How to Manage the Pediatric Airway
This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.
“Medic 7 and Rescue 5, Lilly Lake Day Care, 3-year-old choking. All responding units, be advised object is dislodged, child is not breathing, prearrival being initiated.”
As you arrive on the scene, you are met by a distraught daycare provider who takes you inside. There two colleagues are desperately attempting to clear vomitus out of the 3-year-old’s mouth. “We have a pulse,” one of them tells you anxiously. As you turn the patient onto her side, your partner prepares the battery-operated suction, and you insert a large-bore suction catheter, using gravity and suction to clear the remaining vomitus from the child’s mouth. As you roll her back, one of the EMTs grabs a nearby blanket, quickly folds it and places it under the patient’s shoulders to help with positioning. You assess the level of consciousness and find the child unresponsive to painful stimuli. Next, while you are looking and listening for breathing, you simultaneously assesses for a carotid pulse. The child is still not breathing, but has a pulse of 70. From the brief initial history your partner obtained, there is nothing to suggest trauma was involved. You place the bag-valve mask onto the patient’s face, pull the jaw into the mask and begin ventilating as one EMT attaches the BVM to oxygen at 15 lpm and another inserts an oral airway. As one EMT ventilates the patient, you select and place an appropriate-size supraglottic airway, and your partner places a tibial intraosseous needle. Another EMT places cardiac electrodes. Following assessment for proper placement, you secure the SGA and then package the patient on a long spine board with a cervical collar.
Pediatric patients make up a small percentage of most EMS systems’ responses, and critical pediatric responses are even rarer. A survey conducted by the National Registry of EMTs in 2000 found most EMS providers responded to 0–3 pediatric calls a month.1 A 2006 study from a large Canadian metropolitan area found that of 1,377 pediatric patients cared for during a six-month period, only 0.3% received BVM ventilation, and 0.1% were endotracheally intubated.2 Courses like the American Heart Association’s PALS (Pediatric Advanced Life Support) and PEARS (Pediatric Emergency, Assessment, Recognition and Stabilization), the Pediatric Education for Prehospital Providers (PEPP) course, and Pediatric International Trauma Life Support (PITLS) have helped standardize and disseminate prehospital pediatric education and training, but even with these courses and required hours for all levels of nationally registered EMS providers, many providers still describe a need for additional education and training on pediatric patients (i.e., from newborn to around 3 years old).1 The leading causes of cardiac arrest in young children are respiratory compromise/failure from sudden infant death syndrome (SIDS), trauma, a primary respiratory problem and near-drowning, and the average age of pediatric cardiac arrests is 3 months to 3 years.3–5 This supports EMS providers’ desire for additional education and training in assessment and management of pediatric patients.
Positioning, Opening and Suctioning
Whether you are a basic or advanced provider, the key elements of airway management are patient positioning, provider positioning, opening the airway and suctioning.6–8 For children 3 and under, the foundation of positioning is padding under the shoulders and/or upper torso to obtain a neutral or “sniffing” position; those over 3 may require padding under their occiput.7 Bath blankets, towels and folded sheets work well for this.
Patient location can affect patient positioning. There are times when the patient has to be managed where they are found—for example, in a vehicle with extrication required. If the patient is located in a bathroom, cramped room or small space, moving them as soon as possible will allow for better positioning and room for log-rolling and suctioning if required. It is optimal to have plenty of space to conduct all aspects of the resuscitation.
The next component is positioning of the provider(s) managing the airway. The provider delivering BVM ventilations should be at the top of the patient’s head (though patient location may require modification of this and other positions until the patient can be moved). Having the provider managing the airway at the head not only allows for proper positioning, but also allows control of the head if the patient needs to be log-rolled or turned for suctioning. It also allows coordination of airway interventions with other procedures, such as CPR and/or defibrillation.9
Next, using an team approach, positioning the provider assisting to the right side of the patient allows that individual to not only assist with patient positioning and suctioning, but also to hand the suction catheter, a bougie or the ET tube to the intubating provider without forcing that provider to take their eyes from their airway view or requiring the assisting provider to reach across the patient.
Next, the provider at the top will choose which method to use to open the airway. That will be based on mechanism of injury or personal preference. All three methods—head-tilt/chin-lift, jaw thrust and modified jaw thrust (jaw thrust without head-tilt)6—work equally, but with an airway team approach, the jaw thrust and modified jaw thrust are most effective for BVM ventilation and further airway interventions. If cervical spine trauma is suspected or unknown, the modified jaw thrust is preferred.10 If the modified jaw thrust fails to open the airway, attempt it using the jaw thrust or head-tilt/chin-lift. Remember, the child may or may not have a cervical spinal injury, but without a patent airway, the child will die.11
Once the airway is open, the last part of the foundation, suctioning, can be used if required. Suctioning can be achieved by four methods. First is the use of gravity, or simply turning or log-rolling the patient, with c-spine stabilization, when trauma is suspected. Second—and this can be used once you’ve turned or even while you’re turning the patient—is sweeping out any visible pieces from the mouth with your finger. Third is using a manual suction device with either a large-bore or pediatric suction catheter attached. Last is motorized suction, which can either be portable and battery-powered or on-board and vacuum-powered.6 For initial airway management, a large-bore/diameter suction catheter is typically used as needed to clear the airway.6
The Impact of Anatomy and Physiology on Managing the Airway
The anatomy and physiology of the pediatric airway differ from those of the adult in a number of ways that can impact your ability to manage the airway and influence the adjuncts you use. Foremost to consider is that airway sizes and anatomy may vary greatly in children of the same age.6 With these variations, weight- or length-based resuscitation tapes should be readily available and have demonstrated accuracy in determining a child’s weight and starting point for appropriate-size adjuncts.12
Comparing the pediatric and adult airway, the most prominent difference is the child’s relatively larger head compared to the body. This difference can present challenges in positioning the child’s head. Remember, these are starting points for further airway maneuvers such as the head-tilt/chin-lift6 and may need to be adjusted based on individual patient size. Once the torso and head are positioned and you open the mouth, the tongue will appear larger in proportion to the oral cavity than an adult’s. It is the most common obstruction of the child’s airway, but is easily corrected with a head-tilt/chin-lift or modified jaw thrust, if trauma is suspected, and placement of an appropriate-size oral airway.6
Next, not visible externally is that the oral pharynx and trachea are much smaller and narrower than an adult’s and can easily become compromised by secretions, blood or foreign objects.7 For the advanced provider placing an endotracheal tube, the larynx is higher at C3–C4, the epiglottis is more oblong in infants and horseshoe or omega-shaped as the young child grows, and the softer cartilage of the airway may cause the epiglottis to be floppy and more difficult to control than that of an adult.7,13 It is also important to remember that the 10th cranial nerve, the vagal nerve, is spread throughout the pharyngeal portion of the airway, and stimulation of it may cause bradycardia, which may be more pronounced in children due to their greater response to vagal stimulation.7,14 Thus, too large an oral airway, suctioning or ET intubation may cause significant vagal response and subsequent bradycardia, which is usually correctable with BVM ventilation and/or administration of IV or IO atropine sulfate.14
If all other methods of airway management have failed in children less than 8 years of age, a needle cricothyroidotomy is the final option. Unlike an adult’s, the trachea in children is small, tracheal rings have not have fully developed, and the trachea itself is pliable and collapsible and can be kinked or compressed easily. This makes a needle cricothyroidotomy in children challenging even for an experienced provider.
Simple Adjuncts, BVM Ventilation and Cricoid Pressure
Now that your team has positioned, opened and suctioned the airway, you can begin ventilations using a self-inflating BVM (or barrier device), which delivers a volume of 450–500 milliliters, supplemental oxygen, and a simple adjunct such as an oral or nasal airway. You may also initially begin without an adjunct and/or supplemental oxygen. A child not breathing is receiving 0% oxygen. With just BVM ventilation and no supplemental oxygen, they are receiving 21%.6 Initiate BVM ventilation, then attach supplemental oxygen and place a simple adjunct as resources allow. A BVM attached to oxygen with a reservoir at 3 lpm will deliver roughly 60% oxygen; at 8 lpm it will deliver in the high 90% range.15 Always refer to your device manufacturer’s operational ranges and service guidelines.
Providing effective ventilations includes placing the patient in a neutral or “sniff” position and re-evaluating the size of BVM mask being used (it should fit from the bridge of the nose to the chin). If you’re unable to obtain an adequate seal, consider a larger or smaller mask. Ideally, you should have a selection of different-size masks to choose from. Next look for equal chest expansion, and if you notice the stomach distending, try repositioning the head and/or adding padding. Improving skin color and/or increasing pulse oximetery saturation readings demonstrate that ventilations are being delivered effectively.
Now that good, solid BLS airway management has been initiated, the team needs to consider what it needs to accomplish—ventilation, oxygenation, clearing/suctioning or securing the airway. By way of example, a pediatric drowning patient may require all four, whereas a postical pediatric seizure patient may require only ventilation and oxygenation for a brief period. Answering this question will also assist the team in determining if it will continue ventilations with a BVM and oral or nasal airway, move to a supraglottic airway, or perform ETI with or without cricoid pressure.
Cricoid pressure to prevent gastric inflation and subsequent aspiration was first used in 1774, and discussion focused around the very issues that have reemerged around its use today.16 Cricoid pressure has been used by both BLS providers during BVM ventilation and ALS providers to improve their view during ETI. This continues to be taught and used, even though there is no evidence to support that it prevents aspiration during ETI in children,17 and the evidence that it may decrease the incidence of gastric inflation is not conclusive.17–19 In place of cricoid pressure, another method used is the BURP technique (for backward, upward and rightward pressure); applied externally to the trachea, this may improve visualization of the vocal cords more effectively than cricoid pressure.20 Ultimately, providers should move the external trachea in whichever direction enhances their view of the vocal cords and facilitates ETI.
Many EMS systems, both BLS and ALS, have begun using supraglottic airways in managing adult patients. A smaller number have begun using them to manage pediatric airways21,22 as an advanced adjunct in lieu of or as an alternative to ET intubation, or as a backup airway if ET intubation is unsuccessful.23 SGAs are placed blindly and are fast and easy to use, with insertion times as fast as five seconds.24 SGAs can be placed with CPR in progress, minimizing interruption of compressions, which makes them an ideal airway choice for first responders and BLS services that do not perform ET intubation.18 SGA is a broad term describing airway devices that may or may not have inflatable cuffs. If the SGA is cuffed, one cuff is typically inflated in the posterior oral pharynx, and often a second cuff in the upper esophagus, though this varies with manufacture and type.25 Some SGAs now use innovative materials that do not require cuffs and allow the airway to mold and seal around the device. SGAs come in many shapes and sizes from neonate to adult and may be reusable or disposable. Most SGAs decrease the potential for aspiration, but do not completely eliminate the risk. By placing a gastric tube with or following placement of an SGA, the risk of aspiration can be further reduced.26 Once the SGA has been placed, assess for the presence of bilateral lung sounds and the absence of gastric sounds to confirm correct placement. Secure the SGA with tape or a commercial tube restraint.
Endotracheal intubation is the placement of a cuffed or uncuffed endotracheal tube under direct visualization into a patient’s trachea to secure the airway. ETI has been used by advanced-level prehospital providers for years in unconscious, not-breathing cardiac arrest patients with success rates from 85%–95% in adult patients27,28 and 50%–89% in pediatric patients.29,30 Over the years more ALS services have added rapid sequence induction/intubation (RSI). RSI is the administration of an induction or sedative medication and a neuromuscular blocking agent or paralytic to facilitate orotracheal intubation; this process has yielded success rates that mirror that of non-RSI orotracheal intubation.31,32 Pediatric ETI followed adult ETI with mixed success. The verdict as to whether it improves or compromises outcomes in pediatric patients is still out.2,33–35 While the gum elastic bougie (GEB) 36 has become an integral part of many ALS providers’ arsenal of adult airway tools, the pediatric GEB has not. The GEB is designed to facilitate ET intubation when the inlet of the trachea is not completely visible. It has been associated with increased success rates and shorter times required to intubate.36–38
Pediatric ET tubes, unlike adult ET tubes, may be cuffed or uncuffed.39 As early as 1994 there was discussion as to whether cuffed pediatric ET tubes would cause damage to the trachea. In 2005 the AHA’s recommendation was that the use of cuffed ET tubes was safe and effective on pediatric patients of all ages,39,40 though in neonates noncuffed tube are still recommended41 since they remain in place for extended periods of time. The reasons to ET intubate a child are the same as they are for an adult. Once the decision is made to intubate the pediatric patient, a backup plan must be in place. For example, after two attempts we place an SGA and begin packaging the patient for transport. Next, an appropriate-size ET tube must be selected by one of two methods. First and most accurate (up to 35 kgs) is to use a length-based resuscitation tape.39 Second, for children older than 1, you can calculate the correct size ETT with the following formula: [Child’s age + 16]/4 = ETT size. For example, for a 6-year-old, 6 + 16 = 22, and 22/4 = a size 5.5 ETT. It is also a good habit to have handy tubes 0.5 mm smaller and larger in case the tube you selected is too large or small.
Length and weight can also help the provider determine what type and size of laryngoscope blade to select. In younger children up to around 18 kgs, a straight (Miller) #1 blade is typically preferred; this directly lifts the epiglottis, which may be floppier. In older children starting around 19 kgs, a curved (Macintosh) #2 blade, which slides into the vallecula and indirectly lifts the epiglottis,9 may be used instead. Blade style and size choice is often influenced by provider experience and preference.
Once the ET tube has been placed, assessment for correct placement can be accomplished by a number of methods. The first is watching the tube pass through the vocal cords, followed by chest rise and fall with ventilation and the presence of bilateral breath sounds and absence of gastric sounds. If the child is over 5 years, an esophageal detection device may be used as another tool prior to initiation of ventilations.42 End-tidal carbon dioxide (EtCO2) monitoring should be initiated at this time by quantitative waveform capnography43 and pulse oximetry.9 Once placement is confirmed, the device can be secured with either tape and an oral airway or a commercial tube restraint. Some services elect to also c-collar and place the patient on a spine board to further secure the tube for transport.44,45
Recent advances in fiber optics, video and computer technology have resulted in an explosion of indirect video laryngoscopes (IVLs) designed specifically for ET intubation.46 These devices use a non-line-of-sight view, an intense light source and a fiber-optic camera built into the distal end of the laryngoscope.47 All were designed for adult use, but most have or will ultimately have pediatric and neonate versions or adapters. The term videoscopes encompasses a number of different devices, including those that are hand-held, with an attached camera but separate viewing screen, and those with viewing eyepieces attached to the handle that you look down through. They may be classified as those having a guiding channel for the ET tube to follow and those without. Most have disposable adapters/blades, while others are intended for complete disposal after use.
Current research has shown that IVLs provide better glottic views,47 higher success rates across a wide range of patients, including children,48,49 and against varying degrees of airway difficulty compared to direct-visualization intubation.49–51 That being said, there are challenges as well benefits with any new technology. There have been reports of cameras fogging and views being obstructed by blood or secretions. The latter, as with direct visualization, may only be remedied by the use of suction.
At the same time, with most of these devices, more than one provider can visually verify placement, meaning they offer an outstanding tool for teaching ET intubation.48 If research continues to show improved success rates in children, decreased time to intubation and fogging issues resolved or minimized, just as 12-lead EKGs moved from the hospital to the streets, video laryngoscopy could represent the future of prehospital ET intubation.
The Final Option: Surgical Airway
Surgical airways are rarely performed on adult patients by civilian EMS, and even more rarely on children. In a four-year study of one service, there were roughly 4,091 ET intubations out of 80,501 ALS patients. During that time just 11 patients required cricothyroidotomy to manage their airways.52–54 Since the structures of the child’s airway are not fully developed, transtracheal catheter ventilation,39 also referred to as high-frequency jet ventilation55 or needle cricothyroidotomy, is used in children under 8 years of age. The procedure consists of inserting a 14–20-gauge over-the-needle catheter (or commercial equivalent)6 into the trachea through the cricoid thyroid membrane and removing the needle once it’s placed. The child is then ventilated utilizing some form of interface between the catheter and oxygen supply tubing set at 25 lpm or higher to deliver at least 50 psi.6
There are also a number of commercial devices specifically designed for this purpose for both adult and pediatric patients. In the absence of these, a 2.5 mm ET tube adapter can be attached to the catheter and ventilations begun with a BVM. Once ventilations are begun, assessment for correct placement is performed no differently than following placement of an endotracheal tube. EtCO2 can be assessed by placing a 2.5 mm ET tube BVM adapter onto the end of the catheter and attaching either a colorimetric or quantitative capnography device to the adapter during exhalation.56 Transtracheal catheter ventilation is an effective and lifesaving procedure when no other option is left. It is a short-term intervention until a more definitive airway can be established, and the patient may begin retaining CO2 within 30 minutes depending on the size of catheter used.6 Securing can be accomplished by manual stabilization or tape.
The foundation of pediatric airway management has been and will continue to be BLS interventions: positioning, suctioning and ventilating, followed by appropriate ALS interventions. As providers we must choose the correct tool for the job. When the trauma center is three minutes away, an oral airway, BVM and suctioning may be more appropriate than spending 10 minutes on scene unsuccessfully trying to place an ET tube. Ultimately we must embrace tools that improve patient outcomes and re-evaluate or discard those that don’t.
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Scott Tomek, MA, EMT-P, has been a paramedic for 25 years, 23 with Lakeview Hospital EMS in Stillwater, MN. He is a faculty member with the Century College paramedic program, and a curriculum development specialist.