Overview: Airway & Breathing
Without enough oxygen, a patient dies within minutes. Out here you'll find and manage airway and breathing problems without advanced equipment, mostly with your hands and how you position the patient.
These kill fast. Airway and breathing problems can kill in minutes. You find and manage them in the primary survey, the A and B of XABCDE.
Why it's harder out here
- Remote location: You may not have advanced airway equipment. Positioning and manual maneuvers are your main tools.
- Delayed evacuation: You may have to keep an airway open for hours before rescue can reach you.
- Altitude effects: There's less oxygen at elevation, and that makes any breathing problem worse.
- Cold/heat: Extreme cold or heat changes how fast and how hard people breathe.
Key points
In an unconscious patient, the tongue is the most common cause of airway obstruction.
A choking patient with an effective cough needs encouragement. Go hands-on only when the cough fails.
Rescue breathing is a core skill at this level. It can keep someone alive until help arrives.
Wilderness CPR can run long. Don't assume a hypothermic patient is dead.
Airway Management
Airway anatomy
Where air goes, and where it gets stuck:
- Nose/Mouth: where air gets in
- Pharynx: the throat, and a common spot for blockage from the tongue, blood, vomit, or swelling (edema).
- Larynx: the voice box. It can swell from an allergic reaction or trauma.
- Trachea: the windpipe, the main airway to the lungs
- Bronchi: the right and left branches, one into each lung
Common causes of obstruction
- Tongue (most common in unconscious patients): it relaxes and falls back across the pharynx
- Foreign body: food, a rock, dentures, vomit
- Blood/Vomit: fluid blocks the airway
- Swelling (edema): from an allergic reaction, infection, inhalation injury, or trauma
- Direct injury: trauma to the neck, or direct damage to the larynx
Opening techniques
Both techniques below lift the tongue off the back of the throat so air can move again.
Snoring or gurgling in an unresponsive patient is a blocked airway. Don't wait for it to get worse. Open the airway, and if they're breathing, roll them onto their side.
Head-tilt chin-lift
- When to use: no concern for a spinal injury
- How: put one hand on the forehead and gently tilt the head back. Put the fingers of your other hand under the chin and lift. That pulls the tongue off the pharynx.
- Advantage: opens the airway in most cases
- Disadvantage: can make a neck (cervical spine) injury worse, if there is one
Jaw thrust
- When to use: suspected spinal injury (trauma, a fall, unknown mechanism)
- How: grip the angles of the jaw (mandible) from below and behind, and pull it forward without tilting the head. The cervical spine stays in line.
- Advantage: opens the airway and protects the cervical spine
- Disadvantage: harder to do, and it takes practice
Practice first. The jaw thrust is harder than the head-tilt chin-lift. Practice it on a friend at home before you need it on a scree slope.
Recovery position
When to use: an unconscious patient who's breathing, with no concern for a spinal injury
- Roll the patient onto their side
- Rest the head on the extended arm to keep the airway open
- Bend the top leg so they don't roll
- Why: if they vomit, it drains out of the mouth instead of going into the lungs (aspiration)
- Monitor: watch for vomiting, keep the airway positioned, and recheck breathing
Suctioning and clearing the airway
- Patient positioning: on their side with the mouth angled down, so gravity drains the fluid. With a spine concern, roll them as one unit with the head in line.
- Finger sweep: only if you can actually see the object. Never do a blind finger sweep in an adult. You can push the blockage deeper.
- Patient coughing: if they're conscious or semi-conscious, encourage them to cough out the fluid or foreign material
- Suction improvisation: no suction device? Roll them onto their side and let gravity work.
Choking (foreign body airway obstruction)
When a conscious patient chokes, on food or anything else, you have one question to answer fast. Is their cough working?
- Universal choking sign: hands clutched to the throat. Recognize it and move.
- Ask: "Are you choking? Can you speak?" The answer decides what you do next.
- Effective cough: they can speak, cry out, or cough forcefully. Their own cough clears an obstruction better than anything you can do. Encourage the coughing, stay close, and watch. Do not step in physically.
- Ineffective (silent) choking: can't speak, a weak cough or none, a high-pitched noise on the in-breath, turning blue (cyanosis). The airway is blocked. Act now.
Silent means minutes. A choking patient who can't make a sound will pass out within minutes. If they can't speak or cough forcefully, start back blows and abdominal thrusts right away.
Relieving choking: conscious adult or child
- 5 back blows: lean them forward and give 5 firm blows between the shoulder blades with the heel of your hand.
- 5 abdominal thrusts: stand behind them. Put a fist, thumb side in, just above the navel. Grab it with your other hand and pull sharply in and up.
- Alternate: keep cycling 5 back blows and 5 abdominal thrusts until the object comes out or they go unresponsive
- Pregnant or very large patients: use chest thrusts instead of abdominal thrusts. Fist on the center of the breastbone, thrust straight back.
- Choking while alone: give yourself abdominal thrusts with your own fist, or drive your upper abdomen against a firm edge like a chair back, a log, or a boulder
- Infants (under 1 year): alternate 5 back slaps and 5 chest thrusts. Never abdominal thrusts.
Eating on the move. Watch for dry jerky and hard candy eaten on a river trip or a bumpy ride, especially by someone laughing mid-bite. Have people slow down to eat, and keep an eye on the group at meal breaks.
If the choking patient goes unresponsive
- Lower them carefully to the ground, and send someone for help if anyone else is there.
- Start CPR, beginning with compressions. Compressions raise the pressure in the chest and may dislodge the object.
- Look before you breathe: before each set of breaths, open the mouth and look. Take an object out only if you can see it. No blind finger sweeps, same rule as clearing the airway above.
Aftercare:
- Medical evaluation: anyone who got abdominal thrusts needs a medical evaluation. The thrusts can cause internal injury.
- Far from help: a partial obstruction far from help is an airway emergency. Lower your threshold for evacuation. A "mostly cleared" airway can swell or block again.
Airway adjuncts (reference only)
What EMS will do: EMS carries airway adjuncts, the nasopharyngeal airway (NPA) and the oropharyngeal airway (OPA), to help hold an unconscious patient's airway open. Using them is beyond the scope of this course. Your tools are positioning. A head-tilt chin-lift or jaw thrust opens the airway, and the recovery position protects it.
Breathing Emergencies
Recognizing respiratory distress
Signs a patient is struggling to breathe:
- Rate: normal for an adult is 12-20 a minute. Over 20 is fast (tachypnea) and worth watching. Under 10 (bradypnea) or over 30 is a red flag.
- Accessory muscle use: the neck muscles (SCM) and the muscles between the ribs (intercostals) are working hard
- Nasal flaring: the nostrils widen with each breath, a sign of effort
- Pursed lips: they're breathing against resistance
- Tripod position: sitting forward, braced on their hands, to bring in the accessory muscles
- Abnormal sounds: stridor (a high-pitched sound on the in-breath), wheezing, gurgling, snoring
Silent isn't better. A silent chest (no breath sounds) in a patient in respiratory distress means almost no air is moving. Help with their own inhaler (or their epinephrine auto-injector if it's anaphylaxis), get the fastest evacuation you can, and be ready to start CPR if they stop breathing normally.
Asthma in the field
- Common triggers: exercise, cold air, allergens, emotional stress
- Signs: wheezing, shortness of breath, chest tightness, cough
- Treatment:
- Sit them upright
- Help them use their own bronchodilator inhaler (albuterol/salbutamol): 4-10 puffs, through a spacer if they have one, repeated every 20 minutes for the first hour as needed
- Keep them calm. Anxiety makes bronchospasm worse.
- Oxygen, if you have it
- Hydration: encourage sips of water
- When to evacuate: if they're getting worse despite treatment, or their breathing isn't resolving (no real improvement within the first hour of treatment), that's an emergent evacuation.
- Status asthmaticus: a severe attack that isn't responding to bronchodilators. It can kill, and it needs an emergent evacuation.
Pneumothorax (collapsed lung)
- What it is: air gets into the space around the lung, and the lung collapses
- Signs: breath sounds quiet or absent on one side, chest pain, shortness of breath (dyspnea)
- Tension pneumothorax (an emergency): pressure builds and pushes on the heart and great vessels. Signs: the trachea shifts away from the affected side (tracheal deviation), bulging neck veins (JVD, jugular vein distension), low blood pressure, shock.
- Field recognition: your job is to recognize the pattern. The diagnosis and the real fix happen in a hospital.
- Field treatment: position of comfort, watch the airway, oxygen if you have it, emergent evacuation
High altitude pulmonary edema (HAPE)
- What it is: fluid fills the lungs because of pressure changes at altitude
- When it happens: usually above 2,500 m (8,000 ft), most often on day 2 or 3 at altitude
- Signs: cough, often with pink frothy sputum; crackles on auscultation (listening to the lungs); severe shortness of breath; more tired than everyone else
- Risk factors: fast ascent, exertion at altitude, a previous episode of HAPE, individual susceptibility
- Treatment: descend immediately. Even 500 m helps. Oxygen if you have it. Sit them upright. Do not delay the descent.
Chest injuries that affect breathing
Flail segment
- What: multiple rib fractures leave a segment that moves opposite to the rest of the chest (paradoxical motion)
- Signs: chest pain, shortness of breath, visible paradoxical motion
- Treatment: pain control; position of comfort, often lying injured side down; a bulky pad held gently over the segment for support; encourage deep breathing; evacuate. Don't tape or wrap anything around the chest. Binding it all the way around restricts breathing.
Open pneumothorax (sucking chest wound)
- What: a penetrating wound through the chest wall that lets air move in and out as they breathe
- Signs: a hole in the chest, air noises with each breath, shortness of breath
- Treatment: leave the wound open to the air, or cover it loosely with a dressing that doesn't seal (non-occlusive). Don't tape it down or seal it. A sealed wound can trap air in the chest and turn into a tension pneumothorax. If it's bleeding, control it with hand pressure over that loose dressing. Position of comfort, and watch for breathing getting worse. If it does and a dressing has stuck down, lift it off. Emergent evacuation.
CPR in the Wilderness
When to start CPR
- They're unresponsive: no response to your voice or to pain
- They're not breathing, or only gasping (agonal respirations)
- No pulse check. Unresponsive and not breathing means you start CPR.
Gasping doesn't count. It isn't normal breathing, and a patient who's gasping still needs CPR.
CPR technique
- Compression rate: 100-120 compressions a minute, roughly the beat of a fast song
- Depth: 2-2.4 inches (5-6 cm) for adults. "Push hard and fast."
- Hand position: heel of one hand on the center of the chest, the other hand on top, arms straight
- Full recoil: let the chest come all the way back up between compressions
CPR ratios and rescue breathing
- Adult CPR ratio: 30 compressions to 2 breaths (30:2). It's the same with one rescuer or two, and using an AED never changes it.
- Rescue breaths: the 2 breaths after every 30 compressions. You don't check for a pulse, so unresponsive and not breathing normally always means full CPR, compressions and breaths.
- What EMS will do: breaths-only rescue breathing (1 breath every 6 seconds) for a patient who has a pulse. It depends on a pulse check, so it's beyond this course.
- Breath technique: mouth-to-mouth or mouth-to-barrier
- Tilt the head back (if there's no spine concern)
- Pinch the nose, seal over the mouth, and blow for 1 second
- Give enough air to make the chest rise with each breath
Give breaths out here. Hands-only CPR (nonstop compressions, no breaths) is a fallback for presumed sudden cardiac arrest when you can't or won't give breaths. It beats no CPR at all. The arrests common in the wilderness are asphyxial, though, from drowning, avalanche burial, or airway obstruction. Those patients ran out of oxygen, so they need rescue breaths.
When to withhold or stop CPR
When not to start CPR:
- Obvious death: decapitation, rigor mortis, dependent lividity (purple discoloration where blood has pooled with gravity)
- Injuries incompatible with life
- Standing orders, or DNR (Do Not Resuscitate) documents
When to stop CPR:
- Signs of life (ROSC, return of spontaneous circulation): they start breathing normally, move, or respond
- Exhaustion: you physically can't keep doing CPR
- Prolonged cardiac arrest (generally 30 minutes) without ROSC in a patient with a normal body temperature (normothermic)
- The exception is hypothermia, including cold-water drowning. "No one is dead until warm and dead." If you suspect hypothermia, keep CPR going even after a prolonged arrest.
Hypothermia and cardiac arrest
Cold can look like death. A severely hypothermic patient may have a pulse you can't detect and look dead, and still be resuscitable.
- If you suspect hypothermia, keep CPR going during the evacuation
- Rewarming in a hospital (heart-lung bypass or ECMO in severe cases) can bring some patients back even after hours without a pulse
- There are case reports of full recovery after cardiac arrest from extreme hypothermia, with core temperatures under 20°C (68°F)
Don't call it early. A hypothermic patient isn't dead until they're warm and dead. Keep CPR going.
AED (automated external defibrillator)
- What it does: reads the heart rhythm and delivers a shock if the rhythm needs one
- Who has one: many wilderness rescue teams carry AEDs
- Wet patient: dry the chest before the pads go on
- Chest hair: press the pads on firmly. Dense hair can keep them from making contact. If the AED can't analyze, quickly shave the pad sites (most AED kits carry a razor for exactly this) or pull the hair off with the first set of pads and put on a fresh set.
- Pacemaker/ICD: place the pads clear of the implanted device if you can, but don't delay defibrillation
- Use: turn it on, follow the prompts, and keep up CPR between shocks
Case Scenarios
Scenario 1: Unconscious drowning victim on a riverbank
Setting: A friend pulls a swimmer out of the river. The swimmer is unconscious and not breathing. You're 2 miles from the trailhead with limited supplies and a satellite communicator.
What you do now:
- Lay them on their back on a firm surface
- Check responsiveness and breathing, taking no more than 10 seconds
- They're not breathing. Drowning is an asphyxial (oxygen-deprivation) arrest, so open the airway and give 2 rescue breaths first.
- Then continue CPR at 30 compressions to 2 breaths (30:2)
- Don't do hands-only CPR for drowning. The problem is a lack of oxygen, so they need the breaths.
- Call for a SAR helicopter on the satellite communicator without stopping CPR
Water in the lungs: Drowning patients may have inhaled (aspirated) water, and CPR may not work as well. Do it anyway.
Cold water: After a cold-water drowning, survival is possible even after a long time under. Keep CPR going. Do not stop because of how much time has passed.
Evacuation: Emergent. Keep CPR going through the evacuation. Stop only for ROSC, exhaustion, or definite signs of death.
Scenario 2: Asthma attack on a remote trail
Setting: A 35-year-old with known asthma is hiking at 9,000 ft. After a hard climb she starts wheezing and gets short of breath. She has her rescue inhaler (albuterol) and has used it, but she's getting more distressed and wheezier anyway.
What's going on:
- Respiratory distress: wheezing, shortness of breath, fast breathing
- She's likely using her accessory muscles
- She's anxious, and that makes the bronchospasm worse
What you do now:
- Stop, and sit her upright
- Help her use her own albuterol inhaler: 4-10 puffs, through a spacer if she has one, repeated every 20 minutes for the first hour as needed
- Keep her calm. Speak slowly and reassure her.
- Offer small sips of water
- Watch whether the inhaler is helping
Evacuation decision: Even if the wheezing improves, she rests and then heads down. After an attack this bad, lower your threshold for evacuation. If she's getting worse despite treatment, or her breathing isn't resolving, it's an emergent evacuation. At altitude, going lower helps on its own, because there's more oxygen down there.
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Lesson Summary
The short version
The tongue is the most common airway obstruction in an unconscious patient.
Use a jaw thrust if you're worried about the spine, and a head-tilt chin-lift if you're not.
The recovery position protects the airway if they vomit.
Choking with an effective cough: encourage the cough. Silent or ineffective: alternate 5 back blows and 5 abdominal thrusts until it clears or they go unresponsive.
If a choking patient goes unresponsive, start CPR with compressions. Look in the mouth before breaths. No blind finger sweeps.
Anyone who got abdominal thrusts needs a medical evaluation afterward.
Respiratory distress shows in the rate, effort, sounds, and how they position themselves.
Asthma: position them, help with their bronchodilator, keep them calm, and evacuate if they don't improve.
CPR: 100-120 compressions a minute, 2-2.4 inches deep, 30:2 with rescue breaths.
Hypothermia is the exception. Keep CPR going. They're not dead until they're warm and dead.
AED: use one if you have it, and keep up CPR between shocks.