Pediatric Corner

Identify signs of dangerous pediatric airway problems

Intubation may be necessary

Children are more susceptible to acute airway compromise due to the unique characteristics of a child's airway, according to Eileen Callahan, RN, BSN, an ED pediatric nurse educator at Tufts Medical Center and the Floating Hospital for Children in Boston, MA.

"Maintaining a patent airway is essential for adequate oxygenation and ventilation," she warns. "Failure to do so can be life-threatening." Here are points to consider:

• The pediatric airway is small in diameter and short in length, which may result in marked increased resistance to airflow when edema, increased secretions, or a foreign body is present.

"The shorter length may result in an increased risk of right mainstem bronchus intubation or accidental extubation," says Callahan.

• The tongue, which is large in relation to the size of the oral cavity, can be a major cause of airway obstruction, especially in the unconscious or somnolent infant in the supine position.

"A jaw thrust maneuver, oral or nasopharyngeal airway, and a towel roll under the shoulders are all potential ways to improve airway management," says Callahan.

• Infants younger than four months of age are obligatory nasal breathers, and the nares are easily obstructed by secretions, edema, blood, or even oxygen nasal prongs that are too large.

"All of these may result in signs of airway compromise," says Callahan. "Keeping the nares clear with a simple bulb syringe will allow the infant to breathe more easily, as well as tolerate feedings without difficulty."

Look for these signs

Watch for decreased level of consciousness, restlessness, anxiety, diaphoresis, excessive drooling, stridor, grunting, or any sign of increased work of breathing, says Callahan, as these are signs of air hunger, hypoxemia, or compromise in gas exchange.

Intubation is indicated most frequently for acute respiratory failure, upper airway obstruction, shock or hemodynamic instability, neuromuscular weakness with progressive compromise, absent protective airway reflexes, inadequate respiratory drive, or cardiopulmonary arrest, says Callahan.

"Supplemental oxygen, airway adjuncts, or position changes may assist in airway management," she says. "If no improvement is seen with these modalities, then bag mask ventilation should be initiated and preparation for intubation should be underway." (See clinical tip, below, on bag mask ventilation.)


For more information on pediatric airway management in the ED, contact:

  • Eileen Callahan, RN, BSN, Pediatric Nurse Educator, Emergency Department, Tufts Medical Center and the Floating Hospital for Children, Boston, MA. Phone: (617) 636-9649. E-mail:
  • Chris Ruckman, RN, MBA, CEN, Manager, Adult Emergency Services, Vanderbilt University Hospital, Nashville, TN. Phone: (615) 875-4606. Fax: (615) 322-1494. E-mail:

Clinical Tip

Avoid decompensation with bag mask ventilation

Administering oxygen to a child via bag mask ventilation "can significantly alter the patient's outcome for the better," says Chris Ruckman, RN, MBA, CEN, manager of adult emergency services at Vanderbilt University Hospital in Nashville, TN.

A child's cellular system compensates for an elongated period of time until they have reach maximum compensation, explains Ruckman, then they decompensate rapidly over a short period of time.

"Providing them with positive pressure ventilations allows for oxygen to be forced into the lung fields, then passed through the circulatory system throughout the vital organs and body," says Ruckman.