little airways, big challenges · another pitfall that often results from pro-vider stress is...

26 JEMS | MARCH 2017 www.jeMs.CoM

Proper mask size selection is critical when assisting pedi-

atric patients with ventilation or administering oxygen.

Photos courtesy Chelsea White/Dorothy A. Habrat

1703JEMS_26 26 2/13/17 2:37 PM

www.jems.com mARcH 2017 | JEMS 27

An overview of pediatric airway management

By Dorothy A. Habrat, DO; Daniel R. Shocket, MD, MPH&TM

& Darren Braude, MD, EMT-P

1703JEMS_27 27 2/13/17 2:37 PM

Child Adult

Tongue: Child’s is larger

in proportion

to mouth

Larynx:

More anterior

and superior

in child

Epiglottis:

Floppier, U-shaped

in child; shorter

in adult

Vocal cords:

Upward slant in child,

horizontal in adult

Cricoid: Narrowest part of child’s airway

Trachea: Narrow and less rigid in child

Lungs: Less capacity in child


You arrive on scene, walk into the home and find

a mother sitting on the couch with a 1-year-

old child on her lap. She explains her daughter

has been sick for several days, but today it was

much harder than usual to wake her up from

a nap and, “She just isn’t acting like herself.”

The girl appears limp in her mother’s

arms and doesn’t look up at you. She appears

diaphoretic and her respiratory rate is approx-

imately 8 breaths per minute. You look at your

partner, who appears just as worried about

the patient as you are, and quickly begin tak-

ing action.

Your partner hooks up the small patient

to the monitor while you continue to assess

her. She barely wakes up from the feel of the

blood pressure cuff and is lethargic. Her sys-

tolic blood pressure is 90 mmHg, oxygen sat-

uration is 84%, temperature is 101 degrees F,

and heart rate is 160. Her respiratory rate is very

slow at 8 breaths per minute, and so you imme-

diately jump into airway and respiratory support.

PEDIATRIC PERIL

It doesn’t matter whether you’re a seasoned

professional or on your first EMS call: Being

dispatched to a scene with a sick pediatric

patient evokes feelings of fear in even the most

seasoned provider. Sick pediatric patients are a

low-volume, high-acuity call, and those who’ve

treated sick children know how fast they can

deteriorate and how quickly one must act.

It’s never a bad idea to brush up on pediatric

care, and where better to start than the airway?

Although pediatric airways may seem intim-

idating, arming yourself with knowledge and

clinical experience make them manageable.

Pediatric patients are responsible for approx-

imately 7–13% of EMS calls.1 The Pediatric

Emergency Care Applied Research Network

found the most common chief complaints

were traumatic injury (29%), pain (combining

abdominal and others) (10.5%), general illness

(10%), respiratory distress (9%), behavioral

disorder (8.6%), seizure (7.45%), and asthma

(3.9%).2 Regardless of the chief complaint of

the call, early and appropriate airway manage-

ment is a very important first step.

ANATOMY & PHYSIOLOGY

The statement, “children are just little adults,”

is a long-dispelled myth. In fact, pediatric air-

ways can be vastly different from the adult

airways EMS providers more commonly

Figure 1: Pediatric vs. adult upper airway anatomy

It’s a beautiful Saturday afternoon and you and your partner

are discussing how slow the day has been. Your conversation is

interrupted by dispatch informing you of your next call, “a 1-year-

old female with high fever, not alert.” It’s been a while since you

and your partner have had to manage a pediatric airway, and you

both begin to mentally prepare for the call.

LITTLE AIRWAYS, BIG CHALLENGES

1703JEMS_28 28 2/13/17 2:37 PM

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1703JEMS_29 29 2/13/17 2:37 PM



Neutral supine position showing flexion of the neck due to a child’s proportion-

ally large head.

Figure 2: Proper and improper pediatric positioning

Proper positioning of a towel under a child’s shoulders to counter neck flexion.

Improper positioning of a towel to counter neck flexion.

encounter. These differences are due to anatomical differences that

amount to physiologic changes that predispose the patient to airway

obstructions.3 (See Figure 1.)

Head: In the supine position, a young child’s head will cause a

natural flexion of the neck due to its large size. This neck flexion can

create a potential airway obstruction. Patients usually benefit from

a towel to elevate the shoulders as well as someone to assist to help

hold the head, as it can be floppy.

Tongue: A child’s tongue is proportionally larger in the orophar-

ynx when compared to adults, and it may obstruct the airway due

to this size.

Larynx: Located opposite C2–C3, a child’s larynx is higher up

than in an adult, creating a more anterior location that often results

in difficulty when a provider attempts to visualize a child’s airway.

Epiglottis: The adult epiglottis is flat and flexible, while a child’s is

U-shaped, shorter and stiffer. This makes it more difficult to manip-

ulate and is a common reason providers can’t visualize an airway with

a curved blade in a pediatric patient.

Vocal cords: The anterior attachment of a pediatric patient’s

vocal cords is lower than the posterior attachment, which cre-

ates an upward slant, whereas in adults, the vocal cords are hor-

izontal. This concave shape may affect ventilation, and it ’s

important for providers to use a jaw-lift maneuver to open

the arytenoids.

Trachea: The trachea is shorter in pediatric patients, which

increases the likelihood of right mainstem intubation.

Airway diameter: A child’s airway is narrowest at the cricoid ring.

As a result, secretions can easily obstruct the airway, due to its small

size, and even a small amount of cricoid pressure can cause com-

plete airway obstruction.

Residual lung capacity: Smaller lung capacity in pediatric patients

means that a child can become hypoxic more quickly than an adult.

Providers should make sure to closely monitor oxygen saturation and

avoid prolonged periods without ventilation.

PEDIATRIC AIRWAY POSITIONING

The best way to set yourself up for airway success is by placing the

pediatric patient in the proper position. (See Figure 2.)

Taking into account anatomical considerations, start by placing

the patient in the position of comfort. Should you need to assist the

child’s ventilation, lay them supine. You can counter the flexion of the

neck due to a child’s large head by placing a towel under the shoul-

ders. Remember, the goal is to place the patient in a “sniffing position.”

Another way to think of this is aligning the ear canal with the ster-

nal notch. This position isn’t only optimal for intubation, it’s also ideal

when you’re ventilating with a bag-valve mask (BVM).

AIRWAY OPENING & SUCTION

Start with the basics, and make sure the patient has an open airway.

For any airway management case, pediatrics included, remember that

the least invasive maneuvers are often the most beneficial. If your pedi-

atric patient is hypoxemic, use the head-tilt chin-lift if you don’t need

to take C-spine precautions.

If there’s concern for C-spine injury, use a simple jaw thrust. Sup-

plemental oxygen can be applied if you believe the patient may ben-

efit from it.

Taking these actions quickly and correctly is sometimes all you have

to do to assist a pediatric patient with oxygenation and ventilation.

These simple airway opening techniques can have a dramatic effect,

so don’t underestimate them.

If a child is drooling or can’t handle secretions due to obstruction,

help them use gravity to expel secretions by placing them upright in

a position of comfort or on their side. Laying them down could be

detrimental rather than helpful.

1703JEMS_30 30 2/13/17 2:37 PM

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Remember, infants preferentially breathe

through their nose and can have significant

respiratory distress from nasal secretions alone.

Thus, suctioning these secretions can decrease

the work of breathing dramatically.4

If you continue to see minimal chest rise

or low oxygen saturation readings after per-

forming basic positioning and suction maneu-

vers, airway reinforcements will help provide

additional assistance.

Though the tongue can be an obstruction

in any airway, you may find it particularly

hindering in pediatric airway management.

Thus, inserting an oral or nasal airway can

be extremely helpful.

Remember that an oral airway is contrain-

dicated if the patient is alert or has an intact

gag reflex, and that a nasal airway adjunct is

contraindicated in severe central face trauma. If

needed, two nasal airways and one oral can all

be placed in order to facilitate a patent airway.

VENTILATION

Proper ventilation technique using a BVM

is critical—potentially far more important

than any invasive airway procedures such as

an extraglottic airway device or endotracheal

intubation. Ideally, this procedure is performed

with two providers: one to ensure a good mask

seal and the other for bag squeezing.

The first focus should be on creating a good

mask seal. This starts with selecting the cor-

rect mask size based on the patient’s weight

and ensuring it covers the mouth and nose. Be

mindful that in younger patients without teeth,

it can be difficult to create a good seal because

there’s no platform for the mask to rest on.

Next, properly place your hands using an

E-C grip if you’re the only one providing venti-

lation support, or the T-E grip if there another

provider is available. The T-E grip is helpful

because it keeps four fingers free to help keep

the patient’s airway open using the jaw lift.

During bagging, be mindful of not press-

ing the mask to the face but actually lifting

the patient’s face into the mask.

Lastly, focus on your target respiratory rate

as well as the amount of compression on the

bag. Barotrauma can result due to excessive

pressure being applied to the airway and this

can often occur due to provider stress and

distraction.

Another pitfall that often results from pro-

vider stress is hyperventilating the patient, so

remember to focus on the rate you’re squeez-

ing the bag during each ventilation. The ideal

respiratory rate for an infant up to 3 years is

20–30 breaths per minute. For older children

(ages 3 and up), the target respiratory rate is

16–20 breaths per minute.

INVASIVE TECHNIQUES

Positioning and BVM-assisted ventilations

will suffice for the great majority of situa-

tions requiring airway management of pedi-

atric patients; however, it may occasionally

be necessary or helpful to incorporate more

advanced airway techniques requiring place-

ment of a tool into the airway itself.

Extraglottic airway devices (EGDs): EGDs

are inserted blindly into the airway and have

very high success rates of providing oxygen-

ation and ventilation with a minimum of initial

and ongoing training. EGDs bypass common

challenges for achieving a tight mask seal,

free providers from performing two-person

BVM ventilation, may be placed easily despite

ongoing CPR, and decrease the risk for gas-

tric insufflation and aspiration as compared

to BVM.

Although these devices are being widely

incorporated by EMS systems for all these

reasons, there’s still little data on their use for

prehospital pediatric patients.

In adults, there are mixed results from pre-

hospital studies on the risks and benefits of

EGDs compared to intubation in cardiac

arrest,5,6 with larger studies now ongoing.7,8

There are a variety of EGDs now available

on the market, some of which offer pediatric

sizes. A number of them also have a channel

to facilitate gastric tube placement. The two

major categories are: 1) supraglottic devices

(e.g., laryngeal mask airways) that effectively

move the facemask from the BVM inside the

patient so that it sits over the glottis; and 2)

retroglottic devices that sit within the prox-

imal esophagus and have two balloons—one

in the pharynx to keep air from exiting the

mouth and one in the esophagus to keep air

from entering the stomach, directing gases

into the airway by default. (See Table 1, p. 34.)

Endotracheal intubation (ETI): ETI is ideal

for airway protection because the occluded tra-

chea mostly prevents aspiration of saliva, blood

and gastric contents into the lungs.

Though it’s an excellent means of oxygen-

ation and ventilation, it’s not the only way to

do so and basic maneuvers should be attempted

first before invasive procedures are performed.

Due to the success of non-invasive air-

way management, recent data has called into

question the utility and safety of ETI in all

prehospital patient populations and is a par-

ticularly hot debate in pediatrics.9

As a result, some large EMS systems have

chosen to remove this skill from the para-

medic scope of practice, including Los Ange-

les County and Orange County, Calif., and

the entire state of New Mexico. (See sidebar,

“Removing Pediatric ETI from Scope of Prac-

tice?” on p. 37.)

Despite the controversies, there are still

many prehospital providers who are perform-

ing ETIs and this skill should be reviewed

often. Anatomical differences in pediatric

patients require adjustments to your approach.

This starts with choosing your equipment.

When picking equipment, you should keep

in mind that pediatric patients generally have

a more U-shaped and stiffer epiglottis, mak-

ing a Miller blade preferable.

The potential variation in the size of your

patient is considerable, which can make ET

tube selection a challenge. Use of a Broslow

tape or the Handtevy System can help pro-

viders more quickly identify the blade and

ET tube size.

When choosing your ET tube, there’s a

choice between cuffed or uncuffed. It’s been

the school of thought for several years that

cuffed ET tubes resulted in mucosal injury in

pediatric patients. However, newer ET tube cuff

designs and monitoring of ET tube pressures

have minimized this risk. Some research has

shown no difference in post-extubation stridor

rates between uncuffed vs. modern cuffed ET

tubes in pediatric patients.10 However, long-

term consequences haven’t been studied.

Lastly, inexperience in the management of

Infants preferentially breathe through their nose

and can have significant respiratory distress from

nasal secretions alone.

1703JEMS_32 32 2/13/17 2:37 PM


1703JEMS_33 33 2/13/17 2:37 PM



pediatric airways often leads to higher stress

resulting in increased difficulty. Pediatric EMS

calls account for only 7–13% of all calls. Of

these, only 0.3% required intubation.1 Sim-

ulation training and keeping up to date on

pediatric airway skills are one way to reduce

the high stress of pediatric intubation and may

result in increased proficiency.

Video laryngoscopy (VL): Several VL

devices have been introduced over the last

decade to assist with ETI, and they’re generally

considered to improve intubation success and

aid in teaching ETI technique. By projecting

the intubation view onto a screen, VL allows

for others to provide real-time assistance and

the option to record the experience for qual-

ity improvement.

Larger VL devices have generally been used

in the hospital, but small, portable options

geared toward prehospital providers are now

readily available and have been shown to aid in

more successful first pass intubation attempts

in adults.11–13 (See Table 2, pp. 35–36, for an

overview of currently available devices.) Direct

sunlight can make screen visualization difficult

with some VL devices and this is important

to keep in mind when using them in the pre-

hospital setting.

Surgical vs. needle cricothyrotomy: In

the rare instance where you can’t oxygenate a

patient via less invasive methods, a cricothy-

rotomy may be indicated (but performed only

if it is within your scope of practice).

There are two broad categories of cricothy-

rotomy: surgical and needle. For many pediat-

ric patients a surgical airway is contraindicated

because smaller cricothyroid membranes and a

funnel-shaped, more compliant pediatric lar-

ynx can lead to an inadvertent incision of the

larynx as well as post-surgical complications

such as subglottic stenosis.3

Textbooks vary considerably regarding

the age cutoff for surgical cricothyrotomy,

but most agree that it is not indicated for

patients less than 8 years of age.3 On the

other hand, for patients over 12 years old,

the anatomy will generally permit surgical

cricothyrotomy—keep in mind it may not

be included in your scope of practice. Nee-

dle cricothyrotomy usually allows for oxygen-

ation, but ventilation will be less than ideal.

This procedure is generally utilized to keep

the patient alive until a more definitive air-

way can be obtained.

The decision to perform a cricothyrot-

omy—either needle or surgical—is often the

most difficult part of the procedure. Regular

practice helps to allay fears, as does planning

ahead of time whenever you anticipate a diffi-

cult airway by finding the anatomic landmarks,

marking the site and having the necessary

equipment ready.

CASE CONCLUSION

After you recognize the need to intervene

in the patient’s airway, you place the child

Table 1: Overview of extraglottic devices with pediatric sizes available

De

vic

e

Laryngeal mask airways King Laryngeal Tube (King LT) CombiTube

Ty

pe

Supraglottic Retroglottic Retroglottic

Ch

ara

cte

rist

ics

Most require air to inflate the cuff.

Usually have a port for a gastric tube,

allowing for less gastric distension,

which faciliatates more effective BVM

ventilation.

Some are designed for an ET tube to

be passed into the trachea.

Single inflation port inflates both

upper and lower balloons.

Recent models have a port for a

gastric tube, allowing for less gastric

distension. which faciliatates more

effective BVM ventilation.

Two separate ports for inflation of the

balloons and separate attachments

for the BVM.

Providers must assess if the distal end

is in the stomach or trachea prior to

using the BVM. (This is difficult and

increases the chance of error.)

Siz

es Usually come in pediatric and

neonate sizes.Comes in pediatric and neonate sizes.

Smaller-size 37F is available to use in

patients ≥ 4 feet. (No sizes available

for patients < 4 feet.)

1703JEMS_34 34 2/13/17 2:37 PM

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• An integral component in the SALAD Technique for clearing the airway

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Table 2: Overview of VL devices with pediatric sizes available

De

vic

e

Glidescope C-MAC PM McGrath MAC EMS

Sty

le Hyper-angulated blade ideal for

anterior airwaysMiller and Macintosh blades Macintosh-style angle curvature

Op

tio

ns

Reusable or disposable plastic covers. Reusable or disposable plastic covers. Reusable or disposable plastic covers.

Siz

es

No Glidescope rigid stylet available for

pediatric-sized ET tubes. Use the thick-

est, most rigid stylet possible to aid

tube placement.

Pediatric/neonate blades: Miller 0 and

1, Mac 0 and 2, and hyper-angulated

D-Blade Ped for difficult airways.

Pediatric size 2 blade available with

neonate size 1 coming soon.

1703JEMS_35 35 2/13/17 2:37 PM

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supine and position a towel behind her shoulders such that she’s in

good sniffing position.

You confirm with her shallow respirations that she has breath sounds

bilaterally. Supplemental oxygen and two-person BVM ventilation is

started and the patient is loaded into the ambulance.

En route, respirations continue to be adequately supported by BVM.

You arrive safely at the destination and transfer care to the ED team,

who continues resuscitative efforts.

You and your partner debrief while cleaning your ambulance and

prepare for the next call. Turns out it wasn’t such a quiet Saturday

afternoon after all. JEMS

Dorothy A. Habrat, DO, is an EMS fellow and an emergency medicine physician at the Uni-

versity of New Mexico Health Sciences Center. She’s also a flight physician with Lifeguard Air

Medical Services in Albuquerque. Contact her at [email protected].

Daniel R. Shocket, MD, MPH&TM, is an EMS fellow and an emergency medicine physi-

cian at the University of New Mexico Health Sciences Center. He’s also a flight physician with

Lifeguard Air Medical Services in Albuquerque.

Darren Braude, MD, EMT-P, is a professor of emergency medicine and anesthesiology at

the University of New Mexico (UNM) School of Medicine. He’s the director of the UNM EMS Fel-

lowship Program and EMS Academy, the medical director of three EMS/police organizations,

and is the medical director and national course director for The Difficult Airway Course: EMS.

REFERENCES

1. Hansen M, Lambert W, Guise JM, et al. Out-of-hospital pediatric airway management in the

United States. Resuscitation. 2015;90:104–110.

2. Lerner EB, Dayan PS, Brown K, et al. Characteristics of the pediatric patients treated by the Pediatric

Emergency Care Applied Networks affiliate EMS agencies. Prehosp Emerg Care.2014;18(1):52–59.

3. Roberts JR, Custalow CB, Thomsen TW, et al., editors: Roberts and Hedges’ clinical procedures in

Table 2 (continued): Overview of VL devices with pediatric sizes available

De

vic

e

Rusch Airtraq SP VividTrac KingVision

Sty

le

Macintosh-style angle curvature Macintosh-style angle curvature Macintosh-style angle curvature

Op

tio

ns

Single-use channel-loading device. Single-use channel loading device.Single-use channeled and traditional

blades available.

Siz

es Size 1 supports ET tube sizes

4.0–5.5 mm (pediatric); size 0 supports

ET tube sizes 2.5–3.5 mm (infant).

Pediatric blade supports ET tube sizes

4.0–6.0 mm.

Pediatric aBlades with adapter, sizes

1, 2 and 2C.

1703JEMS_36 36 2/13/17 2:37 PM

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emergency medicine, 6th ed. Saunders: Philadelphia, 2013.

4. Marx JA, Hockberger RS, Walls RM, et al., editors. Rosen’s

emergency medicine: concepts and clinical practice. Mosby:

Philadelphia, 2010.

5. Tiah L, Kajino K, Alsakaf O, et al. Does pre-hospital endotra-

cheal intubation improve survival in adults with non-trau-

matic out-of-hospital cardiac arrest? A systematic review.

West J Emerg Med. 2014;15(7):749–757.

6. Hasegawa K, Hiraide A, Chang Y, et al. Association of prehos-

pital advanced airway management with neurologic outcome

and survival in patients with out-of-hospital cardiac arrest.

JAMA. 2013;309(3):257–266.

7. Benger JR, Voss S, Coates D, et al. Randomised comparison

of the effectiveness of the laryngeal mask airway supreme,

i-gel and current practice in the initial airway management

of prehospital cardiac arrest (REVIVE-Airways): A feasibility

study research protocol. BMJ Open. 2013;3(2).

8. Wang HE, Prince DK, Stephens SW, et al. Design and implemen-

tation of the Resuscitation Outcomes Consortium Pragmatic Air-

way Resuscitation Trial (PART). Resuscitation. 2016;101:57–64.

9. Prekker ME, Delgado F, Shin J, et al. Pediatric intuba-

tion by paramedics in a large emergency medical services

system: Process, challenges and outcomes. Ann Emerg Med.

2016;67(1):20–29.

10. Weiss M, Dullenkopf A, Fischer JE, et al. Prospective randomized

controlled multi-centre trial of cuffed or uncuffed endotracheal

tubes in small children. Br J Anaesth. 2009;103(6):867–873.

11. Wayne MA, McDonnell M. Comparison of traditional versus

video laryngoscopy in out-of-hospital tracheal intubation.

Prehosp Emerg Care. 2010;14(2):278–282.

12. Jarvis JL, McClure SF, Johns D. EMS intubation improves

with King Vision video laryngoscopy. Prehosp Emerg Care.

2015;19(4):482–489.

13. Boehringer B, Choate M, Hurwitz S, et al. Impact of video

laryngoscopy on advanced airway management by critical

care transport paramedics and nurses using the CMAC pocket

monitor. Biomed Res Int. 2015;2015:821302.

14. Sakles JC, Chiu S, Mosier J, et al. The importance of first pass

success when performing orotracheal intubation in the emer-

gency department. Acad Emerg Med. 2013;20(1):71–78.

15. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-

hospital pediatric endotracheal intubation on survival and

neurological outcome: A controlled clinical trial. JAMA.

2000;283(6):783–790.

REMOVING PEDIATRIC ETI FROM SCOPE OF PRACTICE?

Endotracheal intubation (ETI) is a skill that requires repetition to reinforce proficiency,

and depending on the structure of your local EMS system and makeup of the patient

population, intubation rates per paramedic vary considerably.

A study conducted in King County, Wash., showed that pediatric intubation attempts

occurred in 1 out of 2,198 EMS calls.9 Moreover, with the improvements made on

modern extraglottic devices, it’s likely that prehospital ETI will continue to occur

with less frequency.

Although eventual successful intubation was achieved in 97% of pediatric intubation

cases studied in King County—a high-functioning EMS system—only 66% achieved

first pass success (53% in infants).9 King County paramedics had an average of six live

pediatric intubations during initial training and annual pediatric intubation simulations,

which is considerably more experience than the average paramedic. It’s likely that ser-

vices with less pediatric ETI experience will have even lower rates of first pass success,

resulting in higher complication rates.

A first pass success rate is important because complications increase as the number

of intubation attempts increase. One study showed adverse event rates increasing from

14.2% (for cases with successful intubation on the first attempt) to 47.2% (in cases

with second pass success) and to 63.6% (in cases with successful intubation on the third

pass).14 Although this study only included adult patients, it’s likely that similar results

would hold true for pediatric patients.

Research suggests that prehospital ETI in pediatric patients doesn’t improve sur-

vival when compared to bag-valve mask (BVM). In one study, pediatric patients had no

difference in survival to discharge nor neurological outcome when airway emergencies

were managed with a BVM vs. ETI. This included patients with medical and trau-

matic cardiac arrests, respiratory arrest and distress, head trauma with poor neurolog-

ical response, and provider assessment that the patient required ventilatory support.15

Given that the rare occurrence of pediatric ETI results in poorer first pass success

rates, which thereby increases the chances for complications, additional EMS systems

may begin to reconsider allowing pediatric ETI within the scope of practice for pre-

hospital providers.

1703JEMS_37 37 2/13/17 2:37 PM

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