Putting The Pieces Together: Components of Airway Management

Administering emergency oxygen is an effective option to provide during patient care (photo(s) credit, Pete DeQuincy, East Bay Regional Parks

In a critical incident the primary objective is to keep the victim alive. Airway management is one crucial skill that accomplishes that objective but is often overlooked. The level of care for airway management can range from monitoring a conscious victim to providing an oropharyngeal airway/nasopharyngeal airway (OPA/NPA) during rescue breathing with the use of a BVM and supplemental oxygen. This article will go over maneuvers that maintain a patent airway, use of OPA’s and NPA’s, the need for suction, oxygen delivery, and the drills for in-service training. The medical care discussed will be for a non-spinal victim unless stated. The level of care is the standard level of CPR/AED/First Aid for lifeguards. If trained at a First Responder or EMT level, then train accordingly and adhere to your county and agency protocols.

Let’s review what normal breathing is:

  • Unlabored with no use of accessory muscles to breathe
  • Adequate inhalations and exhalations
  • Clear lung sounds
  • Equal (bilateral) movement with chest expansion and contraction
  • Adult breathing: between 12-20 breaths per minute
  • Child breathing: between 15-30 breaths per minute
  • Infant breathing: between 25-50 breaths per minute

If the victim is conscious, then monitor and look for any changes. If the victim doesn’t have all of these signs listed above or is unconscious, then move to airway management with supplemental oxygen (if available).

Always assess your patient on which emergency oxygen treatment to use: Nasal cannula or Nonrebreather Mask

The unconscious victims will need to be in a supine position with a lifeguard maintaining their airway even if the victim has a pulse and is breathing. The lifeguard will either use the head-tilt/ chin-lift maneuver or the jaw-thrust with head extension maneuver. The lifeguard needs to remember the most common airway obstruction is the tongue. It is acceptable and necessary at times that one lifeguard be solely responsible for maintaining the victim’s airway.

Airway adjuncts, like oropharyngeal airways (OPA) are used to keep the tongue from blocking the upper airway and allow the lifeguard to provide suctioning if necessary. OPAs work on unconscious and unresponsive victims without a gag reflex. Nasopharyngeal airways (NPA) are used on unconscious and semiconscious victims with an intact gag reflex. If tolerated by the victim, OPA/NPAs can be used during rescue breathing with BVM use. Remember to follow county and agency protocols and adhere to indications and contraindications on use. Only use airway adjuncts if you’ve been trained to do so.

Keeping the victim’s airway clear is the priority.  This can often be done by rolling the victim onto their side and doing a finger sweep to remove fluids, secretions and foreign matter. At most aquatic facilities, if suctioning is available, it will be done with a manual suctioning device. Manual suction devices are lightweight, compact, easy to store in a medical pack or jump bag alongside your BVM and oxygen delivery system. Most have alternate catheter tip options for different size victims. Suction and oxygen delivery systems are independent of each other. Your agency doesn’t need an oxygen delivery system in order to provide suctioning. 

Oxygen delivery comes in either a fixed flow-rate system or a variable flow-rate system. Fixed systems allow for only one flow-rate and usually have the necessary oxygen adjunct already attached, allowing for quick delivery of supplemental oxygen to the victim: simply turn on and provide care. Variable flow-rate systems require the rescuer to determine the flow-rate, assemble the oxygen adjunct, turn on, and provide care. Selecting which supplemental oxygen adjunct to use depends on the medical condition the victim presents. It could start with a victim who has minor difficulty breathing and progress all the way to a non-breathing victim. With any of the oxygen adjuncts, lifeguards must practice assessing which adjunct to use, quick assembly and proper patient application.

Make sure to take the time and practice jaw-thrust with head extension


AIRWAY MANEUVER DRILL: Primary lifeguard 10 feet away from the victim who is in the supine position. OJECTIVE: Move quickly and provide care. Victim is non-spinal. Go through each maneuver:

  • Head-tilt/ Chin-lift
  • Jaw-thrust with head extension

TIMING GOAL: 3-5 seconds for each maneuver.

Once proficient, add a variation(s) to the maneuver:

  • Victim is in the lateral (coma) position (add 10 seconds)
  • Victim is in the prone position (add 10 seconds)
  • Add a second lifeguard, and do variations listed above (no time change)


AIRWAY MANAGEMENT PROGRESSION DRILL: Lifeguard is 10 feet away from the victim. Victim is unconscious and non-spinal. Building on the airway maneuver drill, primary lifeguard will add the following steps:

  • Glove up
  • Primary assessment with one of the airway maneuvers, state victim has a pulse and is breathing

OBJECTIVE: Complete the steps listed above as quickly as possible. TIMING GOAL 15-20 seconds to complete the steps. Once proficient, incorporate the progression steps and adjust timing goal. If staff is not trained to use OPA or NPA, then ignore OPA/NPA options.

  • Victim (dry) is not breathing but has a pulse, lifeguard uses pocket mask and provides rescue breathing for 3 breaths (add 10 seconds)
  • Second lifeguard arrives with OPAs, OPA is correctly measured and inserted, rescue breathing continues (add 10 seconds)
  • Second lifeguard arrives with OPAs and suction device, as above adding, suction device is assembled and ready to use (add 10 seconds)
  • Second lifeguard arrives with OPAs and suction device, as above adding, victim vomits and requires suctioning(add 10 seconds)
  • Second lifeguard arrives with OPAs, suction device, and BVM. As above without vomiting, transition to using the BVM (add 15 seconds)
  • As above including victim vomits and require suction. Once suction is complete, continue rescue breathing (add 15 seconds)
  • As above, once suction is complete, mask is compromised and needs to be replaced. Continue rescue breathing with new mask attached to BVM (add 20 seconds)

Variations include:

  • NPA instead of an OPA
  • Add a third, then fourth lifeguard to assist
  • Victim is  wet, pulled from the water
  • Victim is an adult, child, or infant
  • Incorporate supplemental oxygen to the BVM (add 20 seconds)

Remember you can have supplemental oxygen delivered through a BVM

SUPPLEMENTAL OXYGEN PROFICIENCY DRILL†: Primary lifeguard with an oxygen delivery system and a victim that is conscious and non-spinal. OBJECTIVE: Assemble for oxygen delivery and provide care to the victim as quickly as possible.  TIMING GOAL: 60 seconds to achieve objective. Go through each oxygen adjunct:

  • Nasal Cannula
  • Non-Rebreather Mask
  • Resuscitation Mask with oxygen inlet (if available)

Once proficient, add variations:

  • BVM with oxygen (victim is unconscious)
  • Add a second lifeguard to assist
  • Do the drill without any verbal communication
  • Progression, transition from Nasal Cannula to Non-Rebreather Mask (add 20-30 seconds)
  • Progression, transition from Non-Rebreather Mask to BVM (add 20-30 seconds)


Changing out a tank is a necessary skill. Make sure to follow you follow proper safety precautions

OXYGEN TANK CHANGE OUT DRILL†: Begin with a 2-person lifeguard team providing supplemental oxygen to the victim. OBJECTIVE: Provide continued care during an oxygen tank exchange (the first tank is empty and traded out for a replacement). TIMING GOAL: up to 60 seconds. Go through each oxygen adjunct:

  • Nasal Cannula
  • Non-Rebreather Mask*
  • Resuscitation Mask with oxygen inlet (if available)*
  • BVM**

*Mask must be removed from victim’s face when no oxygen is being administered.

**BVM requires 2 lifeguards to use, this drill will require 3 lifeguards to effectively provide care and change out the oxygen tank.

Once proficient, incorporate variations:

  • Add a third lifeguard to assist (no time change)
  • Combine with Airway Management Progression Drill
  • Combine with Supplemental Oxygen Proficiency Drill
  • Victim’s condition declines into no breathing, and no pulse. Incorporate AED.
  • Staggered start of third lifeguard
  • Staggered start of third lifeguard bringing the AED
  • Victim needs to be moved due to the scene becoming unsafe

Good airway management is a skill that is prized by EMT’s, Paramedics, and Fire Personnel.  Consider it a compliment if, during an emergency, your lifeguard staff is allowed to continue to provide airway management to the victim after EMS has arrived and taken over patient care. This means EMS professionals consider your staff abilities to be competent and an integral resource in providing care to the victim. What a great goal for your lifeguard team to strive for. Keep training.

† Must be certified in Administering Oxygen and follow safe handling practices designated by county and agency protocols.

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