Overview: Airway & Breathing
The airway is your primary lifeline. Without adequate oxygen, a patient will die within minutes. This lesson covers recognition and management of airway and breathing emergencies in the wilderness setting where advanced equipment may be limited.
Critical: Airway and breathing problems are immediately life-threatening. Assessment and management happen as part of the primary survey (A-B in XABCDE).
Why This Matters in Wilderness Medicine
- Remote location: You may not have advanced airway equipment. Positioning and manual maneuvers are your primary tools.
- Delayed evacuation: Maintaining an adequate airway for hours until rescue is possible
- Altitude effects: Lower oxygen levels at elevation compound breathing problems
- Cold/heat: Respiratory rate and work of breathing change with environmental extremes
Key Points
The tongue is the most common cause of airway obstruction in unconscious patients
A choking patient with an effective cough needs encouragement, not intervention — go hands-on only when the cough fails
Rescue breathing is a core skill at this level — it can sustain life until help arrives
CPR in the wilderness may be prolonged — do not assume a hypothermic patient is dead
Airway Management
Airway Anatomy
Understanding the airway path helps you recognize obstruction:
- Nose/Mouth: Entry points for air
- Pharynx: Common area for obstruction from tongue, blood, vomit, edema
- Larynx: Voice box; can swell from allergic reaction or trauma
- Trachea: Windpipe; main airway to lungs
- Bronchi: Split into right and left, enter lungs
Common Causes of Obstruction
- Tongue (most common in unconscious patients): Relaxes and blocks pharynx
- Foreign body: Food, rock, dentures, vomit
- Blood/Vomit: Fluids occlude airway
- Swelling (edema): Allergic reaction, infection, inhalation injury, trauma
- Direct injury: Trauma to neck, direct laryngeal damage
Opening Techniques
Head-Tilt Chin-Lift
- When to use: No spinal injury concern
- How: Place one hand on forehead, gently tilt head back. Place fingers under chin and lift upward. Lifts tongue off pharynx.
- Advantage: Opens airway effectively in most cases
- Disadvantage: May worsen cervical spine injury if one exists
Jaw Thrust
- When to use: Spinal injury is suspected (trauma, fall, mechanism unknown)
- How: Grip the angles of the mandible (jaw) from below and behind. Pull forward without tilting head. Maintains cervical spine alignment.
- Advantage: Opens airway while protecting cervical spine
- Disadvantage: More difficult, requires practice
Important: Jaw thrust is more difficult than head-tilt chin-lift. Practice this skill before you need it in the field.
Recovery Position
When to use: Unconscious patient who is breathing, no spinal injury concern
- Turns patient on their side
- Positions head on extended arm to keep airway open
- Top leg bent for stability
- Why: If patient vomits, fluid drains from mouth instead of aspirating into lungs
- Monitor: Watch for vomiting, position airway, reassess breathing
Suctioning & Airway Clearing
- Patient positioning: Head-down to allow gravity to drain fluids
- Finger sweep: Use only if you can VISIBLY see an object. Never perform blind finger sweeps in adults (risk of pushing obstruction deeper).
- Patient coughing: If patient is semi-conscious or conscious, encourage coughing to help expel fluid or foreign material
- Suction improvisation: If suction device unavailable, roll patient on side, let gravity work
Choking (Foreign Body Airway Obstruction)
A conscious patient choking on food or another object needs a fast decision: is the cough working, or not?
- Universal choking sign: Hands clutched to the throat — recognize it and move
- Ask: "Are you choking? Can you speak?" The answer drives everything that follows
- EFFECTIVE cough: Patient can speak, cry out, or cough forcefully. Their own cough clears an obstruction better than anything you can do. Encourage coughing, stay close, and watch — do NOT intervene physically.
- INEFFECTIVE (silent) choking: Cannot speak, weak or no cough, high-pitched noise on inhalation, cyanosis (turning blue). The airway is blocked — act now.
Critical: A silent choking patient has minutes before losing consciousness. If they cannot speak or cough forcefully, begin back blows and abdominal thrusts immediately.
Relieving Choking — Conscious Adult or Child
- 5 back blows: Lean the patient forward. Deliver 5 firm blows with the heel of your hand between the shoulder blades.
- 5 abdominal thrusts: Stand behind the patient. Place a fist, thumb-side in, just above the navel. Grasp it with your other hand and pull sharply inward and upward.
- Alternate: Repeat 5 back blows and 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive
- Pregnant or very large patients: Use chest thrusts (fist on the center of the breastbone, thrust straight back) instead of abdominal thrusts
- Choking while alone: Give yourself abdominal thrusts with your own fist, or thrust your upper abdomen against a firm edge — a chair back, log, or boulder
- Infants (under 1 year): Alternate 5 back slaps and 5 chest thrusts — never abdominal thrusts
Wilderness setup: Choking loves the trail — eating on the move, laughing mid-bite, dehydrated jerky and hard candy on river trips or bumpy rides. Slow down to eat, and keep an eye on the group at meal breaks.
If the Choking Patient Becomes Unresponsive
- Lower the patient carefully to the ground and send for help if others are present
- Begin CPR, starting with compressions — compressions raise chest pressure and may dislodge the object
- Look before you breathe: Before each set of breaths, open the mouth and look. Remove an object only if you can SEE it — never perform a blind finger sweep (same rule as airway clearing above).
Aftercare:
- Medical evaluation: Anyone who received abdominal thrusts needs medical evaluation — thrusts can cause internal injury
- Wilderness note: A partial obstruction far from help is an airway emergency. Lower your evacuation threshold — a "mostly cleared" airway can swell or re-obstruct.
Airway Adjuncts (Reference Only)
For reference: EMS providers carry airway adjuncts — the nasopharyngeal airway (NPA) and oropharyngeal airway (OPA) — to help hold an unconscious patient's airway open. Using these devices is beyond the scope of this course. Your tools are positioning: head-tilt chin-lift or jaw thrust to open the airway, and the recovery position to protect it.
Breathing Emergencies
Recognizing Respiratory Distress
Signs a patient is struggling to breathe:
- Rate: Tachypnea (>20 breaths/min) or bradypnea (<10 breaths/min)
- Accessory muscle use: Neck muscles (SCM) and muscles between ribs (intercostals) working hard
- Nasal flaring: Nostrils expand with each breath (sign of effort)
- Pursed lips: Patient breathing against resistance
- Tripod position: Patient sitting forward on hands to use accessory muscles
- Abnormal sounds: Stridor (high-pitched inhalation sound), wheezing, gurgling, snoring
Critical sign: Silent chest (no breath sounds) in a patient with respiratory distress is extremely serious. Immediate aggressive airway management needed.
Asthma in the Field
- Common triggers: Exercise, cold air, allergens, emotional stress
- Signs: Wheezing, shortness of breath, chest tightness, cough
- Treatment:
- Sit patient upright
- Help the patient use their OWN bronchodilator inhaler (albuterol/salbutamol) — 4-10 puffs (through a spacer if available), repeated every 20 minutes for the first hour as needed
- Calm the patient (anxiety worsens bronchospasm)
- Provide oxygen if available
- Hydration: encourage sipping water
- When to evacuate: Deteriorating despite treatment = EMERGENT evacuation. If there is no meaningful improvement within the first hour of treatment, evacuate urgently.
- Status asthmaticus: Severe asthma attack not responding to bronchodilators — life-threatening, requires urgent evacuation
Pneumothorax (Collapsed Lung)
- What is it: Air enters the space around the lung, causing collapse
- Signs: Absent or diminished breath sounds on one side, chest pain, dyspnea
- Tension pneumothorax (EMERGENCY): Pressure builds, pushing heart and great vessels. Signs: tracheal deviation (trachea shifts AWAY from affected side), JVD (jugular vein distension), hypotension, shock.
- Field recognition: Your job is to recognize the pattern, not to definitively diagnose it. Definitive treatment is hospital-level.
- Field treatment: Position of comfort, monitor airway, oxygen if available, EMERGENT evacuation
High Altitude Pulmonary Edema (HAPE)
- What is it: Fluid fills lungs from pressure changes at altitude
- When it occurs: Typically >2,500m (8,000 ft), usually day 2-3 at altitude
- Signs: Cough (often with pink frothy sputum), crackles on auscultation, severe dyspnea, fatigue worse than peers
- Risk factors: Rapid ascent, exertion at altitude, prior HAPE, individual susceptibility
- Treatment: IMMEDIATE descent (even 500m helps). Oxygen if available. Position upright. DO NOT delay descent.
Chest Injuries Affecting Breathing
Flail Segment
- What: Multiple rib fractures causing segment to move opposite to rest of chest (paradoxical motion)
- Signs: Chest pain, dyspnea, paradoxical motion visible
- Treatment: Pain control, position of comfort (often lying injured side down), hold a bulky pad gently over the segment for support, encourage deep breathing, evacuate. Do NOT tape or wrap anything around the chest — circumferential binding restricts breathing.
Open Pneumothorax (Sucking Chest Wound)
- What: Penetrating wound to chest wall allowing air in/out with breathing
- Signs: Hole in chest, air sounds with breathing, dyspnea
- Treatment: Cover with 3-sided occlusive dressing (tape 3 sides, leave 1 side loose to allow air to escape but prevent air from entering). Monitor for tension pneumothorax development — if breathing worsens after sealing, lift ("burp") the dressing edge to release trapped air. Urgent evacuation.
CPR in the Wilderness
When to Start CPR
- Patient is unresponsive (no response to verbal or pain stimulus)
- Patient is NOT breathing or only gasping (agonal respirations)
- No pulse check needed — if unresponsive and not breathing, start CPR
Note: Gasping is NOT normal breathing. A patient who is gasping still needs CPR.
CPR Technique
- Compression rate: 100-120 compressions per minute (roughly the beat of a fast song)
- Depth: 2-2.4 inches (5-6 cm) for adults. "Push hard and fast."
- Hand position: Heel of one hand on center of chest, other hand on top, arms straight
- Full recoil: Let chest fully recoil between compressions
CPR Ratios & Rescue Breathing
- Adult CPR ratio: 30 compressions : 2 breaths (30:2) — the same ratio for single-rescuer AND two-rescuer CPR. Using an AED never changes the ratio.
- Rescue breathing (patient HAS a pulse but is not breathing adequately): 1 breath every 6 seconds (10 breaths per minute), reassessing about every 2 minutes
- Breath technique: Mouth-to-mouth or mouth-to-barrier
- Tilt head back (if no spine concern)
- Pinch nose, seal mouth, blow for 1 second
- Adequate volume = chest rises with each breath
Wilderness reality: Hands-only CPR (continuous compressions without breaths) is a fallback for presumed sudden cardiac arrest when you are unwilling or unable to give breaths — better than no CPR at all. But for the asphyxial causes common in the wilderness (drowning, avalanche burial, airway obstruction), the underlying problem is lack of oxygen: rescue breaths are essential.
When to Withhold or Stop CPR
When NOT to start CPR:
- Obvious death: decapitation, rigor mortis, dependent lividity (gravity-dependent purple discoloration)
- Injuries incompatible with life
- Standing orders or DNR (Do Not Resuscitate) documents
When to stop CPR:
- ROSC (Return of Spontaneous Circulation) — patient has a pulse and is breathing
- Exhaustion: you can no longer perform CPR
- Prolonged cardiac arrest (generally 30 min) without ROSC in a normothermic patient
- EXCEPTION — Hypothermia or drowning: "No one is dead until warm and dead." Continue CPR even after prolonged arrest if hypothermia or drowning suspected.
Hypothermia & Cardiac Arrest
Critical principle: A severely hypothermic patient may have an undetectable pulse and appear dead but still be resuscitable. "No one is dead until warm and dead."
- Continue CPR during evacuation if hypothermia suspected
- Hospital rewarming (in severe cases heart-lung bypass/ECMO) may restore life even after hours without a pulse
- Case reports of full recovery after cardiac arrest from extreme hypothermia (core temp <20°C/68°F)
Remember: A hypothermic patient is not dead until they are warm AND dead. Keep CPR going.
AED (Automated External Defibrillator)
- What it does: Analyzes heart rhythm and delivers shock if defibrillation indicated
- When available: Many wilderness rescue organizations carry AEDs
- Wet victim: Dry chest before applying pads if wet
- Chest hair: Press pads on firmly. Dense hair can prevent pad contact — if the AED cannot analyze, quickly shave the pad sites (a razor is in most AED kits) or pull the hair off with a first set of pads and apply a fresh set.
- Pacemaker/ICD: Place pads to avoid implanted device if possible, but don't delay defibrillation
- Use: Turn on, follow prompts, continue CPR between shocks
Case Scenarios
Scenario 1: Unconscious Drowning Victim on Riverbank
Setting: A swimmer is pulled from a river by a friend. Victim is unconscious and not breathing. You're 2 miles from trailhead with limited supplies and a satellite communicator.
Immediate Actions:
- Position victim supine on firm surface
- Assess responsiveness and breathing (take up to 10 seconds)
- No breathing detected — drowning is an asphyxial (oxygen-deprivation) arrest: open the airway and give 2 initial rescue breaths FIRST
- Then continue CPR at 30 compressions : 2 breaths (30:2)
- Hands-only CPR is NOT appropriate for drowning — the victim's problem is lack of oxygen, so rescue breaths are essential
- Continue CPR while activating satellite communicator for SAR helicopter
Water Aspiration Concern: Drowning victims may have aspirated water. CPR effectiveness may be limited. Continue anyway — CPR is the only hope.
Hypothermia Consideration: Cold water drowning = potential for survival even after prolonged submersion. Continue CPR. Do NOT stop due to time elapsed.
Evacuation: URGENT. Continue CPR during evacuation. Only stop if ROSC, exhaustion, or definite signs of death.
Scenario 2: Asthma Attack on Remote Trail
Setting: A 35-year-old with known asthma is hiking at 9,000 ft elevation. She starts wheezing and shortness of breath after a strenuous climb. She has her rescue inhaler (albuterol) with her but is becoming more distressed and wheezy despite use.
Assessment:
- Respiratory distress — wheezing, dyspnea, tachypnea
- Accessory muscle use likely
- Anxiety (worsens bronchospasm)
Immediate Treatment:
- Stop activity, sit patient upright
- Help her use her own albuterol inhaler — 4-10 puffs (through a spacer if available), repeated every 20 minutes for the first hour as needed
- Calm patient (speak slowly, reassure)
- Offer small sips of water
- Observe for response to medication
Evacuation Decision: Even if the wheezing improves, she should rest and descend — lower your evacuation threshold after a significant attack. If she is deteriorating despite treatment, evacuation is EMERGENT. At altitude, descent to lower elevation also helps (more oxygen available).
Knowledge Check
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Lesson Summary
Key Concepts
The tongue is the most common airway obstruction in unconscious patients
Head-tilt chin-lift vs. jaw thrust: choose based on spinal injury concern
Recovery position protects airway if patient vomits
Choking: effective cough → encourage coughing; silent/ineffective → alternate 5 back blows and 5 abdominal thrusts until relieved or unresponsive
Choking patient goes unresponsive: begin CPR starting with compressions; look in the mouth before breaths, no blind finger sweeps
Anyone who received abdominal thrusts needs medical evaluation afterward
Recognize respiratory distress: rate, effort, sounds, patient positioning
Asthma in field: position, use bronchodilator, calm patient, evacuate if no improvement
CPR: 100-120 compressions/min, 2-2.4 inch depth, 30:2 ratio with rescue breathing
Hypothermia exception: continue CPR — patient not dead until warm and dead
AED: use if available, continue CPR between shocks