Airway

The patient’s airway is the first priority. There are fundamental differences between the airway of a child and that of an adult. The pediatric airway (Figure 1-1) is more anterior than the adult airway, requiring less manipulation to bring the oral, pharyngeal, and tracheal axes into alignment. In addition, the head-to-body proportion is larger in infants than in adults, and thus extreme hyperextension of the neck may exacerbate airway obstruction in younger children. The pediatric airway is narrower, and the tongue is relatively large compared with the jaw, increasing the risk of airway obstruction. The pediatric larynx is located more anteriorly and cephalad than the adult larynx.

Figure 1-1 Pediatric and adult airway anatomy.

The provider should assess airway patency using the “look, listen, and feel” approach. The provider should look at the chest wall and listen to the mouth and nose to detect whether there is evidence of air movement. Findings suggesting airway obstruction include increased respiratory effort with retractions, abnormal inspiratory sounds, or episodes during which no airway or breath sounds are produced despite respiratory effort. If a child is speaking, crying, or otherwise verbalizing, the airway is intact. Attention should be paid to the quality of the sounds. A hoarse or high-pitched cry should alert the provider to the possibility of airway compromise without complete obstruction. Finally, the provider should feel for air movement using a hand or cheek close to the patient’s mouth.

The most effective maneuvers for opening an obstructed pediatric airway are the head tilt–chin lift or jaw thrust techniques (Figure 1-2). In the head tilt–chin lift maneuver, the head is tilted back slightly (without overextending), and the chin is lifted gently with one finger on the bony prominence to avoid placing pressure on the soft tissues of the neck. A roll or towel may be placed under the shoulders to maintain the position.

Figure 1-2 Head tilt–chin lift and jaw thrust maneuvers.

If there is a risk of a neck injury, it is critical to stabilize the cervical spine during evaluation of the airway and avoid extending the neck. Manual cervical spine stabilization is accomplished by holding the head in the midline position while applying gentle cephalad traction. A cervical collar may be applied, taking care to size the collar appropriately. It is important to remember that neither manual nor collared stabilization provides true immobilization.

The jaw thrust maneuver should be attempted in these cases by lifting the jaw forward with the provider’s third or fourth fingers (or both) “hooked” under the angles of the mandible while avoiding compression of the soft tissues. The goal is to pull the mandibular block of tissue forward so that the lower central incisors are anterior to the upper central incisors.

At any point, if it is determined that the patient is unable to independently maintain the patency of his or her airway, the provider should open the airway to maintain adequate ventilation and protection from the aspiration of stomach contents. Simple suctioning should be attempted first because it may relieve an airway obstructed by secretions or foreign materials. Bag–valve–mask (BVM) ventilation (see below) may provide an open airway if a good mask seal is achieved and airway positioning is maintained.

In an unconscious patient, an oropharyngeal airway can be used to help stent the mandibular block of tissue away from the posterior hypopharynx (Figure 1-3). A nasopharyngeal (NP) airway is another option. NP airways are well tolerated in unconscious and semiconscious patients and may even be used in conscious individuals with upper airway obstruction. NP airways should be used with caution when midface trauma is suspected because of the risk of inserting the airway through fractured bone into intracranial structures. Laryngeal mask airways (LMAs) are supraglottic airway devices that are being increasingly used in resuscitation settings to help bypass the soft tissues of the anterior oropharynx and to deliver oxygen directly to the proximal trachea.

Figure 1-3 Oral and nasopharyngeal airways.