Instructing Jaw-Thrust (with Head Extension) Maneuver. (Photo credits: Emily Plurkowski and Pete DeQuincy, Mills College)


In-water ventilation provides a victim quick effective care when immediate extrication is not an option. It’s performed on a victim who is unconscious, not breathing, has a pulse and cannot immediately be removed from the water or definitive care will be delayed by 30 seconds or longer. To be successful in giving in-water ventilations, the primary rescuer should have a resuscitation mask, assembled with a one-way valve attached (not within the case) in the fanny pack (easy access). This article discusses in-water ventilation drills for a victim that has not sustained a spinal injury.

Review the following three skills for a single rescuer in shallow water prior to beginning the drills that follow:

1. Rescue tube placement:

  • The primary rescuer fails to wrap the victim’s arms under the rescue tube. This often forces the rescuer to continuously stabilize the victim on the rescue tube. Depending on the size and weight of the victim, the rescuer might need to slide the rescue tube lower on the victim’s body to allow their airway to fall open in preparation of in-water ventilations.
  • The lack of symmetry of the rescue tube placement could allow it to slip out.  Proper rescue tube placement should allow the rescuer to be hands-free. Watch out for entanglement with the rescue tube strap on both the rescuer and the victim.

2. Airway management, non-spinal victim: The primary rescuer needs to be proficient in opening the airway with the Head-tilt/ Chin-lift and Jaw-thrust maneuver with head extension.

  • For Head-tilt/ Chin-lift, remind rescuers to check for a pulse on the same side as their body placement, and to look down the body for the chest to rise. Ear placement should be directly over the victim’s mouth, feeling for possible breathing.  Rescuers sometimes forget to the pulse-check due to using both hands on the Head-tilt/ Chin-lift.
  • For Jaw-thrust maneuver with head extension, when checking for breathing, the rescuer’s head should be slightly to one side, allowing the rescuer’s ear to be directly over the victim’s mouth.
  • Due to the victim’s possible facial structure and/or the lack of a firm surface to assist in keeping the resuscitation mask firmly sealed, the rescuer could consider doing the Head-tilt Chin-lift for checking the victim’s breathing and pulse, then moving body position and utilizing Jaw-thrust maneuver with head extension for delivery of rescue breaths.

3. Resuscitation mask use: The fanny pack will be underwater and the rescuer should be able to remove with one hand.  Shake the mask several times to remove any water before placing it on the victim.

  • Rescuer should consider using the Jaw-Thrust maneuver with head extension, using the double “C” double “E” method to seal the mask from the head (cephalic) position. This uses the fingers and thumbs pushing against each other while gripping the victim’s jaw to keep the mask sealed, whereas, the Head-tilt/ Chin-lift  requires the utilization of downward pressure on a hard surface to assist in sealing the mask.
  • The mask seal should be effective in preventing water to intrude or air to escape if the mask-face contact line is submerged. Remind rescuers that the mask can be fully submerged with only the tip of the one-way valve exposed and still be effective in delivering rescue breaths.
  • When giving ventilations, the rescuer needs to be directly over the victim in order to give adequate breaths. This will be challenging when the in-water ventilations are delivered in deep water. NOTE: in the training review, if the “victim” has anxiety about having the resuscitation mask on his or her face, remove the one-way valve to increase the air flow or substitute the victim.

Rescuer can still give effective in-water ventilations even when the victim is completely submerged


After completing the single rescuer skills review, divide lifeguards into groups of 3 or 4 to work on the following three team rescuer skills:

Primary lifeguard support: The primary lifeguard may need assistance in victim stabilization which can be accomplished through additional rescue tube placement, having a secondary lifeguard physically supporting the victim or primary lifeguard with a rescue tube or their own body.

  • Depending on the depth of the water, the primary lifeguard could be challenged to get high enough over the victim’s head to provide adequate breaths which can be remedied by either lifting the primary lifeguard or slightly submerging the victim.

Sequencing from victim contact to in-water ventilations: It’s important for the primary and secondary lifeguards to figure out the nuances of working together and providing care. Here is an example of effective sequencing:

  • Primary rescues victim
  • Secondary assists in placing rescue tube
  • Primary checks breathing and pulse
  • Secondary preps resuscitation mask, and passes mask to Primary
  • Primary gives rescue breaths, then begins rescue breathing
  • Secondary assists primary rescuer in airway management, or supports victim, or supports Primary
  • Primary reassesses victim
  • Secondary determines extrication route

Determining extrication needs and continued victim care: Definitive care happens out of the water, so establishing a quick and efficient extrication route is necessary. Movement toward land can be in progress while assessing the patient and giving rescue breaths.

  • Lifeguards will need to decide if they will provide the 2 initial breaths, then rapidly tow the victim in or tow while continuing rescue breathing.

For clarification: the term “airway management” will refer to opening/maintaining the airway during and after checking for breathing and a pulse has occurred.



  • Victim is face down on the surface, drill ends when victim is secured, and airway management has occurred.  Rescuer assesses victim and states, “Victim has a pulse and is breathing.” (15-20 seconds)
  • Victim is face down on the surface, drill ends when victim is secured, airway management has occurred. Rescuer states, “Victim has a pulse but is not breathing.” Resuscitation mask is pulled and 2 breaths are delivered. Rescuer assesses victim and states, “Victim is breathing.” (15-20 seconds)


  • Victim is face down on the surface, drill ends when victim is secured, airway management has occurred. Rescuer assesses victim and states, “Victim has a pulse but is not breathing.” Resuscitation mask is pulled and 2 breaths are delivered. Rescuer states, “Victim is breathing.” Rescuers tow victim to side. (20 seconds)
  • Victim is face down on the surface, drill ends when victim is secured, airway management has occurred. Rescuer assesses victim and states, “Victim has a pulse but is not breathing.” Resuscitation mask is pulled and 2 breaths are delivered. Rescuer begins rescue breathing for 3 breaths (30 seconds)
  • Change-up variation: As the trainer, during one of the drills, you state which rescuer has the resuscitation mask, or that neither have one (20-40 seconds)

Several variables can be substituted to change the difficulty of the drills. This includes shallow (3-5 feet), mid-depth (5-7 feet), deep water (over 7 feet), and victim being face up, face down, submerged face up and face down, facing the rescuer, facing away, and resting on the bottom.

In-water ventilations can still be accomplished with the primary lifeguard on deck. This would be done if immediate extrication was not possible

Remember, you’re equipment is only useful if you know how to use it and developing the skill of providing in-water ventilations as individual rescuer and as part of a team adds another tool to the lifeguard toolkit, which could make the difference in saving a life.



In-water Ventilations 1-Hour Training Curriculum (12 lifeguards)


Briefing/Suit up: 5 minutes


Single Rescuer Review, lifeguards paired up, 10 minutes


Single Rescuer Drills (use variables, shallow and mid-depth water): 10 minutes


Team Rescuer Review: 15 minutes


Team Rescuer Drills (use variables victim body position, shallow and deep water): 15 minutes


Debrief/Break-down: 5 minutes

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Tags: aquatics, drills, education, in-service, lifeguarding, safety, teamwork, training, water


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