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The pediatric airway and its differences to an adult airway. The first thing we need to remember is, children have not yet developed their muscle tone in their necks and their muscle structure, so their head is a floppy ball on top of their shoulders, which means it's very easy to hyper-extend or under-extend the neck itself. So we have to have positioning and placement correct. With an adult, we hyper-extend the neck to open the airway and bring the tongue off the back of the throat, but with a child, we use a position called sniffing the morning air or neutral position. The easiest way to remember it is if somebody is cooking a bacon sandwich and you can smell that in the room, you normally lift your nose slightly to sniff. And that lifting the nose is all we need to do to open a child's airway. We also have to remember the child's airway is very narrow compared to an adult airway. So if we hyper-extend or under-extend as you can see on this plastic tube, it kinks.

So that is the reason we do not want to hyper-extend or under-extend the neck because we create kinking of the airway reducing the airflow into the patient. Another important thing to remember is a child's tongue in relation to its airway and in relation to an adult is much larger. So it becomes a much bigger problem with a patient or a child lying on their back, or in a position where the tongue slumps to the back of the throat, in cardiac arrest or unconscious casualties. So the tongue has to be managed and that is the position, sniffing the morning air will put enough pressure on the tongue to bring the tongue away from the back of the throat, and not kink the airway itself.

Also, small children up to about the age of five months are what we call obligatory nasal breathers, so they will breathe and drink at the same time. You cannot do it, but they do because they have to suckle to feed and they have to be able to breathe while they are suckling. So they can actually drink and breathe at the same time, but after about the age of about five months, that starts to fade away and they then have to breathe, as well as swallow at a different time, and exactly the same as an adult. So we have to bear that one in mind.

The neck itself is very short. So the trachea is much shorter and as I have already said, it is much more flexible. So another thing we have to be careful of is actually the length of the trachea itself. The volume of the lungs will differ. So when we are doing breaths into a child, we are looking for chest rise and fall and nothing more, we are not trying to over-inflate, we are not trying to pressurize. So we can actually use an adult bag and mask as long as we do not try and squeeze the whole bag. All we are trying to do is achieve a raise of the chest and the fall of the chest, and we should not create any overpressure. Look at it like blowing a balloon up. When you blow a balloon up in its initial phase, you do not require any pressure 'cause you are not stretching the balloon and the elastic. As you then start to pressurize the balloon, it becomes harder to blow it up because you are trying to stretch that plastic material.

A child is exactly the same. You gently blow until you see the chest rise and as soon as you feel the pressure start to come on, that is at the point when you stop breathing, and allow the chest to fall. We talk about it in this way, because children literally day-by-day, week-by-week and month-by-month grow, their lungs grow, they become bigger and require more and more and more oxygen until they reach adulthood. Another important thing about the way a child breathes is their ribs are flat, they are not formed and they have not joined the spinal cord at this point. So they are much flatter. So they do not play the same role in breathing as you and me, as an adult would. They become much less important, and they become diaphragmatic breathers. You will see most of their breathing taking place by the diaphragm dropping, sucking air through the airways and the diaphragm relaxing, pushing air back out again.

Another thing that is also very important is cyanosis. Cyanosis and hypoxia with children is a very dangerous situation. Their body requires an awful lot of oxygen to actually keep all of the organs, especially the heart functioning properly. So any small occlusions of the airway on a child need to be dealt with quickly and efficiently to keep that flow of oxygen going in, to keep the oxygen circulating around the body, to keep the heart going, to keep the patient alive. They will show hypoxia very early. So, their lips will grow blue and their ears will start to show signs and the fingertips very early on when they start to struggle with oxygen. So, any signs of bluing and colour changes to the lips or ears, fingertips is a very bad sign with children and needs to be corrected immediately.

So remember, the airway is narrower, it is shorter, it is easily kinked forward or back. They have a large tongue which creates a problem with blocking the airway, and we have to position their airway into sniffing the morning air so as we do not overextend the neck, kinking the airway. Another important thing is the soft palate of the child. When we tip the airway back on a child, we put two fingers onto the jaw itself, two fingers onto the forehead and we tip the airway back using the bone structure to hold to.

If we go onto the soft palate on a child, because their tongue is much bigger and their airway is smaller, we very easily push the tongue onto the back of the throat, occluding the airway and again, giving ourselves another problem created by poor handling of the patient. Also remember, recovery position on the child really should be head down, feet up. If you try to put a baby in a recovery position, they will automatically roll onto the front or their back, but if you actually hold the child down your arm with a leg either side and their head into your hand, feet raised slightly above their head, that is the recognized recovery position for a baby. As they get larger and become more child-sized, then the recovery position works just as effectively as it would with an adult.

  • IPOSi Unit two LO1.2, 1.3, 1.4, 2.1, 2.2 & 2.3