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 approximately 8 breaths per minute. You look at your partner, who appears just as worried about the patient as you are, and quickly begin taking 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 systolic blood pressure is 90 mmHg, oxygen saturation 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 immediately jump into airway and respiratory support.
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 intimidating, arming yourself with knowledge and clinical experience make them manageable.
Pediatric patients are responsible for approximately 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 management is a very important first step.
ANATOMY & PHYSIOLOGY
The statement, “children are just little adults,” is a long-dispelled myth. In fact, pediatric airways can be vastly different from the adult airways EMS providers more commonly encounter. These differences are due to anatomical differences that amount to physiologic changes that predispose the patient to airway obstructions.3 (See Figure 1.)
Figure 1: Pediatric vs. adult upper airway anatomy
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 oropharynx 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 manipulate 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 creates an upward slant, whereas in adults, the vocal cords are horizontal. 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 complete 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.)
Neutral supine position showing flexion of the neck due to a child’s proportionally large head.
Proper positioning of a towel under a child’s shoulders to counter neck flexion.
Improper positioning of a towel to counter neck flexion.
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 shoulders. 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 sternal 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 pediatric 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. Supplemental oxygen can be applied if you believe the patient may benefit 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.
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 performing basic positioning and suction maneuvers, 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 contraindicated 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.
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 correct 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 ventilation 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 pressing 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 provider stress is hyperventilating the patient, so remember to focus on the rate you’re squeezing 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.
Infants preferentially breathe through their nose and can have
significant respiratory distress from nasal secretions alone.
Positioning and BVM-assisted ventilations will suffice for the great majority of situations requiring airway management of pediatric patients; however, it may occasionally be necessary or helpful to incorporate more advanced airway techniques requiring placement 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 oxygenation 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 gastric 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 prehospital 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 proximal 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.)
Endotracheal intubation (ETI): ETI is ideal for airway protection because the occluded trachea mostly prevents aspiration of saliva, blood and gastric contents into the lungs.
Though it’s an excellent means of oxygenation 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 airway management, recent data has called into question the utility and safety of ETI in all prehospital patient populations and is a particularly hot debate in pediatrics.9
As a result, some large EMS systems have chosen to remove this skill from the paramedic scope of practice, including Los Angeles County and Orange County, Calif., and the entire state of New Mexico. (See sidebar, “Removing Pediatric ETI from Scope of Practice?” below.)
Despite the controversies, there are still many prehospital providers who are performing 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, making 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 providers 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 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 Simulation 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 quality 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 prehospital setting.
Surgical vs. needle cricothyrotomy: In the rare instance where you can’t oxygenate a patient via less invasive methods, a cricothyrotomy may be indicated (but performed only if it is within your scope of practice).
There are two broad categories of cricothyrotomy: surgical and needle. For many pediatric patients a surgical airway is contraindicated because smaller cricothyroid membranes and a funnel-shaped, more compliant pediatric larynx 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. Needle cricothyrotomy usually allows for oxygenation, but ventilation will be less than ideal. This procedure is generally utilized to keep the patient alive until a more definitive airway can be obtained.
The decision to perform a cricothyrotomy—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 difficult airway by finding the anatomic landmarks, marking the site and having the necessary equipment ready.
After you recognize the need to intervene in the patient’s airway, you place the child 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.
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 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 endotracheal intubation improve survival in adults with non-traumatic 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 prehospital 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 implementation of the Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART). Resuscitation. 2016;101:57–64.
9. Prekker ME, Delgado F, Shin J, et al. Pediatric intubation 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 emergency 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 services 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 survival 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 traumatic cardiac arrests, respiratory arrest and distress, head trauma with poor neurological 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 prehospital providers.