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SU11.3 | Airway Maintenance Skill — SDL Guide (Part 2)

Recognising a Patent versus an Obstructed Airway

Performing a manoeuvre is only half the skill; the other half is reading whether the airway is actually open, because an intervention that has not worked must be recognised and corrected at once. The bedside method is look, listen and feel, and you must be able to interpret each. A patent airway shows quiet, unobstructed breathing with visible, symmetrical chest rise, audible normal breath sounds at the mouth, and felt airflow; when you are ventilating, the chest rises with each breath. An obstructed airway declares itself by the absence of these signs and by added noises that localise the problem: snoring suggests soft-tissue (tongue) obstruction relievable by basic manoeuvres; gurgling suggests fluid (secretions, blood, vomit) needing suction; stridor suggests laryngeal-level narrowing (laryngospasm, oedema, foreign body); and complete obstruction is ominously silent — paradoxical 'see-saw' chest and abdominal movement with no air entry and no sound at all, the most dangerous pattern of all. The interpretation drives the next action: a snore means lift the jaw or insert an oral airway; a gurgle means suction; a silent see-saw means urgent escalation. Where the patient has been intubated, the gold-standard confirmation that the endotracheal tube is correctly placed in the trachea (and not the oesophagus) is capnography — a sustained end-tidal carbon-dioxide waveform — supported by seeing symmetrical chest rise and hearing equal bilateral breath sounds. Continuous reassessment after every step is the discipline that turns a manoeuvre into a maintained airway.

Provided image

Sign	Patent airway	Obstructed airway
Look	Symmetrical chest rise; no distress	See-saw chest/abdomen; accessory muscle use; cyanosis
Listen	Quiet normal breath sounds	Snoring (tongue), gurgling (fluid), stridor (larynx), or SILENT (complete)
Feel	Airflow at mouth/nose	No airflow felt

Practising Airway Maintenance on the Mannequin

Because this is a competency to be demonstrated, the knowledge above must be turned into smooth hand skills, and the place to do that safely is the simulation mannequin. Practise the whole sequence repeatedly under supervision until each step is automatic and flows into the next. Begin every run the same way: ensure safety, then assess with look-listen-feel. Open the airway with a head-tilt/chin-lift, switching deliberately to a jaw thrust in the scenario where neck injury is flagged, and verify that the chest now moves and the obstructed noise clears. Size and insert an oropharyngeal airway correctly — measuring from the angle of the mouth to the angle of the jaw, inserting it upside-down and rotating it into place over the tongue (or inserting it the right way up with a tongue depressor in the manikin) — and confirm it has improved, not worsened, the airway. Deliver bag-mask ventilation: select the right mask size, achieve a leak-free seal (practise both the one-hand 'EC' grip and the two-person technique), attach oxygen, and watch for visible chest rise with each squeeze, ventilating at a controlled rate without over-inflation. Rehearse suctioning a simulated obstruction and recognising when to escalate. Where the mannequin and supervision allow, practise inserting a laryngeal mask airway, understanding that it secures ventilation but not aspiration, and observe or simulate the steps of endotracheal intubation with capnographic confirmation. Throughout, reassess after every step and verbalise what you are doing and why. Deliberate, repeated, supervised practice is what builds the reliable, unhurried competence that a real airway emergency demands.

Check Your Understanding

Consolidate the skill by mentally walking the airway ladder from collapse to a maintained airway. Start by recognising the problem with look, listen and feel, interpreting the added noises — snoring means the tongue, gurgling means fluid, stridor means the larynx, and an ominous silence with see-saw movement means complete obstruction. Open the airway with a head-tilt/chin-lift, or a jaw thrust when cervical-spine injury is suspected, pulling the tongue off the pharyngeal wall. Support it with an adjunct — an oropharyngeal (Guedel) airway sized angle-of-mouth to angle-of-jaw for the patient with no gag reflex, or a nasopharyngeal airway for the semi-conscious patient (avoided in base-of-skull fracture). Ventilate inadequate breathing with bag-mask and oxygen, watching for chest rise. Escalate to a laryngeal mask airway (ventilates but does not protect against aspiration) or a cuffed endotracheal tube (the definitive airway that does protect against aspiration, confirmed by capnography). Self-test on four links: can you name the commonest cause of obstruction in the unconscious patient and the manoeuvre that relieves it; can you size and state the indication for an oropharyngeal versus a nasopharyngeal airway; can you list the airway devices in order and say which one protects against aspiration; and can you interpret look-listen-feel to tell a patent from an obstructed airway? The questions here check exactly these.