EMT-Basic Exam: The Basics of Advanced Airway - Advanced Airway Management of Children and Infants

Managing the airway is crucial in saving any patient’s life, but it’s especially critical in cases concerning children and infants because so many pediatric emergency situations involve respiratory or airway problems. Understanding the proper techniques for managing the airways of your smallest patients is vital.
Many airway obstruction cases can be solved with the basic techniques we outlined earlier. However, advanced techniques may be necessary in certain emergency situations. These techniques should only be performed by EMT-Basics who are highly trained in advanced pediatric airway management.
Always contact the medical direction physician before performing any of these interventions.

1. Nasogastric Tubes
Unlike adults, children rely heavily on their diaphragms to assist in breathing. This makes them more prone to developing gastric distention during ventilation. You can release the air trapped in the stomach by using a nasogastric tube. Nasogastric tubes are used in hospitals to relieve bowel obstructions, remove toxins or blood from the gastrointestinal tract, and administer medications or nutritional supplements. In emergency settings, this long tube is inserted into the nose, down the esophagus, and into the stomach to decompress air in intubated or unitubated patients.

Tip: An EMT-Basic should insert a nasogastric tube in an unresponsive child or infant who requires ventilation for an extended period of time. It should not be used on patients with facial, head, or spinal trauma.

To insert a nasogastric tube in a child or an infant, first ensure that the patient is in the supine position with his or her head turned to the left. You should place a rolled-up towel under the patient’s neck to elevate his or her head. After measuring the tube and selecting the correct size, lubricate the tube for easier insertion. Carefully insert it into the patient’s nose. When you’re done, you must ensure that you have the correct placement.

To check that the tube has been placed correctly, attach a syringe to the end of the tube and withdraw the contents of the stomach. Next, inject air into the tube and listen for gurgling noises over the stomach. After you’ve ensured the tube is in the correct place, attach the tube to a suction device to aspirate the stomach contents.

The Nasogastric tube.

Complications can occur after the nasogastric tube is placed. Some of these complications can include
- Nasal trauma
- Tracheal insertion
- Vomiting
- Accidental passage of the tube into the patient’s cranium in patients with skull fractures
- Obstruction of the patient’s airway if the tube curls up in the back of the patient’s throat

2. Orotracheal Intubation
The anatomy of a child or an infant differs greatly from the anatomy of an adult. Understanding these differences is vital to performing orotracheal intubation on children or infants. The following lists some of the most important anatomical differences between children/infants and adults that you should consider when performing advanced airway techniques:
- A child’s or infant’s airway is much smaller than an adult’s airway, making it more susceptible to obstruction by fluids, materials, or swelling.
- Children’s tongues are proportionally larger and take up more space in the mouth than adults’ tongues do. This makes opening the airway and lifting the tongue for airway management slightly more challenging.
- An infant’s or child’s airway is cone-shaped, which creates a seal at the narrowest point. Because of this, cuffs are not needed to seal the airway when inserting an endotracheal tube. Uncuffed endotracheal tubes are used on children under 8 years of age.
- Infants’ and children’s heads are proportionally larger than adults’ heads. This factor may compromise the airway when the patient is in the supine position.
- A child’s trachea and vocal cords lie higher and closer to the front than an adult’s. Because of this, a straight blade, or Miller blade, is used when intubating children and infants using a laryngoscope.

While you should always refer to your medical direction physician for the proper protocols, the EMT-Basic should consider using orotracheal intubation for children and infants in the following prehospital situations:
- Prolonged artificial ventilation is required.
- Artificial ventilation is impossible by any other method.
- The patient is apneic or unresponsive.
- The patient doesn’t have a gag reflex.

The equipment for intubating a child is the same for intubating an adult—only on a smaller scale. When treating an infant or a child, ensure that you choose the correct size bag-valve mask (BVM). You should also use the straight laryngoscope blade (Miller blade) in younger children because it lifts the epiglottis (which is proportionally larger in children) out of the way for a better view of the glottic opening. A curved laryngoscope blade (MacIntosh blade) should be reserved for older children and adults.

Selecting the correct endotracheal tube size is also important. You should use the following guidelines when determining which size to use:
- Newborns/infants: 3.0–3.5 mm
- Up to 1 year of age: 4.0 mm
- 2 years and up: Use the formula (age + 16) ÷ 4 to determine the correct size

You can also use the Broselow tape device, which is used to measure the patient from head to toe to calculate the proper tube size.

Broselow tape device.

In emergency situations, you shouldn’t focus on recalling charts or figuring out formulas—use clues, such as the size of the child’s pinky or the inside diameter of the child’s nostril, to determine which size tube to use. Most pediatric endotracheal tubes have black rings near the tip of the tube that help you determine how far the tube should be inserted. For proper insertion, you should know the distance from a child’s teeth or gum line to the midtrachea:
- 6 months–1 year: 12 cm
- 2–4 years: 14 cm
- 4–6 years: 16 cm
- 6–10 years: 18 cm
- 10–12 years: 20 cm

a. Endotracheal Tube Insertion
Inserting the endotracheal tube in a child is similar to inserting the tube in an adult. Before inserting the endotracheal tube, put on a mask, eye protection, and gloves to protect yourself and the patient.
Select the appropriate laryngoscope blade and the proper size endotracheal tube. Insert the laryngoscope blade to reveal the airway. Lubricate the tube and use a stylet to aid in insertion. After the endotracheal tube is in position, remove the laryngoscope blade and secure the tube.
After the endotracheal tube is inserted, the EMT-Basic should ventilate the patient and ensure that the tube has been placed in the proper position. A misplaced endotracheal tube may be hard to recognize in children and infants. Monitor the patient’s vital signs for any indication of improper insertion. Breath sounds are not a reliable indication of proper insertion in infants and children.

If the tube is placed properly, but the patient’s lungs are not expanding normally, there are several possible causes:
- The tube is too small. This may create an air leak. Listen above the neck to determine if this is the case. If you can hear air escaping, remove the tube and replace it with a larger one. If the child is over 8 years old, make sure you’re using a cuffed tube.
- The bag-valve mask or tube is leaking or malfunctioning. Check the bag-valve mask and tube and replace with a new tube if necessary.
- Inadequate ventilation is being administered. Ventilate with more volume or use a larger bag-valve mask.
- The tube is blocked. Suction the tube to remove fluids or materials. If this doesn’t work, replace the tube.

Tip: Be careful not to ventilate a child too forcefully as this can cause the patient’s lung to collapse.

Once the tube is placed correctly, continue to monitor the patient to ensure that the tube doesn’t move or become extubated. Just as with adults, complications, such as vomiting and self-extubation, can arise even with a correctly placed endotracheal tube. These complications are far more common in children than adults.
Remember, if you’re unable to correctly place the endotracheal tube after two attempts, do not attempt to insert it again. Stimulation of the airway can slow the heart rate and complications could arise.

Related Topics You Should Review:
- Differences between basic airway management techniques in adults and children
- Inserting the nasogastric tube in a child
- Determining endotracheal tube size for children