The Little Things Count: Airway Assessment of Children

Robert K. Waddell // January 1, 2013

Despite the many treatment advances prehospital care continues to enjoy year after year, the need to achieve 100 percent accuracy in basic airway care remains a hallmark that cannot be neglected.

For a number of years, prehospital providers have been afforded the opportunity to deliver an ever increasing level of care to their patients through advancements in treatment modalities.

Several advancements have been due to the introduction of new equipment and medications, and several due to procedures being made available to us, which were once only provided in the in-hospital setting.

Yet despite all these wonderful opportunities, the fact is more children are stabilized and life threats averted through the provision of the basics.

The science of pediatric emergencies tells us to base our proficiency not on the number of procedures we perform, but on the number of crisis we avert. But what is meant by this?

Basic care
Most pediatric patients need basic care to be stabilized. Fancy equipment and advanced protocols more often than not cause delays in the provision of appropriate care and can be responsible for the deterioration of the critically ill or injured child.

Respiratory distress has been identified as the most common cause for EMS and Emergency Department (ED) encounters will children. Krauss and Donoghue et al 1, 2 have shown that children in various degrees of respiratory distress are responsible for nearly 10 percent of all ED visits and 20 percent of hospitalizations.

In the prehospital setting, respiratory distress is the chief complaint in 20 – 50 percent of all pediatric responses. Sixty percent of those responses involve a critical child needing advanced level care, yet what does all the research and all the many years of knowledge teach us? Basic respiratory system assessment, recognition and management saves lives. More is less!

The American Academy of Pediatrics developed the "Pediatric Assessment Triangle" (PAT) as a tool to increase the assessment capabilities of EMS and other healthcare providers through the use of a simple three sided process.

The PAT focuses the EMT's attention to the obvious; the child's "General Appearance," their "Work of Breathing" and the "Circulation to the Skin."

From 20 feet away, you can begin assessing your patient with a high level of accuracy. If the child looks sick from 20 feet, they probably are.

Simply getting closer and touching them will not normally cause any medical malady to improve. Sick is sick, and transport decisions need to be made.

Does that mean treatment decisions should not be made? Absolutely not. The decision to provide treatment should have started when you first saw the child.

Is the child adequately exchanging respiratory gases? Are their respirations compatible with life or not? Are they able to maintain and/or continue to maintain their own airway?

Do you need to provide supplemental oxygen? Is an airway adjunct required or not? Is the child alert or lethargic, or something in between? Where is the nearest facility capable to caring for this pediatric patient? Where is the nearest facility capable to caring for the critical pediatric patient? Do I need additional resources; personnel, equipment, transport mode?

These and many other questions need to be answered and thus far you've only evaluated the General Appearance of the child.

Next is the right side of the PAT, or the Work of Breathing. Again, from 20 feet you can start gathering clues to the child's overall condition.

If you can hear respiratory effort from across the room, this child is working hard to breath and is in critical condition until proven otherwise. Your assessment will include questions such as:

  • How long have they been breathing this hard?
  • Are they using accessory muscles?
  • How many of the accessory muscle groups are involved?
  • Are there inspiratory or expiratory sounds? Both? Neither?
  • Is the cause involving the upper respiratory system of the lower one?
  • Is this episode acute, chronic or neither?

Is the Work of Breathing directly related to the child's General Appearance or is there more than one malady at work here? Children who have been working to breathe for extended time periods will begin to tire.

Runs and runs
The classic description of this situation is the Warner Brothers' cartoon, Wile E. Coyote. He runs and runs and then falls off the cliff. Just like Wile E., children work and work and work and then fall off the cliff. Medically we call it respiratory failure or arrest.

Circulation to the Skin is both the appearance of the child's skin and its physical conditions.

Is the child's skin obviously wet or dry? What is the general skin temperature? Hot, warm, cool, cold? Does it feel clammy? Dry? Is the skin pale, flushed or cyanotic?

Are the extremities one condition and the body core another? What is the status of the distal and central circulation? Is there distal circulation? Is the Condition of the Skin directly related to either or both of the other two sides of the PAT? Is it unrelated?

As you can see, the assessment of the airway and subsequent questioning can go into great depth, encompassing massive amounts of medical knowledge and yet you must ask yourself, "Does this child have the luxury of time or will time be their grim reaper?"

As you quickly evaluate the child using the PAT or whatever assessment process you are most proficient at, you realize that if any of the assessment criteria for this child are less than adequate you will need to intervene.

The primary intervention is mostly likely going to involve the respiratory system and airway management. One of the hallmark statements of the NAEMT's Emergency Pediatric Care (EPC) course 3 is, "Success in airway management is based on the achievement of physiologic goals, not the accomplishment of a particular procedure."

The statement is intended to enhance the focus on the child and not just the procedures we can perform.

Airway management starts with placing the child in a comfortable position. Initially that may be with mom or other loved one holding the child. (Please understand that during transport, all occupants in the ambulance must be properly secured in approved vehicle restraining devices).

Next, as stated above, does the child need supplemental oxygen? An extremely small number of children ever need to be intubated regardless of the etiology of the respiratory complication.

Simple oxygen therapy is usually sufficient. How much oxygen is needed? Can you put a nasal cannula on this child?

Wrestling match
Frequently in younger children, because they don't feel well in the first place, trying to place a cannula or even a mask can create a wrestling match that you will lose, and the child will ultimately or physiologically lose.

Forcing a child to receive oxygen frequently causes the child to burn more oxygen than what is being given, so the net effect is now the child is in a greater state of hypoxia and extremis than they would have been if you simply did nothing.

If your assessment determines the child needs supplemental oxygen, try to find a mutually beneficial method of delivering it, possibly via a mask that a parent or loved one holds in the direction of the child, letting the child hold the mask, or even play a game and have the child hold the mask toward you and then toward themselves.

No one approach will work with every child, but if they need oxygen, you can't wait for them to become lethargic before you treat their respiratory distress. The only absolute is don't make them worse.

One of the primary respiratory or airway adjuncts we have come accustomed to applying without regard to what the tool is telling us is pulse oximetry. Many EMS systems now require pulse oximetry to be used routinely if oxygen is being administered.

This is neither good nor bad, depending on the reasoning behind its use. Remember that pulse oximetry readings may lag several minutes behind actual hemoglobin oxygen attachment percentage.

Children frequently have pulse oximetry readings well within the normal range (95 – 100 percent) on room air and yet, at the cellular level, they may be at varying stages of hypoxia. The takeaway message is this: Treat the patient, not the machine.

In summary, pediatric airway management is complex only because you must have above average working knowledge of the respiratory systems and more specifically the pediatric respiratory system.

Being able to quickly assess the child, make the appropriate decision(s) as to treatment now versus treatment enroute and determining whether the situation requires invasive procedures is what will make a positive difference in the lives of the children we are entrusted to care for.

Failing to recognize the child that appears minimally compromised only to discover they have transitioned from compensation to decompensation in a matter of minutes or seconds is a nightmare situation you never want to find yourself and your patient in.

Kids can be difficult to care for because kids aren't supposed to be sick. Yet, when they are, they are trusting us to properly care for them.


1. Krauss BS, Harakal T, Fleisher GR. The spectrum and frequency of illness presenting to a pediatric emergency department. Pediatr Emerg Care 1991; 7:67.

2. Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med 2005; 46:512.

3. Emergency Pediatric Care course, NAEMT, 2010


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