# Basic Airway Manoeuvres

## Overview

This module describes the head-tilt chin-lift and jaw thrust manoeuvres to assist with opening the airway. In basic life support, they are often followed by insertion of airway adjuncts such as an oropharyngeal airway or nasopharyngeal airway.

## Indications

1. Impaired consciousness but still breathing independently
2. Assisted ventilation or advanced airway interventions
3. Jaw thrust indicated in suspicion of cervical spine trauma or with limited neck movement

## Contraindications

1. Head-tilt chin-lift is contraindicated in suspicion of cervical spine trauma or with limited neck movement

## Patient information & consent

This procedure is usually done as an emergency measure with an unconscious patient. However, it may be explained to family members afterwards.

### How do I explain this procedure?

“I have to put the patient’s neck and jaw in the best position to open their airway and help them breathe.”

## Preparation

Follow the Basic or Advanced Cardiac Life Support algorithm, which starts with checking that the environment is safe.

## Site & Positioning

The patient should be lying on their back. These manoeuvres are best performed from behind the head of the bed.

For patients with no spinal movement restrictions, the ear lobe should ideally be in line with the sternal notch.

## Procedure

### Head-tilt chin-lift

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene. Don non-sterile gloves.
2. Check patient positioning— aim for earlobe in line with sternal notch using folded blankets or sheets.
3. Push down on the patient’s forehead to tilt the head back.
4. Use your fingers to hook under the bony part of the chin and pull to the ceiling to open the airway.
5. Hold to keep the airway open. Consider OPA or NPA.

### Jaw thrust

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene. Don non-sterile gloves.
2. Check patient positioning— aim for earlobe in line with sternal notch using folded blankets or sheets.
3. Place your palms on the patient’s temples.
4. Hook your fingers behind the angles of the mandible and push up to the ceiling. The lower incisors should be higher than the upper incisors.
5. Hold to keep the airway open. Consider OPA or NPA.
6. Bagging may be initiated using two-handed mask seal technique. Remember to pull the jaw into the mask rather than squashing the mask onto the face. An assistant is required to squeeze the bag.
7. You know that the manoeuvre is successful when there is no snoring or resistance to ventilation, such as the bag-valve-mask valve popping

## Troubleshooting

The patient is very obese and the earlobe is not in line with the sternal notch.

You may need to build a ramp of sheets, towels or blankets under the patient’s neck and shoulders so that their ear and sternal notch are aligned, which facilitates air movement.

I am having difficulty ventilating the patient.

Check your own body position and that you are not leaning onto the patient. Consider using an OPA or NPA (or both) as tolerated by the patient, and build a ramp as above if no spinal injury is suspected. Use two-handed mask seal technique for bagging.

## Risks

1. Spinal cord injury if there is a pre-existing spinal injury
2. Exacerbation of facial injuries

## References

1. Habrat D. (2019). How To Do Head Tilt–Chin Lift and Jaw-Thrust Maneuvers. In: Merck Manual Professional Version. Available from: https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-basic-airway-procedures/how-to-do-head-tilt-chin-lift-and-jaw-thrust-maneuvers
2. Albrecht E, Schoettker P. (2010). The Jaw-Thrust Maneuver. N Engl J Med 363:e32.