There is no more important skill for a pediatric hospitalist than the ability to adequately manage an airway. Whether that is the placement of an emergent and definitive airway, or bag mask ventilation (BMV) until backup arrives, it is imperative that the hospitalist understand the pediatric airway and how to keep it patent. Increasingly, specialists (anesthesia, critical care) are in-house and available to the hospitalist for assistance, so the emphasis in recent years has shifted to effective stabilization, namely effective BMV. For a patient who needs prolonged ventilatory support, however, insertion of an endotracheal tube remains the definitive airway.

Pediatric patients require airway support for a variety of reasons. Many are intrinsic to the respiratory system, but any severe illness can be caused by, or result in, respiratory compromise necessitating emergent airway management. Common scenarios encountered by the pediatric hospitalist include the following:

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  Apnea (e.g. related to respiratory syncytial virus)

  
  
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  Loss of protective airway reflexes (e.g. obtundation from drug overdose)

  
  
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  Respiratory failure (e.g. severe asthma with hypercarbia)

  
  
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  Current or impending airway obstruction (e.g. epiglottitis)

  
  
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  Reduction of intracranial pressure (e.g. head trauma)

  
  
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  Overwhelming systemic illness (e.g. during cardiopulmonary resuscitation)

There are no absolute contraindications to securing a definitive airway. Because the pediatric hospitalist is typically managing the airway in an emergent (as opposed to elective) setting, one should assume that the patient may have a full stomach and is at risk for aspiration of gastric contents during manipulation. For any patient in whom trauma is a consideration, airway management should be performed after cervical spine stabilization. There are a number of factors that might cause a patient to have a difficult airway, including congenital anomalies, face or neck trauma, significant airway obstruction (e.g. epiglottitis), or any patient in extremis. None of these are contraindications to managing the airway, but they are absolutely a reason for the hospitalist to expedite the arrival of a clinician more experienced with airway skills, often anesthesia or critical care. Young hospitalists are much less likely to have had extensive intubation experience during their residency. The recommendation to perform direct laryngoscopy in all neonates delivered through meconium-stained amniotic fluid changed in 2006,¹ and more recently, the introduction of high-flow nasal cannula has dramatically reduced the incidence of intubation in bronchiolitis.² For this reason, the hospitalist should recognize their limitations and call for assistance early, avoiding the temptation to try their hand, with subsequent delay in the arrival of a more experienced clinician to definitively place an airway.

Once the decision has been made to manage a patient’s airway, the importance of preparation cannot be overstated. Any piece of equipment that could potentially be necessary should be within reach (Table 196-1). There should be several assistants present to perform peripheral tasks (e.g. handing the physician the resuscitation bag or endotracheal tube (ETT) for insertion, checking oxygen delivery systems, attaching a carbon dioxide detector, taping the ETT after placement).