways differ in ways the exam tests: a proportionally larger tongue, a larger head that flexes the neck, and a narrower, softer airway, so padding under the shoulders and gentle positioning matter in small children.
Opening the airway
For a medical patient with no reason to suspect spinal injury, use the head-tilt chin-lift. For any patient with a suspected spinal injury, use the jaw thrust so the neck stays in line. If the jaw thrust fails to open the airway of a trauma patient, the airway wins: carefully open it anyway, because a dead patient with a perfectly aligned spine is still dead.
An oropharyngeal airway (OPA) goes only in a patient with no gag reflex, sized from the corner of the mouth to the earlobe. A nasopharyngeal airway (NPA) is tolerated by patients with a gag reflex, sized from the nostril to the earlobe, lubricated, bevel toward the septum. Neither replaces positioning; both keep the tongue off the back of the throat.
Do not insert an NPA when you suspect a basilar skull fracture, signaled by blood or fluid from the ears or nose, raccoon eyes, or bruising behind the ears. And if a patient gags on an OPA, remove it immediately and be ready to suction.
Suction and oxygen
Suction only what you can see, and only on the way out. Limit each pass to about 15 seconds in an adult, 10 in a child, and 5 in an infant, because suction removes oxygen along with the vomit. If the patient needs suction and ventilation at the same time, suction first: forcing air over vomit pushes it into the lungs.
Know your delivery numbers cold.
- Nasal cannula: 1 to 6 liters per minute, delivering roughly 24 to 44 percent oxygen.
- Non-rebreather mask: 10 to 15 liters per minute with the reservoir bag inflated, delivering up to about 90 percent.
Current practice titrates oxygen to keep saturation at 94 percent or better rather than flooding every patient, but a hypoxic patient still gets high-flow oxygen without apology.
Ventilate or oxygenate?
Adequate breathing in an adult is roughly 12 to 20 breaths per minute with good tidal volume, regular effort, and normal mental status. That patient gets oxygen as needed.
Inadequate breathing, meaning too slow, too fast to move real volume, shallow, labored to the point of exhaustion, or paired with altered mental status, gets ventilated with a bag-valve mask.
Rate matters: about one breath every 6 seconds for an adult, one every 2 to 3 seconds for infants and children, each over one second, just enough volume to see the chest rise.
Two rescuers beat one every time. One holds a two-handed mask seal with a jaw lift while the other squeezes. Watch for chest rise, and resist the urge to bag hard and fast: overventilation inflates the stomach, causes vomiting, and drops blood return to the heart.
Respiratory emergencies you will be tested on
- Asthma presents with wheezing and a prolonged exhale; you may assist the patient with their own prescribed metered-dose inhaler per protocol or medical direction.
- Chronic obstructive pulmonary disease (COPD) patients live with chronically poor gas exchange, and current teaching is simple: never withhold oxygen from a hypoxic COPD patient, just monitor them.
- Pulmonary edema from heart failure presents with crackles at the lung bases, breathlessness lying flat, and sometimes pink frothy sputum: sit them upright, give oxygen, and use continuous positive airway pressure (CPAP) where your protocols allow.
When a stem describes slow, shallow, or gurgling respirations with decreased responsiveness, the answer is never a non-rebreather. Oxygen delivery devices require adequate breathing. Inadequate breathing means suction if needed, open the airway, and ventilate with a BVM.