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I remember the first time I had to manually hold a patient’s airway and was astounded at how such a simple maneuver could have such a drastic result. But I also remember being pretty nervous about it, especially since it wasn’t something I’d had to do much as an ICU nurse. After all, many of my patients were intubated, meaning their airways were protected and maintained with endotracheal tubes. It wasn’t until I transferred to the PACU that I got a lot of exposure to compromised airways. In this article, I’m covering why soft tissue obstructions occur, the basics of airway management, and the appropriate techniques and tools to use. So, if you want to get more confident with airway management, keep reading!
When to manage an airway
Situations where a patient would need airway management include:
- Sedated Patients: Patients who are still ventilating but may have an obstructed airway due to sedation, such as those recovering from anesthesia or who have received opioids.
- Basic Life Support: In scenarios involving obtunded or unresponsive patients – remember the ABCs from your BLS class?
- During Anesthesia Recovery: Post-anesthesia care often involves maintaining airway patency to ensure that the patient maintains optimal oxygenation.
- Confirming Apnea: If you open the airway and there’s no air movement, the patient needs immediate ventilation as well as airway management.
Why do airway obstructions occur?
A common reason for airway compromise in the clinical setting is soft tissue obstruction. This occurs when the tongue falls back into the posterior pharynx, which may also be combined with a loss of muscular tone in the soft palate. As a former PACU nurse, I can tell you these obstructions are prevalent in the post-op phase of care, where they account for a significant number of airway related complications. But just because something is common, doesn’t mean it isn’t serious. A key skill to develop is recognizing signs of airway obstruction. So, how do you do that?
Recognizing and responding to airway obstruction
Signs of particle obstruction include audible sounds (such as snoring) with or without accessory muscle use. A complete soft tissue obstruction involves no sound since no air is moving. What you will see, however, is accessory muscle use as the patient tries to move air. Left untreated, a complete obstruction can progress quickly to cyanosis which is a bluish discoloration to the patient’s skin. A patient who has a complete obstruction requires immediate intervention to restore airflow and airway patency.
Optimal positioning for airway patency
The optimal position for airway management is the sniffing position. In sniffing position, the external auditory canal is in line with the sternal notch. View pictures of how to achieve sniffing position here. Here are some key things to know:
- Anatomy varies widely, so you may need to make adjustments to lift the head and achieve the correct alignment.
- Adjustments may include placing pillows or folded blankets under the head or shoulders to achieve this alignment.
- Infants have large occiputs, so this usually means placing a folded towel underneath the shoulders.
- Larger adults may need extensive use of pillows, blankets, or wedges to get the body into proper alignment.
Sometimes, sniffing position will work on its own, but if it doesn’t then it’s time to consider a manual hold or an airway adjunct. Let’s start by talking about manual holds.
Head tilt-chin lift
The first thing to know about the HTCL maneuver is who to not use it on – and that is a patient with confirmed or suspected cervical spine injury. And yes, cervical spine surgery counts as an injury. To perform this maneuver, just follow these simple steps:
- Push down on the forehead with one hand to tilt the patient’s head back.
- With the other hand, use the tips of your index and middle fingers to pull up on the mandible. Be careful to avoid the soft tissue of the neck which could worsen the obstruction.
This maneuver lifts the tongue away from the posterior pharynx and opens the airway.
Jaw thrust maneuver
Another method of opening the airway is the jaw thrust maneuver. This is the preferred method for patients with cervical spine injury, but just be careful not to extend the neck as this could cause further injury. To perform a jaw thrust maneuver, follow these simple steps:
- Stand at the head of the bed and place your palms on the patient’s temples and your fingers under the mandible. Again, be careful you’re not pressing on soft tissue, as this can worsen the obstruction.
- Next, lift the mandible upward with your fingers. You want to lift at least until you see the lower incisors are pushed up higher than the upper incisors. Again, be careful you are not extending the neck in your cervical spine injury patients!
Using airway adjunct devices
In cases where manual methods are insufficient or you’re anticipating a long hold time, airway adjunct devices like the oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) become vital. Another instance you may want to consider using an adjunct is if you are manually bagging a patient with a BVM. With manual bagging, it is possible to push down on the chin as you work to keep the seal intact. So, using an OPA or NPA helps keep the airway patent as you ventilate the patient.
The key things to understand are proper measurement and insertion of these devices.
Oropharyngeal Airway (OPA)
An OPA is used only in unconscious patients without a gag reflex. If you were to use an OPA on a patient with a gag reflex, this can induce vomiting which can lead to aspiration.
To size an OPA:
- Place the device against the side of the patient’s face with the flange at the corner of the mouth and the tip pointing down.
- The end of the device should reach to the angle of the mandible. If it’s too short or too long, grab a different device and try again.
- Too short of an OPA either won’t help at all or could worsen the obstruction.
- Too long of an OPA can cause laryngospasm, which is an airway emergency that you definitely want to avoid.
To insert an OPA:
- Before inserting the OPA, clear the oral cavity of any secretions.
- Adding lubricating jelly can make the insertion easier – just don’t use so much that it becomes an aspiration hazard.
- There are three ways to insert an OPA:
- The main method is to place it in the mouth with the curved end towards the roof of the mouth. As you advance the device and it nears the posterior pharynx, rotate it 180 degrees into the correct position (the tip pointing down).
- Another option is to use a tongue blade to press the tongue down and insert the OPA with the curved portion facing down.
- A third option is to point the tip toward the corner of the mouth, and rotate the device 90 degrees as it is advanced to the posterior pharynx.
- Once inserted, the flange should rest at the patient’s lip.
- Keep a close eye on the device to ensure it doesn’t become dislodged, which could compromise your patient’s airway.
You can view photos of how to size and insert an OPA here.
It is extremely important that you do not leave the patient’s side the entire time they have an OPA in place. First, you need to ensure it stays positioned optimally and that your airway remains patent. And secondly, as your patient wakes up, the gag reflex kicks in and they could start gagging and even vomit. Be ready with gloves and a tissue for quick removal once the patient’s gag reflex returns.
Contraindications for an OPA are:
- Patient with a gag reflex (hint, if they can cough, they have a gag reflex)
- Patient with oral trauma or a wired jaw
- Patient with oral trismus which includes spasms of the oral musculature
- Presence of a foreign body obstructing the airway
- Presence of a nasal fracture or actively bleeding nose
Complications of OPA use:
- Vomiting, which can lead to aspiration
- May worsen airway obstruction if the wrong size is utilized
- Larngyspasm
- Damage to the mouth or teeth during insertion
Nasopharyngeal Airway (NPA)
An NPA is suitable for patients who have a gag reflex but are obstructing their airway when not awake. A great example of this is the extremely drowsy patient who is waking up from surgery. When they’re awake, they’re able to maintain a patent airway, but when they drift off they begin occluding. Another example could be a patient undergoing sedation for a procedure.
To size an NPA, you’re looking at diameter and length:
- The diameter of the device should be just slightly smaller than the nare.
- To measure length, place the NPA on the side of the patient’s face with the flange at the nare. The device should angle down to the earlobe.
- If the NPA is too short, it will not be effective.
- If the NPA is too long, it will enter the larynx and cause gagging, or it will enter the vallecula which could potentially cause an airway obstruction.
- If you have to choose between length or diameter, length is the more important measurement to go by.
View this quick video by EMTPrep to see how to size an NPA.
To insert the NPA:
- Apply lubricating jelly to the device.
- Point the bevel toward the septum and follow the floor of the nasal cavity as you advance the NPA.
- If you meet resistance, you can rotate it slightly, but do not force the device forward. If you are unable to advance the NPA, withdraw and try on the other side.
- Examine the oral cavity. If the NPA is too large, you will be able to see that it is lower than the uvula. If this is the case, remove the device, measure again, and insert a smaller size.
As with an OPA, it is also imperative you stay at the patient’s bedside the entire time they have an NPA in place.
Contraindications for an NPA are:
- Basilar skull fractures, nasal fractures, facial trauma
- Any disruption to the nasopharynx, roof of mouth or midface
- Coagulopathy or use of anticoagulants (high risk for bleeding)
- Nasal obstruction such as choanal atresia
- Active sinus infection
- Suspected epiglottitis
- Recent nasal surgery
- Large nasal polyps
Potential complications of NPA use are:
- Vomiting and aspiration (typically occurs when NPA is too long)
- Intracranial insertion
- Airway obstruction due to improper sizing
- Epistaxis
- Gastric distension if the NPA is too large
- Turbinate fracture – fracture of bones within the nasal cavity
- Retropharyngeal laceration/dissection
- Sinusitis
So there you have it, your overview of airway management. Hopefully, you’re feeling more confident in your ability to handle a soft tissue airway obstruction. To learn more about the respiratory system, check out these articles here.
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The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.
References:
ACLS.com. (n.d.). Effective Use of Oropharyngeal and Nasopharyngeal Airways. Retrieved April 6, 2025, from https://acls.com/articles/nasopharyngeal-oropharyngeal-airways/
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Castro, D., & Freeman, L. A. (2025). Oropharyngeal Airway. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470198/
EMTPrep. (2017, September 8). How to size NPA [Video recording]. YouTube. https://www.youtube.com/watch?v=oJgpWPiH-Q4
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Kalra, A. (2024). Positioning Infants and Children for Airway Management. In Pediatric Anesthesia Digital Handbook. Tufts Medical Center. https://www.maskinduction.com/positioning-infants-and-children-for-airway-management.html
REAL First Aid. (2021, July 27). Basic Airways – OPAs & NPAs. REAL First Aid. https://www.realfirstaid.co.uk/basicairways
Snyders, S. (2014, January). 10 Tips for Effective Airway Management and Ventilation. EMSWorld. https://www.hmpgloballearningnetwork.com/site/emsworld/article/11264318/10-tips-effective-airway-management-and-ventilation
Tarantino, B. (2023, November 10). The Sniffing Position. The Protected Airway Collaborative. https://theprotectedairway.com/2023/11/10/the-sniffing-position/
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Last Updated on April 24, 2025 by Maureen Osuna, MSN, RN
