What are the steps for managing the airway in Pediatric Advanced Life Support (PALS)?

PALS Airway Management

In pediatric cardiac arrest, continue bag-mask ventilation rather than attempting advanced airway placement, as it provides adequate oxygenation with lower complication rates and better outcomes. 1

Initial Airway Opening Maneuvers

Basic Positioning Techniques

• Use head tilt-chin lift for children over 1 year old to open the airway by lifting the tongue off the posterior pharynx 1
• Use jaw thrust as the primary maneuver for infants under 1 year, as it is typically most effective in this age group 1
• Position the infant's airway in the neutral "sniffing" position—avoid hyperextension as the large occiput naturally flexes the neck 1
• For older children, slight extension improves airway patency 1

Critical Pitfall to Avoid

• Never perform blind finger sweeps of the pharynx, as this can impact a foreign body into the larynx and worsen obstruction 1
• Only remove visible foreign bodies that can be easily grasped 1

Ventilation Strategy

Initial Rescue Breathing

• Deliver 5 initial breaths immediately if no spontaneous respiration is detected 1
• Each breath should last 1 to 1.5 seconds 1
• For infants: breathe into both mouth AND nose simultaneously 1
• For older children: breathe into mouth only with nose pinched 1

Bag-Mask Ventilation Technique

• Use a self-inflating bag (500 ml for infants, 1600 ml for children) attached to high-flow oxygen at 15 L/min 1
• Ensure the face mask is soft, clear plastic with a good seal 1
• Maintain compression-to-ventilation ratio of 5:1 at a rate of 100 compressions per minute, regardless of number of rescuers 1

Advanced Airway Decision-Making

When to Continue Bag-Mask Ventilation

• For out-of-hospital cardiac arrest, it is reasonable to continue bag-mask ventilation throughout resuscitation rather than attempting endotracheal intubation 1
• This recommendation is based on evidence showing no mortality benefit and potential harm from prehospital intubation attempts 2
• Proper endotracheal tube placement is achieved in only 48% of pediatric prehospital attempts, with 41% requiring multiple attempts 2

When Advanced Airway May Be Considered

• In-hospital settings with experienced providers where continuous high-quality CPR can be maintained 1
• When bag-mask ventilation is ineffective despite proper technique 1
• Secure airway and effective ventilation are essential priorities in advanced life support 1

Equipment Selection for Intubation (If Performed)

• Use straight-blade laryngoscope for infants and young children due to their high, anterior larynx and large epiglottis 1
• Use curved blade for older children after puberty when airway structures have descended 1
• Plain plastic (uncuffed) endotracheal tubes cause less local edema and are preferred 1

Special Circumstance: Foreign Body Airway Obstruction

Infant Choking Protocol (Under 1 Year)

• Deliver 5 back blows to the middle of the back with infant prone and head lower than chest 1
• Hold small infant along your forearm for proper positioning 1
• Follow with 5 chest thrusts (NOT abdominal thrusts) with infant supine and head lower than chest 1
• Chest thrusts should be sharper and more vigorous than compressions, at approximately 20 per minute 1
• Check mouth for visible foreign body after each cycle 1
• Repeat this sequence until airway is cleared—do not progress to abdominal thrusts in infants as they may rupture abdominal viscera 1

Child Choking Protocol (Over 1 Year)

• Start with 5 back blows (child across thighs while kneeling) 1
• Follow with 5 chest thrusts for first cycle 1
• After second round of back blows, substitute 5 abdominal thrusts (Heimlich maneuver if conscious, supine with heel of hand if unconscious) 1
• Alternate between back blows with chest thrusts OR abdominal thrusts in subsequent cycles 1

Anatomical Considerations

Age-Related Airway Changes

• Upper airway structures descend rapidly in the first 2 years of life, then remain stable until puberty 1
• At puberty, further descent of the epiglottis and cricoid occurs, changing optimal equipment selection 1
• The infant larynx is more anterior and cephalad, requiring different technique than adults 1, 3

Key Principle

Since most pediatric cardiac arrests result from respiratory failure (not primary cardiac causes), airway management and ventilation are the fundamental components of successful resuscitation 1. Early recognition and aggressive treatment of respiratory insufficiency to prevent cardiac arrest is more important than advanced airway placement during arrest 1.