In the unconscious patient, who is not breathing and has no pulse, there can be several mechanisms of airway obstruction resulting from a variety of causes (Figure RS.2).

The commonest of these is backward displacement of the tongue and epiglottis in the unconscious supine patient. Three manoeuvres can be used to create a clear upper airway (ERC 1996). Head tilt achieves lower cervical spine flexion and extension of the head at the atlanto-occipital joint, and chin lift is then added to improve the airway. Jaw thrust can further displace the tongue and in addition the thumbs can be used to open the mouth. This technique can be useful if a cervical spine fracture is suspected. It should be used in conjunction with inline stabilisation of the head and neck by another helper and if the base of the thumbs are placed over the maxilla during jaw thrust, some further control of head stability can be assured. With the airway presumed to be clear from tongue obstruction, assessment should be made to look, listen and feel (Figure RS.3).



in the mouth for a foreign body for cyanosis for rise and fall of the chest


for breath sounds (normal or abnormal)


for air flow at the mouth for chest movements for tracheal position for chest abnormalities, e.g. surgical emphysema

Figure RS.3

If the patient is breathing spontaneously and there is evidence of expired air, obstruction is not present. It must be emphasised that if the patient is apnoeic, then it is not until an applied ventilatory volume is given and is seen to produce rise and fall of the chest, that the airway can be confirmed as being clear.

Upper Airway Obstruction by a Foreign Body

Obstruction of the airway by a foreign body is an important diagnosis, which needs to be made swiftly in the patient who has not deteriorated to the point of cardiorespiratory arrest. Whether or not consciousness has been lost, if the patient is still making efforts to breathe, then the degree of obstruction can be assessed. Partial obstruction is indicated by noisy, stridulous breathing with respiratory distress. The conscious patient will also be coughing and indicating choking by clutching their neck. If there is cyanosis and distress, intervention is needed urgently. Complete obstruction is not accompanied by any air flow and is, therefore, silent. Treatment of the choking patient depends upon whether they are conscious or unconscious and recently new guidelines for management have been issued (Figure RS.4).

The best treatment for the conscious patient is encouragement to cough. If this fails or if the patient is already unconscious five back blows (hitting with the heel of the hand between the patient's scapulae) may dislodge an impacted foreign body. Anterior chest thrusts, similar to closed chest compressions but slower, may be used. A finger sweep can be performed but only in adults, and in patients who will not gag or bite. The Heimlich manoeuvre of subdiaphragmatic or abdominal thrusts can cause visceral damage and again should only be used in adults. The fist should be placed well below the xiphisternum and five firm inward and upward thrusts should be given. The basic life support methods of airway assessment should then be used to recheck airway patency and presence of ventilation. Failure to clear the airway will inevitably progress to cardiorespiratory arrest and then management of the airway continues to be a priority, necessitating urgent intubation or even a surgical airway (see later).

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