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3 ways to avoid making critical pediatric airway errors

Follow these tips to avoid mistakes when managing pediatric airways

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3 ways to avoid making critical pediatric airway errors

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By Jonathan Lee for EMS1 BrandFocus

Most prehospital providers are justifiably proud of their airway management skills. However, with the low frequency and high acuity of children requiring airway interventions, it is reasonable to be concerned that mistakes may happen.

Avoid these potential errors when managing airways in children. (Image Pixabay)
Avoid these potential errors when managing airways in children. (Image Pixabay)

In 2016, Hansen published characteristics associated with patient safety events during airway management. They reviewed over 11,000 pediatric patients transported in a metropolitan U.S. city. The authors focused on 490 ‘lights and sirens’ transports from which they isolated 329 patients having some type of airway management intervention.

The Hansen research identifies a number of characteristics related to airway management errors. Armed with this information, the following three steps can help avoid potential errors when managing airways in children.


Data shows that prehospital intubation occurred in 9.5 percent of children requiring airway management. Also, 70 percent of all endotracheal intubation (ETI) contained some type of error. A number of these errors are not unique to children, such as incorrect tube size (usually too small) or incorrect tube position (usually too deep).

Hansen also made more ominous observations, noting that in 58 percent of intubations the paramedic was unable to place the tube or ETI required three or more attempts.

Furthermore, patients who were successfully intubated, 13 percent had the tubed dislodged during transport. Finally, reviewers felt that in 24 percent of intubated patients, the procedure was not indicated.

The American Heart Association Pediatric Advanced Life Support guidelines recommends that BVM in the prehospital setting, especially when transport times are short, is a reasonable alternative to ETI and successful ETI in infants and children is related to “length of training… adequate ongoing experience and the use of rapid sequence intubation”—all  factors which are highly variable among prehospital providers.

ETI should not be a routine part of airway management; instead, it should be reserved for specific situations such as when BVM is ineffective or transport times will be prolonged.


Errors related to BVM stand in stark contrast to errors related to ETI. Reviewers noted that the most common issues related to BVM included failure to performed when indicated, or insufficient BVM prior to attempting intubation.

The review found no incidence of inappropriate usage or complications related to the usage of airway adjuncts (oral/nasal airways, supraglottic airways). In fact, Hansen noted the airway adjuncts were used infrequently and all errors were related to a reluctance to use the devices when indicated.

What does this mean for pre-hospital providers? If a patient requires ventilatory support and BVM is insufficient, airway adjuncts such as oral or nasal airways, and two-person bagging should be added to optimize ventilation. Supraglottic airways are a rapid, low risk intervention to increase airway support.

In the unlikely event that a pediatric patient requires prehospital ETI, two minutes of BVM ventilation washes out nitrogen and decreases the risk of desaturation during laryngoscopy.

Bag valve mask ventilation is the foundation of all airway management and effective ventilation mitigates much of the risk associated with pediatric airways.


Analysis of patient factors demonstrated that infants suffered a significantly higher number of airway management errors.

Severe error rates approach 30 percent in the under 28 day age group but drop below 10 percent once the patient is over one year of age. The smaller size of the patient may certainly contribute to the increase in errors rates, as well the increased likelihood that ETI would be attempted in these populations. Increasing training and experience in these age groups has already been suggested as one option for reducing errors.

However, the Hansen noted that both cardiac arrest and age less than one year subgroups are also associated with increases in non-airway errors. This led to the hypothesis that errors maybe the result of cognitive overload.

Take advantage of dispatch information to begin a treatment plan and calculating doses. Use cognitive aids such as the Broselow tape.

Finally, avoid complex treatments when possible – the insertion of a SGA is faster and less cognitively intense than direct laryngscopy – allowing attention to be focused on interventions with greater impact, such as providing high quality CPR.

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