In a critical incident, the primary objective is to keep the victim alive. Airway management is one crucial skill that accomplishes that objective, but often is overlooked. This article will go over maneuvers that maintain a patent airway, use of oropharyngeal airways (OPAs) and nasopharyngeal airways (NPAs), 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; adequate inhalations and exhalations; clear lung sounds; and equal (bilateral) movement with chest expansion and contraction.
Adult breathing is 12-20 breaths per minute (bpm); child breathing, 15-30 bpm; and infant breathing, 25-50 bpm.
If the victim is conscious, then monitor and look for any changes. If the victim doesn’t have all of these signs listed earlier or is unconscious, then move to airway management with supplemental oxygen (if available).
The unconscious victim should be supine with a guard maintaining their airway even if they have a pulse and are breathing. The guard will use the head-tilt/ chin-lift maneuver or the jaw-thrust with head extension. Remember, the most common airway obstruction is the tongue. It is acceptable and sometimes necessary for one guard to be responsible for maintaining the victim’s airway.
Airway adjuncts like OPAs are used to keep the tongue from blocking the upper airway and allow the lifeguard to provide suction if necessary. OPAs work on unconscious and unresponsive victims without a gag reflex. NPAs 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 aquatics facilities, if suctioning is available, it’s done with a manual suction device. They are lightweight, compact, easy to store in a medical pack or jump bag beside your BVM and oxygen delivery system. Most have alternate catheter tip options. Suction and oxygen delivery systems are independent of each other. Your agency doesn’t need an oxygen delivery system 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 oxygen adjunct already attached, allowing for quick delivery of oxygen: 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 victim’s medical condition. With any of the oxygen adjuncts, guards must practice assessing which adjunct to use, quick assembly and proper patient application.
Airway maneuver drill: Primary guard is 10 feet away from the victim, who is in the supine position. Objective: Move quickly through each maneuver:
Jaw-thrust with head extension
Timing goal: 3-5 seconds for each maneuver.
Once proficient, add a variation(s) with extra time provided as indicated:
Victim is in lateral (coma) position (10 seconds)
Victim is in the prone position (10 seconds)
Add a second lifeguard, and do variations listed above (no time change)
Airway management progression drill: Guard is 10 feet from unconscious victim. Building on prior drill, primary guard adds:
Primary assessment with one of the airway maneuvers, state victim has a pulse and is breathing
Objective: Finish the steps listed above ASAP. Timing goal: 15-20 seconds. Once proficient, incorporate the progression steps and adjust timing goal. If staff is untrained on OPA or NPA use, ignore OPA/NPA options.
Victim (dry) is not breathing but has a pulse; guard uses pocket mask and provides rescue breathing for 3 breaths (10 seconds)
Second guard arrives with OPAs; OPA is correctly measured and inserted; rescue breathing continues (10 seconds)
Second guard arrives with OPAs and suction device, as above; add suction device, assembled and ready to use (10 seconds)
Second guard arrives with OPAs and suction device, as above; add victim, who vomits and requires suctioning (10 seconds)
Second guard arrives with OPAs, suction device and BVM. As above without vomiting, transition to using the BVM (15 seconds)
As above including victim vomits and requires suction. Once suction is complete, continue rescue breathing (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 (20 seconds)
NPA instead of an OPA
Add a third, then fourth guard to assist
Victim is wet, pulled from the water
Victim is an adult, child or infant
Incorporate supplemental oxygen to the BVM (20 seconds)
Supplemental oxygen proficiency drill†: Primary lifeguard with an oxygen delivery system and a victim who is conscious. Objective: Assemble for oxygen delivery and provide care to the victim ASAP. Timing goal: 60 seconds. Go through each oxygen adjunct:
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 verbal communication
Progression, transition from nasal cannula to non-rebreather mask (20-30 seconds)
Progression, transition from non-rebreather mask to BVM (20-30 seconds)
Oxygen tank change-out drill†: Begin with a two-person guard team providing supplemental oxygen to 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:
Resuscitation mask with oxygen inlet (if available)*
*Mask must be removed from victim’s face when no oxygen is being administered.
**BVM requires two guards to use; this drill will require three guards to effectively provide care and change out the oxygen tank.
Once proficient, incorporate variations:
Add another guard 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 last guard
Staggered start of last guard bringing AED
Victim must be moved; scene is now unsafe.
† Must be certified in administering oxygen and follow safe handling practices designated by county and agency protocols.