Opening the airway: head tilt, jaw thrust and simple adjuncts

What it is

In an unconscious patient the muscles that hold the tongue and soft palate forward relax, and they fall back against the posterior pharyngeal wall: this is the commonest cause of airway obstruction. Basic manoeuvres open the airway without any equipment. The head tilt–chin lift extends the neck at the atlanto-occipital joint and pulls the mandible, and with it the tongue, forward. The jaw thrust lifts the mandible forward from behind its angles with the head kept neutral, so it is the manoeuvre of choice when a cervical spine injury is possible. Simple adjuncts then keep the airway open with less effort. An oropharyngeal airway (Guedel type) is a curved rigid tube that holds the tongue away from the pharynx; it is tolerated only by deeply unconscious patients without a gag reflex. A nasopharyngeal airway is a soft tube passed through a nostril to sit behind the tongue; it is better tolerated in patients with a gag reflex, clenched teeth or seizures. Suction clears blood, vomit and secretions, and an obstructed airway is assessed by looking, listening and feeling for breathing. These steps come first in every airway algorithm and are often all that is needed before help arrives.

Indications

• Any patient with reduced consciousness and signs of airway obstruction: snoring, gurgling, paradoxical chest and abdominal movement.
• Cardiopulmonary resuscitation, before and during bag-mask ventilation.
• Post-ictal, intoxicated or sedated patients and patients recovering from anaesthesia.
• Oropharyngeal airway: deeply unconscious patients with no gag reflex, also as a bite block.
• Nasopharyngeal airway: semi-conscious patients, clenched jaw (trismus) or seizures, where an oral airway cannot be placed.

Contraindications and precautions

• Possible cervical spine injury: avoid head tilt; use jaw thrust with manual in-line stabilisation.
• Oropharyngeal airway with an intact gag reflex: can provoke vomiting and laryngospasm.
• Nasopharyngeal airway: avoid with suspected base-of-skull fracture (raccoon eyes, Battle's sign, CSF leak) or severe facial fractures.
• Nasopharyngeal airway: caution with coagulopathy and nasal deformity, because of the risk of epistaxis.
• Foreign body or upper airway swelling (epiglottitis, angioedema): simple adjuncts may not help; call for expert help early.

Equipment

• Gloves, eye protection and other personal protective equipment.
• Oropharyngeal airways in a range of sizes.
• Nasopharyngeal airways in a range of sizes, with water-based lubricant.
• Rigid wide-bore suction catheter (Yankauer type) with working suction.
• Oxygen with a face mask, pulse oximeter, and a bag-valve-mask ready for the next step.

Step by step (and why)

1. Check the scene is safe, call for help and look for a response — a responsive patient usually protects their own airway.
2. Look in the mouth and remove visible debris with suction or forceps under vision — blind finger sweeps push objects deeper.
3. Head tilt–chin lift: hand on the forehead, fingertips under the bony chin — lifting the jaw pulls the tongue forward.
4. If the neck may be injured, do a jaw thrust from above the head, fingers behind the angles — it opens the airway without moving the neck.
5. Look, listen and feel for breathing for up to 10 seconds — this confirms the airway is open and finds cardiac arrest.
6. Size an oral airway from incisors to jaw angle; insert upside down and rotate 180° (adult) — the curve follows the tongue.
7. In a child, insert the oral airway the right way up over a tongue depressor — rotating it can injure the soft palate.
8. For a nasal airway, measure nostril to tragus, lubricate and pass it straight back along the nasal floor — not upwards towards the skull base.
9. Reassess breathing, give oxygen and keep the manoeuvre going while the adjunct is in — an adjunct does not replace the jaw lift.

Oral versus nasal airway.

Complications

• Vomiting, aspiration and laryngospasm when an oral airway is placed in a patient with a gag reflex.
• Worse obstruction from an airway that is too long (pushes the epiglottis down) or too short (pushes the tongue back).
• Epistaxis, mucosal tear and, rarely, intracranial placement of a nasal airway through a skull-base fracture.
• Dental, lip and soft palate injury during insertion.
• Cervical cord injury if the neck is extended in an unstable spine.

Next step

• If the patient is not breathing normally, start CPR and bag-mask ventilation at once.
• If the airway cannot be kept open with manoeuvres and adjuncts, call the senior airway clinician for a supraglottic device or intubation.
• Give oxygen to the target saturation and monitor saturation, breathing and consciousness continuously.
• Treat the cause of the reduced consciousness: check glucose, look for opioids, seizures or a head injury.
• When breathing well without a suspected spinal injury, place the patient in the recovery position and keep watching.

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Elsewhere in DurgiPedia

• Bronchial obstruction syndrome
• Airway suctioning: oral, nasal and artificial airways
• Basic life support from the nursing side

Connections

← All clinical skills

Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: Airway Management (StatPearls (NCBI Bookshelf), 2025); Oropharyngeal Airway (StatPearls (NCBI Bookshelf), 2023); Nasopharyngeal Airway (StatPearls (NCBI Bookshelf), 2024).

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Representative model, for educational purposes only.