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5 essential tips for managing pediatric airways

Pediatric patients need to be handled with care using these five expert tips.


Follow these five tips to improve your management of these high acuity, low frequency situations.

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The following is paid content sponsored by Ambu.

By Jonathan Lee for EMS1 BrandFocus

Prehospital providers of all levels take tremendous pride in their airway skills.

But that confidence and expertise does not always extend to managing children. Children make up a fraction (7 to 13 percent) of most normal 911 call volume, and only 4.5 percent of those require airway management.

Follow these five tips to improve your management of these high acuity, low frequency situations.


In 2000, Gaushe et al published their landmark paper demonstrating prehospital endotracheal intubation of children provided no survival benefit.

In 2005, the PALS guidelines began to de-emphasize the important of intubation in favor of bag-valve mask ventilation. But prehospital practice is not keeping up with the evidence. In 2015, researchers reviewed almost a million pediatric patients in the National Emergency Medical Services Information System database. They noted a number of concerning trends.

First, intubation success rates are low (81 percent). Second, while success rates with certain supra-glottic airways was high (King LT 89 percent), paramedics still use intubation 10 times as often as SGAs. Most concerning, ETI success rates and SGA usage both decreased as patients got smaller.

The goal of airway management is to have the skills to oxygenate and ventilate the patient, and there is a growing suggestion in the literature that BVM or SGA may be superior to intubation in prehospital pediatrics.


A recent study in Prehospital Emergency Care found the most common knowledge gaps related to patient safety were a lack of experience with pediatric airway management (73.4 percent of respondents) and heightened anxiety when working with children (72.5 percent).

The same study noted the most challenging skill was pediatric advanced airway interventions.

Numerous avenues exist for increasing technical skills as well as comfort and confidence with pediatric patients. PEARS, PALS, PEPP and EPC are available pediatric education courses and accessible to most providers.

Other options include conferences or clinical experience that may be available for continuing education. If the options are not available, then lobby your local service or college to expand their pediatric offerings.

Don’t wait for a bad kid call to be the reason to seek extra training.


A recent study in Academic Emergency Medicine recruited on-duty EMS personnel to perform pediatric scenarios in a mobile simulator.

A major theme emerged as providers delayed oxygen administration or were unable to ventilate the patient. Researchers attribute this to being unfamiliar with the pediatric equipment.

This contributed to over half (54 percent) of providers failing to use an oral oropharyngeal airway during a respiratory arrest scenario.

Regularly inspecting pediatric equipment helps increase familiarity and will reduce the incidence of missing or broken equipment.


Recognizing the physical indications that airway interventions, such as BVM, SGA or ETI, may be difficult can potentially affect patient’s clinical course, transport destination and when to call for help.

It is an essential component to safely administering any medication that could potentially depress respirations such as analgesia, sedation or paralytics.

There are typically two indications that a child will be difficult to ventilate with a BVM and providers at all levels should be familiar with them. First, are there indications it will be difficult to make a good seal such as facial trauma or malformations (congenital), undeveloped teeth. Second, are there indications that it will be difficult to ventilate such as lung pathology, airway obstruction or morbid obesity.

Determining the presence of a difficult airway allows time to form a back-up plan – anticipating the possibility of BVM failure.

The following mnemonics are not pediatric specific, but do provide an excellent memory aid for predicting difficulty during various stages of airway management:

  • Predicting difficult BVM: MOANS
    • Mask seal
    • Obesity/obstruction
    • Age
    • No teeth
    • Stiff lungs
  • Predicting difficult SGA: RODS
    • Restricted mouth opening
    • Obstruction
    • Disrupted or distorted airway
    • Stiff Lungs or cervical spine
  • Predicting difficult intubation: LEMON
    • Look externally
    • Evaluate the 3-3-2 rule
    • Mallampati
    • Obstruction/obesity
    • Neck mobility


Respiratory distress is a common presentation for children, but it is significantly different than respiratory failure.

Respiratory distress represents some combination of dyspnea and tachypnea. Respiratory failure represents the inability of a patient to provide adequate oxygenation or ventilation.

Respiratory failure has all of the same signs and symptoms of respiratory distress (tachypnea, accessory muscle use, as well as abnormal breath sounds). But also has significant hypoxia, hypercarbia or both.

Pallor and cyanosis are common, but the hallmark findings involve neurological changes such as restlessness, anxiety, lethargy or decreased level of consciousness. Special attention should be paid to the heart rate as bradycardia is a common sign of significant hypoxia. Providers must be able to reliably identify respiratory failure as this pediatric patient is likely pre-arrest.

These five tips will help prehospital providers of all levels increase their confidence to managing children.

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