Who does this guideline apply to?

This guideline applies to all persons who need airway management. Airway management is required to provide an open airway when a person is unconscious, has an obstructed airway, or needs rescue breathing.

Who is the audience for this guideline?

This guideline is for use by bystanders, first aiders or first aid providers, first responders and health professionals.

Recommendations

The Australian and New Zealand Committee on Resuscitation (ANZCOR) makes the following recommendations:

1. Check for danger (assess and manage risks to the rescuer and others)
2. In an unconscious person, care of the airway takes precedence over any injury, including the possibility of spinal injury.
3. To assess breathing and airway, leave the person in the position in which they have been found, unless fluid or matter obstructs the airway.
4. To clear the airway the mouth should be opened and the head turned slightly downwards to allow any obvious foreign material (e.g. food, vomit, blood and secretions) to drain.
5. If the airway becomes compromised during resuscitation, promptly roll the person onto their side to clear the airway. Once the airway is clear, reassess for responsiveness and normal breathing. If the person is unresponsive and not breathing normally, follow ANZCOR Basic Life Support Flowchart (Guideline 8).
6. For an unresponsive adult or child, open the airway using the head tilt-chin lift. For an infant, open the airway by placing the head in the neutral position and support the jaw from falling back.
7. Manage Foreign Body Airway Obstructions using the Choking Algorithm (Figure 4).

When someone is unconscious, all muscles are relaxed. If they are left lying on their back, the tongue, which is attached to the back of the jaw, falls against the back wall of the throat and blocks air from entering the lungs. Other soft tissues of the airway may worsen this obstruction. The mouth falls open but this tends to block, rather than open, the airway.

The unconscious person is further at risk because of being unable to swallow or cough out foreign material in the airway. This may cause airway obstruction, or laryngeal irritation and foreign material may enter the lungs. For this reason the rescuer should not give an unconscious person anything by mouth, and should not attempt to induce vomiting. 

If foreign material irritates the vocal cords, a protective reflex muscular spasm (laryngeal spasm) prevents the entry of material into the lungs. This may result in partial or complete airway blockage of the entrance to the trachea (windpipe) with the person often making an abnormal noise (stridor) during attempts to breathe. Airway closure due to laryngeal spasm can be complete; in this case there is no noise (stridor) because there is no airflow. That can persist until the person becomes blue or unconscious from lack of oxygen. When consciousness is lost, the spasm usually relaxes.

In an unconscious person, care of the airway takes precedence over any injury, including the possibility of spinal injury (Refer to Guideline 9.1.6). All who are unconscious should be handled gently with no twisting or bending of the spinal column and especially the neck.¹ If it is necessary, move the head gently to obtain a clear airway. Where possible, an assistant should support the head when an injured person is being moved, but no time should be wasted in detailed positioning.

The person should not be routinely rolled onto the side to assess airway and breathing—leave them in the position in which they have been found. This has the advantages of simplified teaching, taking less time to perform and avoids movement. The exceptions to this would be where the airway is obstructed with fluid (water or blood) or matter (sand, debris, vomit). Here, the person should be promptly rolled onto their side to clear the airway.

The mouth should be opened and the head turned slightly downwards to allow any obvious foreign material (e.g. food, vomit, blood and secretions) to drain. Loose dentures should be removed, but well-fitting ones can be left in place. Visible material can be removed by using the rescuer’s fingers.  Case series reported the finger sweep as effective for relieving foreign body airway obstruction (FBAO) in unconscious adults and children aged >1yr. However, five case reports documented harm to the person’s mouth or biting of the rescuer’s finger².

If the airway becomes compromised during resuscitation, promptly roll the person onto their side to clear the airway. Once the airway is clear, reassess for responsiveness and normal breathing, then begin resuscitation as appropriate following the ANZCOR Basic Life Support Flowchart (Guideline 8).

Regurgitation is the passive flow of stomach contents into the mouth and nose. Although this can occur in any person, regurgitation and inhalation of stomach contents is a major threat to an unconscious person. It is often unrecognised because it is silent and there is no obvious muscle activity. Vomiting is an active process during which muscular action causes the stomach to eject its contents.

In resuscitation, regurgitation and vomiting are managed in the same way: by prompt positioning the person on their side and manual clearance of the airway prior to continuing rescue breathing.

If the person begins to breathe normally, they can be left on their side with appropriate head tilt. If not breathing normally, the person must be rolled on their back and resuscitation commenced.

Airway management is required to provide an open airway when the person:

• is unconscious
• has an obstructed airway
• needs rescue breathing.

For unresponsive adults and children, it is reasonable to open the airway using the head tilt-chin lift manoeuvre.² [Good practice statement] For lay rescuers performing compression-only CPR, there is insufficient evidence to recommend the use of any specific passive airway manoeuvre.² However, the value of maintaining an unobstructed airway is recognised. [Good practice statement]

Airway obstruction may be partial or complete, and present in the conscious or the unconscious person. Typical causes of airway obstruction may include, but are not limited to:

• relaxation of the airway muscles due to unconsciousness
• inhaled foreign body
• trauma to the airway
• anaphylactic reaction.

The symptoms and signs of obstruction will depend on the cause and severity of the condition. Airway obstruction may occur gradually or suddenly, and may lead to complete obstruction within a few seconds. As such the person should be observed continually.

In the conscious person who has inhaled a foreign body, there may be extreme anxiety, agitation, gasping sounds, coughing or loss of voice. This may progress to the universal choking sign, namely clutching the neck with the thumb and fingers (as shown in Figure 3).

Figure 3: Universal choking sign

Airway obstruction will cause the diaphragm muscle to work harder to achieve adequate ventilations. The abdomen will continue to move out but there will be loss of the natural rise of the chest (paradoxical movement), and in-drawing of the spaces between the ribs and above the collar bones during inspiration.

Partial obstruction can be recognised where:

• breathing is labored
• breathing may be noisy
• some escape of air can be felt from the mouth.

Complete obstruction can be recognised where:

• there may be efforts at breathing
• there is no sound of breathing
• there is no escape of air from nose and/or mouth.

Airway obstruction may not be apparent in the non-breathing unconscious person until rescue breathing is attempted.

A Foreign Body Airway Obstruction (FBAO) is a life-threatening emergency. Chest thrusts or back blows are effective for relieving FBAO in conscious adults and children with low risk of harm (only 4 observational studies report harm from back blows and 5 observational studies report harm from chest thrusts).^3-5 Life-threatening complications associated with use of abdominal thrusts (including the Heimlich Manoeuvre) have been reported in  52 observational studies.^3-5  Therefore, the use of abdominal thrusts in the management of FBAO is not recommended and, instead back blows and chest thrusts should be used. [Good practice statement] These techniques should be applied in rapid sequence until the obstruction is relieved. More than one technique may be needed: there is insufficient evidence to determine which should be used first.

1. Hood N, Considine J. Spinal immobilisaton in pre-hospital and emergency care: a systematic review of the literature. Australasian Emergency Nursing Journal 2015;18:118-37.
2. Koster RW, Sayre MR, Botha M, et al. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81:e48-e70.
3. Olasveengen TM, Mancini ME, Perkins GD, et al. Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020;142:S41-S91.
4. Olasveengen TM, Mancini ME, Perkins GD, et al. Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020;156:A35-A79.
5. Couper K, Abu Hassan A, Ohri V, et al. Removal of foreign body airway obstruction: A systematic review of interventions. Resuscitation 2020;156:174-81.

ANZCOR Guideline 9.1.6 Management of Suspected Spinal Injury