ATP 4-02.11 Reference

AIRWAY MANAGEMENT IN TACTICAL SETTINGS

Source: ATP 4-02.11, Chapter 5 — Airway Control, 23 March 2026

Key Points

  • Airway is the "A" in MARCH-PAWS — addressed after massive bleeding
  • If casualty is awake and talking, airway is open
  • Brain cells begin dying within 5 minutes without oxygen
  • Normal adult respiration: 12–20 breaths/minute
  • NPA size 32 French is in the standard JFAK
  • NPA insertion is a Tier 2 (CLS) skill
  • Do NOT use blood or body fluids to lubricate NPA
  • Jaw thrust preferred over head-tilt chin-lift when spinal injury suspected

Common Mistakes

  • Using blood or body fluid to lubricate NPA (use only water-based lubricant)
  • Inserting NPA with bevel facing wrong direction — bevel toward nasal septum
  • Using NPA when basilar skull fracture is suspected
  • Applying head-tilt when spinal injury is suspected
  • Doing abdominal thrusts on a pregnant or obese casualty (use chest thrusts)

Airway Obstruction Signs

  • Casualty cannot breathe properly
  • Snoring or gurgling sounds
  • Visible blood or foreign objects in airway
  • Severe trauma to the face
Critical Principle

After massive bleeding is controlled, move to airway — the first "A" in MARCH-PAWS. If the casualty is awake and talking, you can assume the airway is open. If unconscious, inspect the airway for blockages. Brain cells may die within 5 minutes without oxygen. (ATP 4-02.11, paras 5-1 to 5-2)

Opening the Airway — Tier 1 Techniques

Head-Tilt, Chin-Lift Method

Used when no spinal injury is suspected.

  1. 1

    Place one hand on the casualty's forehead. Place the fingertips of the other hand under the bony part of the jaw.

  2. 2

    Tilt the head backward gently while lifting the chin. This moves the tongue away from the back of the throat.

  3. 3

    Maintain this position to keep the airway open. Check for breathing — look for chest rise, listen for air, feel for airflow on cheek.

Jaw Thrust Method (Suspected Spinal Injury)

Preferred when spinal injury cannot be ruled out — avoids neck movement.

  1. 1

    Position yourself at the casualty's head. Place your hands on each side of the head, fingers behind the angles of the jaw.

  2. 2

    Lift the jaw upward and forward without moving the head or neck.

  3. 3

    If the casualty begins breathing, place them in the recovery position (on their side) to prevent aspiration.

Recovery Position

An unconscious but breathing casualty who is not suspected of having a spinal injury should be placed in the recovery position: on their side, which prevents the tongue from blocking the airway and reduces risk of aspiration if vomiting occurs. (ATP 4-02.11, para 5-19)

NPA Insertion — Tier 2 (CLS) Skill

The CoTCCC-recommended NPA with lubricant is a nonsterile, rubber tube inserted into the nostril to keep the airway open. Only an NPA, size 32 French, is found in the standard JFAK. (ATP 4-02.11, para 5-8)

NPA Contraindications

Do NOT use NPA when basilar skull fractures, disruption of the midface, nasopharynx, or roof of the mouth are present. Assess casualties with facial trauma for these contraindications before inserting an NPA. Do NOT use blood or other body fluids to lubricate the NPA — use only water-based lubricant.

NPA Insertion Procedure

  1. 1

    Apply water-based lubricant to the NPA. Sizing before insertion is not required but helps minimize trauma.

  2. 2

    Insert into the right nostril with bevel facing toward the nasal septum (inside of nose). Use a gentle twisting motion.

  3. 3

    Advance the NPA along the floor of the nostril (not upward) until the flared end rests against the outer nostril.

  4. 4

    If resistance is met, withdraw and try the left nostril. Never force the device.

  5. 5

    If the casualty's gag reflex is triggered and breathing is adequate, remove the NPA. It may not be needed.

BVM — Bag-Valve-Mask Ventilation

The BVM device consists of a self-inflating bag and mask, manually squeezed to deliver positive pressure ventilation. Used when artificial respiration is needed to support or control the patient's breathing. (ATP 4-02.11, para 5-25)

  • EC technique for mask seal: E-grip fingers below, C-grip fingers above the mask
  • Position: kneel at casualty's head, tilt head back, maintain mask seal
  • Ventilate at 1 breath every 5–6 seconds (10–12 per minute for adults)
  • Each breath delivered over 1 second — watch for chest rise

Choking — Airway Obstruction

Signs of airway obstruction from a foreign body include the universal choking sign (hands at throat), inability to speak or cry, high-pitched noises, and weak/absent cough. (ATP 4-02.11, para 5-30)

  • Conscious adult/child: 5 back blows between shoulder blades, then 5 abdominal thrusts (Heimlich maneuver), alternating until object is expelled or casualty becomes unconscious
  • Pregnant or obese casualty: Use chest thrusts instead of abdominal thrusts — position hands on breastbone as for CPR
  • Unconscious: Begin CPR; each time you open the airway to ventilate, look for the foreign object and remove it if visible

ATP 4-02.11 Source

Chapter 5: Airway Control — Army Techniques Publication 4-02.11, Casualty Response, Tactical Combat Casualty Care, and First Aid. Headquarters, Department of the Army, 23 March 2026.

See It in Practice — ESB Tasks

These ESB Medical Lane tasks apply this doctrine directly:

M3: Restore Breathing / CPR
Massive Hemorrhage Control Chest Injuries & Needle Decompression