Part of pre-intubation and emergency rescue breathing procedures, the head tilt–chin lift maneuver and the jaw-thrust maneuver are 2 noninvasive, manual means to help restore upper airway patency when the tongue occludes the glottis, which commonly occurs in an obtunded or unconscious patient.
These methods require active ongoing attendance by the operator and are an integral part of bag-valve-mask ventilation (BVM).
Positioning of the patient in a proper sniffing position, when possible, is a prerequisite to these manual methods as well as to the invasive methods of airway management (ie, supraglottic and tracheal artificial airways).
The addition of continuous positive airway pressure may achieve airway patency when these manual methods alone fail.
- Treatment of suspected upper airway obstruction in obtunded or unresponsive patients
- Part of initial emergency treatment for apnea or impending respiratory arrest
- Improvement of airway patency during BVM ventilation and sometimes during spontaneous breathing
- Confirmation of apnea
- There is no medical contraindication to providing rescue breathing; however, a patient may have a legal contraindication (do-not-resuscitate order or specific advance directive in force).
- Suspected or actual cervical spine injury
Tilting the head or otherwise moving the neck is contraindicated in a patient with a possible cervical spine injury, but maintaining an airway and ventilation is a greater priority. In the setting of a possible cervical spine injury, the jaw-thrust maneuver, in which the neck is held in a neutral position, is preferred over the head tilt–chin lift maneuver.
Complications are uncommon and include
- Spinal cord injury if the cervical spine has an unstable bony or ligamentous injury
- Exacerbation of mandibular injury
- Gloves, mask, gown (ie, universal precautions)
- Towels, sheets, or commercial devices (ramps) for elevating neck and head into optimal positioning
- Suctioning apparatus and Yankauer catheter; Magill forceps (if needed to remove easily accessible foreign bodies and patient has no gag reflex), to clear the pharynx as needed
- Suction should be used if necessary to clear the upper airway.
The sniffing position—only in the absence of cervical spine injury
- Position the patient supine on the stretcher.
- Align the upper airway for optimal air passage by placing the patient into a proper sniffing position. Proper sniffing position aligns the external auditory canal with the sternal notch. To achieve the sniffing position, folded towels or other materials may need to be placed under the head, neck, or shoulders, so that the neck is flexed on the body and the head is extended on the neck. In obese patients, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck. In children, padding is usually needed behind the shoulders to accommodate the enlarged occiput.
Head and neck positioning to open the airway: Sniffing position
A: The head is flat on the stretcher; the airway is constricted. B: The ear and sternal notch are aligned, with the face parallel to the ceiling (in the sniffing position), opening the airway. Adapted from Levitan RM, Kinkle WC: The airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.
If cervical spine injury is a possibility
- Position the patient supine or at a slight incline on the stretcher.
- Avoid moving the neck and do the jaw-thrust maneuver first (before trying the head tilt–chin lift if needed to open the airway).
- Aligning the external auditory canal with the sternal notch may help open the upper airway and establishes the best position to view the airway if endotracheal intubation becomes necessary.
- The degree of head elevation that best aligns the ear and sternal notch varies (eg, none in children with large occiputs, a large degree in obese patients).
Step-by-Step Description of Procedure
Head tilt–chin lift
- Tilt the patient’s head back by pushing down on the forehead.
- Place the tips of your index and middle fingers under the chin and pull up on the mandible (not on the soft tissues). This lifts the tongue away from the posterior pharynx and improves airway patency. Be sure to pull up only on the bony parts of the mandible. Pressure to the soft tissues of the neck may obstruct the airway.
- Stand at the head of the stretcher and place your palms on the patient’s temples and your fingers under the mandibular rami.
- In patients with possible cervical spine injury, avoid extending the neck.
- Lift the mandible upward with your fingers, at least until the lower incisors are higher than the upper incisors. This maneuver lifts the tongue along with the mandible, thus relieving upper airway obstruction. Be sure to pull or push up only on the bony parts of the mandible. Pressure to the soft tissues of the neck may obstruct the airway.
- Maintain these positions as long as necessary.
- Berg RA, Hemphill R, Abella BS, et al: Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122:S685-S705, 2010.