BASIC AIRWAY TECHNIQUES
Airway management is the first priority in pediatric resuscitation, as hypoxia is the leading cause of cardiac arrest in children. Basic airway techniques are the first step in ensuring adequate oxygenation and ventilation before advanced interventions like intubation or supraglottic airway placement become necessary.
These techniques are quick, effective, and lifesaving, making them essential skills for any healthcare provider treating pediatric emergencies.
HEAD-TILT/CHIN-LIFT MANEUVER
The head-tilt/chin-lift maneuver is the preferred method for opening the airway in pediatric patients without suspected cervical spine injury.
How It Works:
- Tilting the head back lifts the tongue away from the posterior pharynx, preventing obstruction.
- Lifting the chin further opens the airway, improving airflow.
Steps to Perform the Head-Tilt/Chin-Lift:
- Place one hand on the child’s forehead and apply gentle backward pressure.
- Use the fingertips of your other hand to lift the bony part of the chin (not the soft tissue).
- Avoid excessive hyperextension, especially in infants, as this may obstruct the airway.
Precautions:
- DO NOT use this technique if a cervical spine injury is suspected.
- Excessive extension in infants can cause airway collapse—use the neutral sniffing position instead.
Clinical Application:
Used in unresponsive patients without spinal trauma. Can improve airway patency before bag-mask ventilation (BMV).
JAW-THRUST MANEUVER
The jaw-thrust maneuver is used when cervical spine injury is suspected, such as in trauma cases, falls, or motor vehicle accidents. It is the preferred technique in suspected spinal cord injury because it opens the airway without moving the neck.
How It Works:
- Lifting the jaw forward moves the tongue away from the airway without extending the neck.
Steps to Perform the Jaw-Thrust Maneuver:
- Place your fingers on both sides of the patient’s jaw (just behind the angles of the mandible).
- Apply firm upward and forward pressure to move the jaw forward.
- Avoid tilting or rotating the head.
Precautions:
- If resistance is met, avoid excessive force, as it may cause pain or injury.
- May not be as effective as the head-tilt/chin-lift but is necessary for trauma patients.
Clinical Application: Used in trauma patients with suspected spinal cord injury. Often performed when assisting ventilations with a bag-mask device.
NASOPHARYNGEAL AIRWAY (NPA) INSERTION
The nasopharyngeal airway (NPA) is a soft, flexible tube inserted into the nostril to maintain an open airway. It is particularly useful in patients who are semi-conscious or have an intact gag reflex and cannot tolerate an oropharyngeal airway.
When to Use an NPA: Patients with intact gag reflex but needing airway support. Patients with seizures or altered mental status where the tongue obstructs the airway. Patients who cannot tolerate an OPA due to gagging.
Steps to Insert an NPA:
- Select the correct size: Measure from the tip of the nose to the earlobe.
- Lubricate the NPA with water-based lubricant.
- Insert the airway along the nasal passage, bevel facing the septum.
- Advance gently until the flange rests against the nostril.
- If resistance is met, try the other nostril—never force insertion.
Precautions:
- Avoid in children with facial trauma or suspected skull fractures (risk of intracranial insertion).
- Excessively long NPAs can cause airway obstruction.
Clinical Application: Used in patients with respiratory distress but a maintained gag reflex. Ideal for seizure patients who need airway support but cannot tolerate an OPA.
OROPHARYNGEAL AIRWAY (OPA) INSERTION
The oropharyngeal airway (OPA) is a rigid, curved plastic device inserted into the mouth to prevent the tongue from obstructing the airway. It is used in unconscious patients who lack a gag reflex.
When to Use an OPA: Unconscious pediatric patients without a gag reflex. To maintain airway patency in postictal seizure patients. Assists in bag-mask ventilation (BMV).
Steps to Insert an OPA:
- Select the correct size: Measure from the corner of the mouth to the angle of the jaw.
- Open the mouth using the head-tilt/chin-lift or jaw-thrust maneuver.
- Insert the OPA upside-down (concave facing up) until the soft palate is reached.
- Rotate 180 degrees so the curve follows the tongue.
- Advance until the flange rests against the lips.
Precautions:
- NEVER use an OPA in a child with a gag reflex—this may cause vomiting and aspiration.
- Incorrect sizing (too large or too small) can cause airway obstruction.
Clinical Application: Used in unresponsive patients needing airway support. Helps prevent the tongue from causing obstruction during BMV.
CHOOSING THE RIGHT AIRWAY TECHNIQUE
| Technique | Best For | Contraindications |
|---|---|---|
| Head-Tilt/Chin-Lift | Non-trauma patients | Suspected spinal injury |
| Jaw-Thrust | Trauma patients | Severe jaw trauma |
| NPA | Semi-conscious with gag reflex | Facial/skull fractures |
| OPA | Unconscious without gag reflex | Conscious patients |
SUMMARY: WHY BASIC AIRWAY MANAGEMENT MATTERS
In pediatric resuscitation, ensuring an open airway is the first step in life support.
Head-Tilt/Chin-Lift is the quickest, easiest way to open an airway—unless cervical spine injury is suspected. Jaw-Thrust Maneuver is used when there is concern for spinal trauma. NPA is great for patients with a gag reflex, but avoid in facial trauma. OPA is ideal for unconscious patients with no gag reflex, but never use it in a conscious child.
Takeaway: If a child cannot breathe, nothing else matters. Basic airway techniques can save a life before advanced interventions are even needed. 