Key Takeaways
- Infants and children have proportionally larger tongues, which are the most common cause of airway obstruction in pediatric patients.
- The pediatric glottis is positioned higher and more anterior than in adults, making visualization during airway management more difficult.
- Infants have a shorter, narrower, and more flexible trachea that is more easily obstructed or kinked.
- The sniffing position (neutral alignment with slight extension) is used for infants; excessive head extension can actually occlude the infant airway.
- Croup presents with a barking (seal-like) cough, low-grade fever, and inspiratory stridor, most common in ages 6 months to 4 years.
- Epiglottitis is a life-threatening emergency with high fever, drooling, dysphagia, and a tripod/sniffing position; do NOT attempt to visualize the airway.
- Pediatric BVM sizes: infant BVM (approximately 450 mL) and child BVM (approximately 750 mL); use the smallest bag that produces visible chest rise.
- Early signs of pediatric respiratory failure include tachycardia, nasal flaring, retractions (intercostal, substernal, supraclavicular), and grunting.
Pediatric Airway Considerations
Children are not simply small adults. Their airways have significant anatomical and physiological differences that affect assessment and management. Pediatric patients can deteriorate rapidly, making early recognition and intervention critical.
Key Anatomical Differences
| Feature | Pediatric | Adult |
|---|---|---|
| Tongue | Proportionally larger; #1 cause of obstruction | Smaller relative to airway |
| Epiglottis | Larger, floppier, omega-shaped | Firmer, flatter |
| Glottis position | Higher (C3-C4) and more anterior | Lower (C4-C6) |
| Trachea | Shorter, narrower, more flexible | Longer, wider, more rigid |
| Narrowest point | Cricoid ring (subglottic) | Vocal cords (glottic opening) |
| Occiput | Larger, causing natural neck flexion | Proportionally smaller |
| Chest wall | More compliant; relies on diaphragm | More rigid; uses intercostals |
| Oxygen reserve | Smaller; desaturates faster | Larger; tolerates apnea longer |
Why These Differences Matter
- The larger tongue is the most common cause of airway obstruction in unresponsive pediatric patients.
- The higher, more anterior glottis makes intubation more difficult (ALS consideration) and airway management more challenging.
- The shorter trachea means there is less margin for error — even small amounts of swelling can cause significant obstruction.
- The larger occiput in infants naturally flexes the neck forward, potentially occluding the airway when lying supine. Padding under the shoulders (not the head) can help achieve a neutral position.
Pediatric Airway Positioning
Infants (0-1 Year): Sniffing Position
- Place the infant supine with the head in a neutral, sniffing position — slight extension of the neck.
- Place a thin folded towel under the shoulders to compensate for the large occiput and prevent neck flexion.
- Do NOT hyperextend the infant's neck — this can kink the flexible trachea and worsen the obstruction.
Children (1-8 Years): Head-Tilt/Chin-Lift
- Use a standard head-tilt/chin-lift but with less extension than for an adult.
- The child's airway is still more anterior and more easily kinked than an adult's.
Older Children and Adolescents
- Manage similarly to adults with standard head-tilt/chin-lift or jaw-thrust as indicated.
Pediatric BVM Ventilation
BVM Sizing
| Patient | BVM Size | Volume |
|---|---|---|
| Infant | Infant BVM | ~450 mL |
| Child | Child/Pediatric BVM | ~750 mL |
| Adolescent/Adult | Adult BVM | ~1,200-1,600 mL |
Key Principles
- Use the smallest bag that produces visible chest rise.
- Deliver breaths slowly over 1 second each.
- Avoid overventilation — excessive volume or pressure can cause gastric distension (air in the stomach), which pushes the diaphragm up and decreases lung volume.
- If gastric distension occurs, reposition the airway and reduce ventilation volume. Do NOT press on the stomach.
Croup vs. Epiglottitis
Two critical pediatric upper airway emergencies that EMTs must differentiate:
| Feature | Croup | Epiglottitis |
|---|---|---|
| Cause | Viral (parainfluenza virus) | Bacterial (historically H. influenzae type B) |
| Age | 6 months - 4 years (most common) | 2-7 years (less common since Hib vaccine) |
| Onset | Gradual (days) | Rapid (hours) |
| Fever | Low-grade | High (often >104F / 40C) |
| Cough | Barking, seal-like cough | Usually absent |
| Voice | Hoarse | Muffled, reluctant to speak |
| Drooling | Absent | Present (inability to swallow) |
| Appearance | Usually not toxic | Toxic, anxious, tripod/sniffing position |
| Stridor | Inspiratory (especially at night) | Inspiratory (quiet, soft) |
| EMT Action | Humidified O2, keep calm, transport | High-flow O2, do NOT examine the throat, do NOT agitate, transport immediately |
Critical Rule for Epiglottitis
Do NOT attempt to visualize the airway or insert any airway adjunct in a patient with suspected epiglottitis. Any agitation can cause the swollen epiglottis to completely obstruct the airway. Keep the child calm, in a position of comfort (usually sitting upright), provide blow-by oxygen, and transport immediately.
Pediatric Respiratory Failure Signs
Children compensate for respiratory distress by increasing their respiratory rate and effort. When they can no longer compensate, they decompensate rapidly.
Early Warning Signs (Distress)
- Tachypnea (increased respiratory rate)
- Tachycardia
- Nasal flaring
- Intercostal, substernal, or supraclavicular retractions
- Head bobbing (infants)
- Grunting on exhalation
Late / Ominous Signs (Failure/Arrest Imminent)
- Bradycardia (a critical late sign in children — often precedes arrest)
- Decreased or absent breath sounds
- Cyanosis (central: lips, tongue)
- Altered mental status, limp muscle tone
- Slow or irregular respirations
Key Point: In pediatric patients, cardiac arrest is almost always caused by respiratory failure, not a primary cardiac event. Aggressive airway management and ventilation can prevent cardiac arrest.
Weight-Based Considerations
Pediatric medication dosing and equipment sizing are often weight-based. The Broselow tape (length-based resuscitation tape) is a valuable EMT tool that estimates a child's weight based on their length and provides color-coded equipment sizes and drug doses.
- When the child's weight is unknown, use the Broselow tape.
- A general estimate: weight (kg) = (age in years + 4) x 2 (for children 1-10 years).
- Example: A 4-year-old weighs approximately (4 + 4) x 2 = 16 kg.
The most common cause of airway obstruction in an unresponsive pediatric patient is:
An EMT is managing the airway of a 6-month-old infant. The correct airway positioning technique is:
A 3-year-old presents with a sudden onset of high fever, drooling, and is sitting in a tripod position with a toxic appearance. The EMT should:
In pediatric patients, bradycardia is significant because it:
When using a BVM on a 2-year-old child, the EMT should be most concerned about:
Match each pediatric upper airway condition to its characteristic presentation:
Match each item on the left with the correct item on the right