Understanding and Managing the Pediatric Airway

By:  Judson Smith, MHA, Paramedic


One of the most fundamental skills of a pre-hospital EMS provider is management of the airway. Having the knowledge of the anatomy and physiology of the pediatric airway along with the various medical tools now at our disposal, gives us the opportunity to have a much more successful rate of securing the pediatric airway.

The most important thing to remember when managing the pediatric airways is that “Kids are not small adults!” There are many differences from the anatomical and physiological perspective, along with pathological conditions that require special attention when providing an airway to the pediatric patient.

Anatomical & Physiological Differences

First and foremost, the one of the biggest and more obvious differences between the adult and pediatric airway is the large occipital lobe of the pediatric patient versus that of an adult. Because of the large shaped head, there is greater potential to cause the head to flex when the child is lying on a flat service causing the airway to become occluded (Figure 1). It is important that we ensure the pediatric patient is in the neutral, sniffing position by placing a rolled-up blanket or some kind of padding under the shoulders (Figure 2).


Figure 1                                                                     Figure 2

The tongue is relatively larger compared to the size of the patient’s pharynx. The large tongue makes it more difficult to visualize the larynx even under direct laryngoscopy. A decreased level of consciousness due to sedation, head injury, metabolic disturbances and other nervous system dysfunctions are some common causes of upper airway obstruction via the tongue.[i]

Another relevant part of the pediatric airway is the epiglottis and the larynx. The epiglottis is large and floppy and the larynx is shaped like a funnel with the narrowest part of the airway at the cricoid cartilage. The larynx in a pediatric is only about 5 to 7 centimeters long resulting in right main‑stem and accidental extubation.[ii]

Figure 3

Just as there are anatomical differences, we cannot forget the physiological differences as well. Due to these noted differences, the patient is more susceptible to hypoxemia. Pediatric patients have a lower functional capacity and an increased tidal volume compared to that of the adult patient.iv

Airway Assessment

A pediatric patient with airway trouble requires a rapid assessment that should be focused initially on the pediatric assessment triangle that covers the patient’s appearance, work of breathing, and skin color and condition. This can be done as you are approaching the patient.

Looking for any accessory muscle use, nasal flaring, intercostal retractions, grunting or noisy breath sounds are indications of respiratory distress in kids. Also obtaining a good history on the patient can provide information as to the potential for a potentially difficult airway. Understanding if there are any past or current history into any upper respiratory problems or congenital defects are all relevant to understanding the potential for a difficult airway in the pediatric patient.

When possible, it is important to consider the use of the equipment to provide additional support and confirmation to the extent of the patient’s condition. Utilizing pulse oximetry and capnography as well as obtaining a full set of vital signs can provide great information into the patients’ respiratory and hemodynamic status.

Obtaining any history of any prescribed medications or over the counter medications the patient is taking as well as to examine the body for any signs of trauma or other abnormal findings are important.


The most important skills to have in the management of the pediatric airway is proper positioning of the patient, placement of the equipment and providing oxygenation and ventilation along with the use of mask ventilation. There is a potential to encounter upper airway obstruction with bag mask ventilation but it can be relieved with a head tilt chin lift or modified jaw thrust ensuring the patients airway is in the neutral sniffing position with padding under the shoulders.v It Is also important to recognize the increase in dead space when using a bag mask compared to that of endotracheal intubation. Because of this the increase in volume is much more significant because of the absolute low volumes of ventilations in the pediatric patient.vi

Basic airway adjuncts play a vital role in managing the airway. Nasopharyngeal airways are good at helping relieve upper airway obstruction during bag mask ventilation. Oropharyngeal airways play a vital role in the management of a patient who is unresponsive with no gag reflex in ensuring the tongue is kept out of the way to ensure proper ventilation and oxygenation to the patient.

Another important thing to remember is that pediatric patients most commonly present with a full stomach as they rarely go longer than just a couple of hours without oral intake. This could present a challenge as managing the patient who has vomited and aspirated becomes much more challenging in providing ventilations and ensuring airway compliance. Think of it this way: “Bellies + bag ‑ mask = barfing.” Even with proper positioning and placement of an oral airway, bag mask ventilation will result in air being forced into the stomach causing the patient to vomit and aspirate making the management the pediatric airway much more difficult.

Supraglottic airway devices have proven to be effective in allowing air to get into the lungs. There are many different types of supraglottic airway devices that now exist. From LMA’s to king airways, selecting the appropriate supraglottic airway device for your patient can be determined through the clinical assessment of the patient, critical thinking and the team approach concept as to how to best manage the patient’s airway. Endotracheal intubation, once known as the gold standard in airway management, even though still important should not always be our first choice when determining the most appropriate device to manage the patient’s airway.

Mostly, the pediatric airway is difficult to manage usually because there is difficulty in performing adequate mask ventilation and intubation or placement of a supraglottic airway. This scenario is referred to as the “cannot ventilate, cannot intubate” scenario. It is important to ensure that the provider have backup airway devices available in case endotracheal intubation is not successful.


Airway management can be a challenge in itself. With a proper assessment and the proper equipment and techniques, managing your patients airway will allow the provider to provide a safe and effective plan in the management of the pediatric airway.


[i] “Airway Management.” Pediatric Fundamental Critical Care Support. Ed. Rodrigo Mejia. Mount Pleasant: Society of Critical Care Medicine, 2008. 2-2. Print.

[ii] Upper airway collapsibility in anesthetized children. Litman RS, McDonough JM, Marcus CL, Schwartz AR, Ward DS, Anesth Analg. 2006 Mar; 102(3):750-4.

iv Andrew, Pollak. “Pediatric Emergencies.” Critical Care Transport. Sudbury: Jones and Bartlett, 2011. Print.

v Meier S, Geiduschek J, Paganoni R, Fuehrmeyer F, Reber A. The effect of chin lift, jaw thrust, and continuous positive airway pressure on the size of the glottic opening and on stridor score in anesthetized, spontaneously breathing children. Anesth Analg. 2002;94:494–9 vi Brambrink AM, Braun U. Airway management in infants and children. Best Pract Res Clin Anaesthesiol. 2005;19:675–97


Judson brings more than 20 years of experience in fire and EMS to his role overseeing Medic-CE. Judson holds numerous EMS teaching credentials and founded one of the first virtual instructor-led EMS training programs in the United States in 2014. A critical care paramedic and former firefighter/paramedic and flight paramedic, Judson also serves as an officer in an Air Force Reserves aeromedical evacuation squadron. He holds a master’s degree in Healthcare Administration and is pursuing a PhD in e- learning.

Related Posts

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: