By Christopher Boyer
The most current version of the EMS Educational Standards requires providers of all skill levels to be able to manage the pediatric patient’s airway [1]. The level of management ranges from basic airway adjuncts and ventilation at the EMT level to intubation and needle cricothyrotomy at the paramedic level.
Despite these training requirements, EMS practitioners utilize these skills infrequently, resulting in a high-risk, low-frequency skill that providers must remain competent in through continuing education [2]. The need for an increase in training for EMS providers in the management of the pediatric airway has been deemed the most important area for further research by the Emergency Medical Services for Children program [3]. Here are some of the best practices for pediatric airway management and analysis of some of the research surrounding the management of the pediatric airway by EMS providers.
Pediatric airway management with BLS techniques
When treating critically ill and injured children, the predominant cause of death is respiratory arrest [2]. When managing the pediatric patient’s airway, the approach to airway management cannot be viewed as a one-time intervention but is rather a series of steps that involves intervention, re-assessment and further intervention if deemed necessary [2]. Basic management of the pediatric airway includes the following steps:
- Proper positioning of the airway, including padding behind the shoulder blades in infants and young toddlers [2, 4]
- Monitoring of respiratory status including waveform capnography and pulse-oximetry
- Managing airway obstruction while remembering the pediatric airway is more susceptible to obstruction by both foreign body aspiration and soft tissue swelling than the adult [4]
- Administration of supplemental oxygen as needed
- Effective BVM ventilation at an appropriate rate [2, 4]
- Utilization of appropriate airway adjuncts including oral and nasal airways
Pediatric airway management with ALS techniques
When the patient exhibits the need to be managed with advanced airway managements, a highly-skilled practitioner should be utilized to perform the skills. Advanced airway management includes the following:
- Recognition of the need for advanced airway management
- Proper selection of appropriate sized equipment
- Appropriate intubation techniques with direct or video laryngoscopy
- Utilization of an alternative airway device, like an LMA or King, as deemed appropriate
- Utilization of an appropriate surgical airway technique for situation with a full or partial obstruction proximal to the glottic opening that is preventing intubation or oxygenation [4]
What does the literature say about pediatric airway management?
In comparing pediatric intubation to adult intubation by prehospital providers, endotracheal tubes placed in pediatric patients are much more likely to be placed incorrectly than adults [2]. Further, the intubation of pediatric patients by prehospital providers has been shown to increase scene times and extend the time to definitive care in the hospital [2].
When attempting a needle cricothyrotomy in the hospital setting, research has shown that as many as 65 percent of these procedures fail resulting in the recommendation that a trained surgeon perform this procedure in the hospital [5].
The use of extraglottic devices, such as the LMA or King airway have been shown to be highly successful and an effective means for managing the pediatric patients airway [5].
Simulation training has also demonstrated that the placement of the King airway in a pediatric patient is not only performed with a higher success rate than intubation, but is a procedure that was preferred over intubation by the paramedics who participated in one study [6].
Further evaluation of paramedic skill performance in managing the pediatric airway in a resuscitation scenario found multiple skill deficiencies, including intubation and the calculation of medication dosages [7].
Memorable quotes from the pediatric airway management literature
Here is a list of memorable quotes from the research literature reviewed for this article.
From “Evidence and Controversies in Pediatric Airway Management”
- Respiratory arrest is the predominant cause of mortality in critically ill and injured children.
- Prehospital airway management can be life saving for critically ill or injured children but is a low-frequency, high-risk event fraught with the potential for error.
- Basic airway maneuvers are the cornerstone of maintenance of oxygenation and ventilation by EMS professionals in the field.
- Overall, the incorporation of pediatric intubation in prehospital protocols has demonstrated more negative than positive impact.
- In a landmark study comparing prehospital intubation to BVM only, “no statistically significant difference was seen for either survival to hospital discharge or good neurologic outcomes.
From “Paramedic King Laryngeal Tube Airway Insertion Versus Endotracheal Intubation in Simulated Respiratory Arrest:
- Our study shows that EMS providers overwhelmingly preferred the KLT airway for pediatric arrests, even with limited training, commenting on its ease of use.
From “Simulation-Based Assessment of Paramedic Pediatric Resuscitation Skills”
- EMS Educators and EMS medical directors should target pediatric resuscitation skill deficiencies when developing continuing education.
Key pediatriac airway management takeaways for EMS providers
After reviewing a set of research articles on pediatric airway management here are four key takeaways for EMS providers.
- Pediatric airway management is a low-frequency, high-risk skill that requires ongoing training and practice to maintain proficiency.
- Providers may consider utilizing an alternative airway, such as the LMA or the King LT-D, when managing the pediatric airway rather than resorting to intubation.
- For services that utilize surgical airways for pediatric patients, this skill requires a great deal of ongoing training and practice as evidenced by the poor success rate among many emergency providers.
- The cornerstone of pediatric airway management remains basic airway maneuvers, and providers should only consider moving to advanced procedures if the basic maneuvers are not effective in maintaining adequate ventilation and oxygenation.
About the author
Chris Boyer, NRP, FP-C., M.A., M.P.A. functions as a lead instructor and the simulation coordinator in the paramedic program at Delaware Technical Community College. He has been an EMS provider since 1999, and has worked in the prehospital and Air Medical Environments. He is a 2003 graduate of the Pennsylvania College of Technology’s Paramedic Program and is currently pursuing the Doctor of Business Administration degree at Wilmington University. You can contact him at chris.boyer@dtcc.edu
References
1. National Highway Traffic Safety Administration, “National Emerngency Medical Services Education Standards,” NHTSA, Washington, DC, 2007.
2. J. Anders, K. Brown, J. Simpson and M. Gausche-Hill, “Evidence and Controversies in Pediatric Airway Management,” Clinical Pediatric Emergency Medicine, vol. 15, no. 1, pp. 28-37, 2014.
3. G. Foltin, P. Dayan and M. Tunik, “Priorities for pediatric prehospital research,” Pediatric Emergenc Care, vol. 26, pp. 113-777, 2010.
4. R. M. Walls and M. F. Murphy, Emergency Airway Management, Philadelphia: Lippincott Williams & Wilkins, 2012.
5. R. A. Sunder, D. T. Haile, P. T. Farrell and A. Sharma, “Pediatric airway management: current practices and future directions,” Pediatric Anesthesia, vol. 22, pp. 1008-1015, 2010.
6. M. S. Mitchell, M. L. White, W. D. King and H. E. Wang, “Paramedic King Laryngeal Tube Airway Insertion Versus Endotracheal Intubation in Simulated Respiratory Arrest,” Prehospital Emergency Care, vol. 16, pp. 284-288, 2012.
7. R. L. Lammers, M. J. Byrwa, W. D. Fales and R. A. Hale, “Simulation-Based Assessment of Paramedic Pediatric Resuscitation Skills,” Prehospital Emergency Care, vol. 13, pp. 345-356, 2009.