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. For lay rescuers performing compression-only CPR, there is insufficient evidence to recommend the use of any specific passive airway manoeuvre. However, the value of maintaining an unobstructed airway is recognised.

One hand is placed on the forehead or the top of the head. The other hand is used to provide Chin Lift. The head (NOT the neck) is tilted backwards (see Figure 1). It is important to avoid excessive force, especially where neck injury is suspected. When the person is on their side, the head will usually remain in this position when the rescuer’s hands are withdrawn.

Figure 1: Head tilt/chin lift manoeuvre

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Chin lift is commonly used in conjunction with Backward Head Tilt. The chin is held up by the rescuer’s thumb and fingers in order to open the mouth and pull the tongue and soft tissues away from the back of the throat.

A suggested technique is to place the thumb over the chin below the lip and supporting the tip of the jaw with the middle finger and the index finger lying along the jaw line. Be careful that the ring finger does not squash the soft tissues of the neck. The jaw is held open slightly and pulled away from the chest.

An infant is defined as younger than one year, a child as one to eighteen years of age (or up to onset of puberty if the age is unknown). In both cases the principle is to maintain an open airway.

Children

Children should be managed as for adults.

Infants

In an infant, the upper airway is easily obstructed because of the narrow nasal passages, the entrance to the windpipe (vocal cords) and the trachea (windpipe). The trachea is soft and pliable and may be distorted by excessive backward head tilt or jaw thrust. Therefore, in an infant the head should be kept neutral and maximum head tilt should not be used (Figure 2). The lower jaw should be supported at the point of the chin while keeping the mouth open. There must be no pressure on the soft tissues of the neck. If these manoeuvres do not provide a clear airway, the head may be tilted backwards very slightly with a gentle movement. [Good practice statement]

Figure 2: Infant in neutral position

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Infant in Neutral Position

(Reproduced Courtesy of European Resuscitation Council)

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).

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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.

All rescuers, including health care professionals, should use unresponsiveness and absence of normal breathing to identify the need for resuscitation.1-4 [Good practice statement] Palpation of a pulse is unreliable and should not be performed to confirm the need for resuscitation

Infants

In infants, ANZCOR suggests the two finger technique should be used by lay rescuers in order to minimise transfer time from compression to ventilation. Having obtained the compression point the rescuer places two fingers on this point and compresses the chest (Figure 2). [Good practice statement]

Figure 2: Method of compression for infants

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Children and Adults

Either a one or two hand technique can be used for performing chest compressions in children.

Administering compressions using one- and two-handed techniques

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                    Child Placement        Adult Placement 

Interruptions to chest compressions must be minimized. A person requiring chest compressions should be placed on their back on a firm surface before commencing chest compressions to optimise the effectiveness of compressions. Compressions should be rhythmic with equal time for compression and relaxation. The rescuer must avoid either rocking backwards and forwards, or using thumps or quick jabs.  Rescuers should allow complete recoil of the chest after each compression.

Depth of Compressions

The lower half of the sternum should be depressed approximately one third of the depth of the chest with each compression. This equates to more than 5cm in adults, approximately 5cm in children and 4 cm in infants. 

Rate of Compressions 

Rescuers should perform chest compressions for all ages at a rate of 100 to 120 compressions per minute (almost 2 compressions/second).

 

AED use should not be restricted to trained personnel. Allowing the use of AEDs by individuals without prior formal training can be beneficial and may be life saving. Since even brief training improves performance (e.g. speed of use, correct pad placement), it is recommended that training in the use of AEDs (as a part of BLS) be provided.

The use of AEDs by trained lay and professional responders is recommended to increase survival rates in those who have cardiac arrest.2  

AED Pad placement

Anterior-lateral pad placement

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Avoid placing pads over implantable devices.  If there is an implantable medical device the defibrillator pad should be placed at least 8cm from the device. Do not place AED electrode pads directly on top of a medication patch because the patch may block delivery of energy from the electrode pad to the heart and may cause small burns to the skin.