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Pediatric Airway Management. Jennifer Oliverio RRT, BSc Clinical Educator Respiratory Services Alberta Children’s Hospital. A & P Characteristics of Newborn Respiratory System. Infant lung is a unique structure not a mini- adult lung

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pediatric airway management

Pediatric Airway Management

Jennifer Oliverio RRT, BSc

Clinical Educator

Respiratory Services

Alberta Children’s Hospital

a p characteristics of newborn respiratory system
A & P Characteristics of Newborn Respiratory System
  • Infant lung is a unique structure not a mini- adult lung
  • Airways, distal lung tissue and pulmonary capillary bed continue to grow and develop after birth
  • General pattern is laid down at birth but upper and lower airways continue to change
  • Alveoli development complete and adult anatomy by 8-10 years of age
  • Ossification of ribs and sternum complete by 25 years of age
  • Obligatory nasal breathing
  • Poor tolerance to obstruction
  • Relatively Large
  • Neck extension may not relieve obstruction


  • Relatively large
  • Anterior flexion may cause airway obstruction
  • Relatively large and U- shaped
  • More susceptible to trauma
  • Forms more acute angle with vocal cords


  • More anterior and cephalad
  • Intubation more difficult
  • Narrowest portion of airway
  • ↑ resistance with airway edema or infection
  • Acts as “cuff” during tracheal intubation


  • Small diameter (6mm), high compliance
  • ↑ resistance with airway edema or infection
  • Collapses easily with neck hyperflexion or hyperextension
  • ↑ closing capacity
  • No pores of Kohn
  • ↑ air trapping and ↓ collateral circulation of air


pulmonary vessels
Pulmonary Vessels
  • ↑ pulmonary vascular resistance (PVR)
  • Very sensitive to constriction by hypoxia, acidosis and hypercarbia
  • ↑ compliance due to weak rib cage
  • ↑ A-P diameter
  • Horizontal ribs
  • Breathing is all diaphragmatic
  • FRC determined solely by elastic recoil of lungs
  • Chest wall collapses with -ve pressures

Chest Wall

  • Weak resp muscles
  • ↑ RR = early sign of resp distress
  • Response to ↓ O2/ ↑ CO2 minimal
  • Tolerates hypoxia poorly

Regulation of Breathing

airway assessment
Airway assessment
  • Best to 1st look from afar. Infants and small children don’t like strangers hard to assess baseline after they are upset.
  • Is the chest moving?
  • Can you hear breath sounds?
  • Are there any abnormal airway sounds (e.g.. Stridor, snoring)?
  • Is there increased respiratory effort with retractions or respiratory effort with no airway or breath sounds?
airway management
Airway Management
  • Simple things to improve airway patency
      • Suction nose and oropharynx
      • Reposition child/ allow child to assume position of comfort
      • head-tilt-chin lift/ jaw thrust
      • Use airway adjuncts- NPA/ OPA
oral nasopharyngeal suctioning
Oral & Nasopharyngeal Suctioning
  • Clean technique
  • Negative pressure of 80 to 120 mmHg. Test suction level on regulator prior to suctioning
  • Nasal and oral suction can be performed with same catheter
  • May result in hypoxia, ↓ HR (vagal), bronchospasm, larygospasm, atelectasis
suction supplies
Suction supplies
  • Clean gloves
  • Suction regulator, canister, tubing
  • Normal saline in cup
  • Yankauer and appropriate suction catheter

Nasopharyngeal Suction

  • Measure length from pt’s earlobe to tip of nose
  • Keep pass <10 sec.
  • Document: pt assessment prior to procedure, time of procedure, amount and type of secretions, pt’s response
  • If pt has preferred position let them remain in that position e.g. tripod
  • Repositioning can greatly improve airway patency
  • Manual airway maneuvers can also help open the airway (head tilt-chin lift/ jaw thrust)
oral pharyngeal airways opa
Oral Pharyngeal Airways (OPA)
  • Only for use in UNCONSCIOUS pt with no intact cough/gag reflex
  • Holds tongue and soft hypopharyngeal structures away from posterior pharynx
  • Still need good head and jaw position to maintain airway patency
  • Suction airway prn
  • Never tape in place
choosing correct opa
Choosing correct OPA
  • Place OPA against side of face. With flange at the corner of the mouth the tip should reach angle of the jaw
      • Too small: will not adequately displace tongue
      • Too large: may obstruct larynx and/ or interfere with mask fit if BVM required
nasopharyngeal airways
Nasopharyngeal Airways
  • Soft plastic pre-made or shortened ETT
  • Provides unobstructed path for airflow between nares and pharynx
  • Can use in conscious/ semi-conscious pt
  • Small internal diameter so must be evaluated frequently and suctioned prn to maintain patency
if these don t work
If these don’t work…
  • Pt may require more advanced interventions to establish a patent airway
      • CPAP
      • Intubation
  • RR
  • Effort
  • Tidal volume
  • Airway and lung sounds
  • SpO2
  • Normals

As per PALS

  • Best to evaluate prior to hands-on assessment
  • Excitement, anxiety, exercise, pain, fever, agitation can all ↑ RR
  • ↓ RR with acutely ill child or with ↓ LOC = ++ cause for concern
  • > 60 in any age is cause for concern
  • Signs of ↑’d respiratory Effort
    • Nasal flaring
    • Chest retractions
    • Head bobbing
      • Chin lifts and neck extends during I
      • Chin falls forward during E
    • Seesaw respirations
      • Chest retracts and abdomen expands during I, reversed during E
      • Very Inefficient= quickly leads to fatigue
    • Grunting
      • Child exhales vs partially closed glottis in an effort to keep small airways open
  • Same landmarking and principals as with adults
  • BUT…smaller size and sound is transmitted much more easily throughout the infant chest.
bag mask ventilation
Bag-Mask Ventilation
  • Indicated when the pt’s spontaneous breathing effort is inadequate despite patent airway
  • Can provide adequate oxygenation and ventilation until definitive airway control is obtained
  • Can be as effective as ventilation through ETT
testing the bagging unit
Testing the bagging unit
  • Check all components before use to ensure proper function. Ideally as part of your daily safety checks.
  • Occlude pt outlet and outflow, squeeze bag ensure no tears/leaks
  • Check that PEEP valve works (2L)
  • Ensure connection to wall O2 and adequate flow
  • Proper size mask with cuff inflated
  • Position pt: sniffing position

Infants: Want exterior ear canal to be anterior to the shoulder

In our experience at ACH we find a shoulder roll works best for positioning infants and small children

  • Position pt: sniffing position
  • Open airway and seal mask to face using E-C technique. You may need OPA.
  • Position pt: sniffing position
  • Open airway and seal mask to face using E-C technique. You may need OPA.
  • Squeeze bag with other hand to deliver tidal volume and produce chest rise. Careful to not over-ventilate!
2 person bmv
2 person BMV
  • One person uses both hands to open airway and maintain tight mask-to-face seal
  • 2nd person bags
monitor effectiveness of ventilation
Monitor effectiveness of Ventilation
  • Visible chest rise with each breath
  • SpO2
  • ETCO2
  • HR
  • BP
  • Pt responsiveness
  • Air entry on auscultation
if ventilation is not effective
If ventilation is not effective…
  • Reposition pt. Reposition airway. OPA.
  • Verify proper mask size and placement
  • Suction airway
  • Check O2 source and flow
  • Check bag and mask for function/leaks
  • Treat gastric inflation
indications for intubation
Indications for intubation
  • Respiratory distress
  • Apnea
  • Self-extubation
  • Upper airway obstruction or the potential to develop upper airway obstruction
  • Actual or potential decrease in airway protection (compromised neurological function)
  • Need to eliminate/ reduce WOB (e.g. cardiac pt)
  • Inadequate ventilation and/or oxygenation
preparing for intubation
Preparing for Intubation
  • Appropriate ETT for >1 yo: (age/4) + 4

Term infant: 3.0-3.5 ID

6 mo: 3.5-4.0 ID

1 yo: 4.0-4.5 ID

  • Cuffed ETT’s for pt’s > 8 yo
  • If you anticipate need for high PEEP or PIP may want to use cuffed ETT with <8 yo. Use ½ size smaller ETT.
  • Remember SOAPME


Suction equipment: yaunkauer, catheters, regulator/canister/tubing,

Oxygen: O2 flowmeter, preoxygenate 2-3 min, manual resuscitator bag with mask

Airway equipment: ETT, stylet, syringe (cuffed ETT), laryngoscope and blade, lubricating gel, OPA

Position, pharmacy, personnel: supine, rolls for positioning, bed height up


ETCO2 detector

post intubation
  • ETCO2 assessment for confirmation of placement
  • Auscultation for bilateral air entry
  • Placement of ETT documented
  • ETT secured with tapes
  • CXR to confirm placement
  • Place pt on ventilator
tube position
Tube Position
  • Remember: Endotracheal tube position follows chin
  • Pt positioning ++ important. Often need shoulder roll to keep chin neutral.
  • CXR need to be done with neutral, midline head position (RRT should be called)
    • Chin low- tube low
    • Chin high- tube high
uncuffed ett s
Uncuffed ETT’s
  • May have issues with leak
  • Better success with Pressure modes of ventilation with a tube leak
  • Position of pt can affect amount of leak
  • If having difficulty with ventilation or oxygenation may need to upsize ETT or Δ to cuffed ETT
  • Short term fix: NS soaked nasal packing packed around ETT. DO NOT CUT the gauze.
cuffed ett
Cuffed ETT
  • Important to assess cuff inflation Qshift
  • > 8 yo can follow adult VAP guidelines
      • 25-30 cm H2O inflation pressure
  • < 8 yo MOV with pressure < 20 cm H2O often quite a bit lower than 20
  • Cuff is circumferential in a growing airway!
suctioning ett
Suctioning ETT
  • Suction frequency depends on ETT size and pt needs:
      • 4.0 i.d. and smaller- a minimum of Q8H unless otherwise ordered
      • 4.5 i.d. and greater- prn or as ordered
      • All pt’s need for suction should be assessed hourly and prn Sterile suctioning
  • Suction depth should only be 0.5 cm past the end of ETT
      • Determine suction depth by using suction guide or match number on catheter to number on ETT and advance 0.5 cm.
assessing need for suction
Assessing need for suction
  • Clinical assessment of pt will determine frequency of suctioning. Many factors influence the need for suction including but not limited to:
        • ETT Size
        • Changes in vital signs
        • Adventitious breath sounds
        • ↓ breath sounds/ chest movement
        • ↓ SpO2
        • Visible secretions in ETT
        • Respiratory distress
        • Coughing
        • ↑TcCO2/ EtCO2
        • ↑ PIP
        • Worsening ABG/CBG
selecting suction catheter
Selecting suction catheter
  • Use largest size that can pass easily down the ETT
  • Ideally not larger than half the diameter of ETT to avoid causing atelectasis
  • TIP: choose double the ETT

e.g. 4.0 i.d. ETT choose 8 Fr suction catheter

wall suction
Wall suction

Use lowest possible setting

  • Normal saline unless otherwise ordered
  • Should occur prn not routinely
  • For <10 FR you can use sterile NS syringe as there is no one-way valve in instillation port. For >12 Fr you will need pink NS nebule.
  • Recommended amounts:

*total volume is especially important to limit and document in infants and small children

suction guide
Suction Guide
  • Should be filled out at the bedside for all ETT < 4.5 and all pediatric tracheostomy pt’s regardless of tube size
  • Suction ½ cm farther than marked length to clear end of ETT unless otherwise ordered (e.g. TEF repair)

Patient Preparation

  • Assess pt visually and auscultate, note monitor readings
  • Determine need for sedation/ analgesia
  • Ensure ETT tapes are secure
  • Explain procedure to pt/ parents
  • Pre- oxygenate and give meds as required
  • Position pt
closed suction55
Closed Suction
  • Ensure suction is on and set appropriately
  • Ensure bagging unit attached to O2, adequate flow, and intact
  • Attach sterile syringe with appropriate instillation solution to instillation port
  • Securely hold ETT with one hand and insert catheter to appropriate depth with the other
  • Apply continuous suction while slowly withdrawing the catheter
  • Flush catheter by instilling into instillation port while applying suction
  • Allow pt to re-oxygenate at least 30 sec between passes
post suctioning
  • Turn suction control to locked position
  • Remove instillation syringe and cap instillation port
  • Disconnect suction tubing and cap end
  • Reasess pt
  • Document:
    • Time
    • Initial assessment
    • Amount of suctioning required
    • Amount and type of secretions
    • Amount and type of instillation
    • Pt response