In a prehospital sector, airway obstruction or non-patent airway is one of the major problems that both medical and trauma patients faceses world-wide or is a challenge that is encountered by prehospital care providers. The goal of airway management is to provide adequate ventilation as part of the overall resuscitation effort, failure to provide it could lead to death. As the patient will experience hypoxia and hypoxemia, hence leading to organ and tissue failure. Certain methods are used to perform this, head-tilt-chin lift and jaw-thrust maneuver and airway adjuncts are used to make the airway patent and makes it easy for patient ventilation with a bag valve mask.

Endotracheal intubation is the definitive method of airway management compared to other methods, e.g. oropharyngeal and nasopharyngeal airway. In a health sector (prehospital) provision of airway management is done according to scope of practice and certain protocols are to be followed to prevent complications when managing airway. Indications include reduced level of consciousness, apnea, confusion due to hypoxia, cyanosis and obstruction to airway.

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Considerations include use of suctioning machines, electro-cardiogram monitor, defibrillator, drugs full airway equipment e.g oxygen masks, tank and other devices used when managing airway.


The three axis alignment theory is a technique used to open an airway or make sure that the airway is patent enough to allow air ventilation, it keeps the airway patent enough by aligning the oral axis, pharyngeal axis and the laryngeal axis. A Sniffing position is also used to acquire this technique.

A review of the classic anesthesiology literature

reveals a common thread in the instructions for direct laryngoscopy: To successfully visualize the larynx, one must align three

(oral, laryngeal, and pharyngeal) anatomic axes.1–7 Placing a patient

in the “sniffing position” is the accepted maneuver for aligning

these axes.

Recently, we evaluated a radiograph obtained during intubation in

the sniffing position, drew lines along the axes (fig. 1), and did not

observe this alignment. We then reviewed the literature to understand

the origin of this concept. The sniffing position has been credited to

Chevalier Jackson in 1913, although he did not use this terminology or

demonstrate alignment of the axes diagramatically. He simply suggested that the patient be placed on a pillow in a natural position with

the head extended.8 He went on to suggest that, in fact, the pillow

might be removed, the thumbs placed on the forehead of the patient,

and the forehead vigorously forced downward and backward, causing

an anterior movement of the skull on the atlas and throwing the

cervical vertebrae forward.

After this proposal by Jackson, numerous authors offered their

modifications of the technique. However, the first (only?) authors to

study the problem experimentally were Bannister and MacBeth,9

whose frequently cited 1944 Lancet article graphically demonstrates the alignment of the three axes by use of an added pillow

beneath the occiput, thus flexing the neck.9 The authors then

propose that straightening the right angle formed by the axis of the

mouth and the pharyngolaryngeal axis requires extension of the

head on the atlantooccipital joint. They support their view with a

series of drawings and radiographs. Although the authors’ drawings

illustrate plainly that the axes may be brought into complete alignment, close examination of the radiographs shows that the drawing

did not coincide with the radiograph. Whereas the hard palate is

aligned with the larynx in the drawing, the angle of the larynx to the

hard palate in the radiograph is roughly 36°. If one compares

radiographs in the article, it becomes apparent that the laryngoscope shown in one radiograph (patient in sniffing position) is not

in the mouth. Otherwise this patient would be missing all the upper

incisors. Perhaps this is what was referred to previously in the

article as “cooking” a diagram. In spite of this, the “three-axes rule”

became reality.

It would appear to us that, although the sniffing position may

provide the best laryngeal view, the explanation of the benefit of the

sniffing position based on alignment of the three axes is an error

perpetuated since 1944 that deserves reexamination.


The Vortex Approach is an airway management technique which is used to familiarize clinicians with an approach to emergency airway management prior to the occurrence of an airway crisis. This technique provides guidance which predominantly directed at anaesthetists and is usually restricted to the circumstance where the primary plan for the airway management is endotracheal intubation. The Vortex Approach, in contrast, is based around a “high acuity implementation”, specifically designed to be used during high stakes, time critical situation of an evolving airway emergency. It is intended to help clinical teams perform under pressure by providing a sample, consistent template that can be taught to all clinicians involved in advanced airway management, irrespective of critical care discipline and whether they are from a medical, nursing or paramedical background, it is used at any context in which airway management takes place. The Vortex implementation tool is based on the premise that there are only three upper airway ‘lifelines’ (non-surgical techniques) by which alveolar oxygen delivery can be established and confirmed: face mask, supraglottic airway and endotracheal tube. If a ‘best effort’ at each of these three lifelines is unsuccessful then a can’t intubate, can’t oxygenate situation (CICO) situation exists and ‘CICO Rescue’ (emergency front-of-neck access) must be initiated.



This is an airway adjunct used to maintain or open the airway by stopping the tongue from covering the epiglottis.


-used on patients with an absence of gag reflex or no gag reflex

– patients with a low oxygen saturation reading


-should not be used on conscious patients with an intact gag reflex

-patient with nasal fractures and/or with active bleeding

-should not be used on patients who had suffered from oral trauma


-able to protect the tongue from seizure activity

-it is simple and quick to insert


-it may induce vomiting which may lead to aspiration

-it may cause or worsen airway obstruction if an inappropriately sized airway is used (can cause laryngospasm)

-can damage oral structures if not used properly


This an airway adjunct designed to be inserted in the nasal cavity to maintain or keep an airway patent or open for easy oxygenation of a patient.


-used on conscious or semi-conscious patients with compromised airway

-patients with intact gag reflex requiring airway management

-patient with injury to the mouth or jaw, making it impossible to use the mouth as the main passageway

-patients with clenched teeth and unable to open mouth due to trauma, seizure and other medical conditions or poisoning


-patient with suspected skull fracture

-patient with blunt trauma to the head or face


-it is quick and easy to insert

-can be used on patients who have mouth opening difficulty

-can be used on semi-conscious and unconscious patients

-provides air passage from the nose to pharynx by holding the tongue away from the pharynx


Should not be used on patients with sinus problems

Should not be used on patients who at risk of nose bleeding


This are airway adjuncts that require more knowledge and skills to use, this includes endotracheal intubation and use of supraglottic device.

The use of an endotracheal tube require use of a laryngoscope since this is the most difficult airway adjunct to insert and most secure airway adjunct available, is the alternative airway adjunct used by ALS (ADVANCED LIFE SUPPORT PARAMEDIC)

As an EMT-A, am only allowed to use laryngeal airway mask/supraglottic device because is the only advanced airway adjunct that I can use when managing airway according to my scope of practice.



Airway algorithm according to the American Society of Anesthesiologists


Airway obstruction is a worldwide problem, dealing with it requires certain skills and techniques in order to maintain it. Full understanding of anatomy and physiology of both upper and lower airways with the use of airway adjuncts are necessary when dealing with airway management. Failure to understand or know how they work or operate could lead to complications which could to lead to loss of life of a patient. For a proper airway management, the three axis alignment, the vortex approach and the sniffing position are used in order to open the airway, the vortex approach is used when there are no improvements in ventilation, different techniques of ventilation are used I the vortex approach until a patient is stable.

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