A & R — Airway and Respiration: Chest Seals, NPAs & Needle D

In the MARCH protocol, the A and R come immediately after massive hemorrhage control — and for good reason. Once the catastrophic bleeding is stopped, the next fastest killers are a blocked airway and a chest that can no longer move air. Airway and Respiration are two separate problems that often get lumped together, so this guide splits them apart: what goes wrong, what the interventions are, what belongs in your kit, and — just as important — which interventions belong only in trained hands.

A — Airway: Keeping the Path Open

An unconscious casualty's most common airway problem is not a foreign object — it is their own anatomy. When muscle tone disappears, the tongue and soft tissue relax backward and can seal off the airway, especially in a casualty lying flat on their back. A person who survived their injuries can suffocate from nothing more than positioning.

The Recovery Position: The Simplest Intervention That Works

For an unconscious casualty who is breathing and has no injuries that prevent it, the recovery position — rolled onto their side, head positioned so fluids drain out rather than down — is the highest-value, lowest-risk airway intervention a layperson can provide. It uses gravity to keep the tongue forward and lets blood, saliva, or vomit exit the mouth instead of pooling in the throat. No equipment, no invasive procedure, and it is taught in virtually every first aid course. If you learn one airway skill, learn this one.

Nasopharyngeal Airways (NPAs)

The NPA is the airway adjunct you will find in nearly every military and law enforcement IFAK. It is a soft, flexible tube inserted through the nostril that creates a passage past the relaxed tongue, and TCCC favors it because it is tolerated by casualties who still have a gag reflex. A pre-lubricated NAR 28F NPA is the standard pick — one less step to fumble under stress.

To be direct about the limits: proper NPA use involves sizing, insertion technique, and knowing the contraindications — certain facial and head injuries make it the wrong tool. That is taught hands-on in TECC-level courses, not learned from a blog post. Carry one so it is available to trained hands on scene, and treat it as a reason to get that training yourself. Browse our A — Airway collection for NPAs and adjuncts.

R — Respiration: When the Chest Is Compromised

Airway is the pipe; respiration is the pump. A casualty can have a perfectly open airway and still die because a hole in the chest wall has broken the mechanics of breathing.

Penetrating Chest Trauma and the "Sucking Chest Wound"

The chest cavity works on negative pressure. Puncture it — gunshot, stab wound, jagged debris — and air can be pulled in through the wound instead of through the airway. Each breath draws more air into the space around the lung, collapsing it. The field-expedient rule taught in TECC courses: penetrating injuries to the chest area get an occlusive seal, and you check for an exit wound, which is why quality seals ship in pairs.

Vented vs. Unvented Chest Seals

Both types close the hole. The difference is what happens to air already trapped inside the chest:

• Vented seals use a one-way valve or channel system that lets trapped air escape while blocking re-entry. Current TCCC guidance prefers vented seals because they reduce the risk of pressure building inside the chest after the wound is sealed.
• Unvented seals are simple occlusive barriers. They work, but if pressure builds, the seal may need to be "burped" — lifted at a corner to release trapped air — which demands closer monitoring.

The HyFin Vent Chest Seal twin pack is the benchmark vented option: two seals for entry and exit wounds and an adhesive engineered to stick to blood- and sweat-slicked skin. There is also a compact version for pocket kits and slim IFAKs. For the full comparison, see Vented vs. Non-Vented Chest Seals.

Needle Decompression: Know What It Is, Know Whose Job It Is

If pressure keeps building inside the chest, the result is tension pneumothorax — trapped air compresses the lung, then the heart and great vessels. The definitive field treatment is needle decompression: a trained provider inserts a large-bore catheter through the chest wall at a specific anatomical site to release the trapped air.

This is a trained-provider-only intervention, and we will not pretend otherwise. It requires anatomical landmark identification, recognition of the indications, and management of what happens next — the domain of paramedics, combat medics, and clinicians operating under medical direction. The reason to understand it as a prepared civilian is situational awareness: recognizing a deteriorating chest-injury casualty, communicating clearly to EMS, and knowing why some kits contain a decompression needle you should leave for credentialed hands. Our R — Respiration collection stocks chest seals and related gear from North American Rescue, an authorized-dealer lineup.

What This Means for Your Kit

For the A and R portion of a MARCH-organized IFAK, the practical civilian loadout is: one NPA, one twin pack of vented chest seals, gloves, and shears to expose the chest. That is it — the highest-value additions here are skills, not more gear. If you are building from scratch, our MARCH-compliant IFAK gear list walks the whole kit letter by letter.

Train the Skills, Then Carry the Gear

Airway positioning and chest seal application are exactly the skills TECC-based courses teach civilians, and Stop the Bleed is the on-ramp for the hemorrhage skills that come before A and R in the sequence. Gear is not a substitute for training — a chest seal in an unopened kit has never saved anyone. Start with the full MARCH protocol guide, take a course, then build the kit to match what you know.

This article is for educational purposes only and is not medical advice; seek professional training and consult qualified medical professionals.