PALS Provider: Course

Advanced Airway Techniques

When basic airway maneuvers and adjuncts (OPA/NPA, bag-mask ventilation) are insufficient to maintain adequate ventilation, advanced airway techniques are required. These interventions provide a secure, reliable airway, allowing for controlled oxygenation, ventilation, and airway protection.

Advanced airway management is particularly critical in pediatric patients, who are prone to airway obstruction and rapid oxygen desaturation.

Laryngeal Mask Airway (LMA) Insertion

The Laryngeal Mask Airway (LMA) is a supraglottic airway device that is inserted into the oropharynx and sits above the glottic opening. Unlike an endotracheal tube (ETT), the LMA does not pass through the vocal cords.

When to Use an LMA:

  • Difficult or failed intubation (LMA serves as a backup airway)
  • Short-term airway management when intubation is not immediately required
  • During procedures requiring general anesthesia

Steps for LMA Insertion:

  • Choose the correct size:
    • Infants (≤5 kg): Size 1
    • Infants (5–10 kg): Size 1.5
    • Children (10–20 kg): Size 2
    • Children (20–30 kg): Size 2.5
    • Children (30–50 kg): Size 3
  • Deflate the cuff completely and lubricate the posterior surface.
  • Position the patient in the sniffing position (unless cervical spine injury is suspected).
  • Insert the LMA following the natural curvature of the airway until resistance is met.
  • Inflate the cuff with the recommended volume of air (based on size).
  • Check for proper placement by auscultating breath sounds and monitoring chest rise.

Precautions:

  • Not a definitive airway—aspiration risk remains.
  • Not effective in complete upper airway obstruction (e.g., foreign body, severe laryngospasm).
  • Should not be used in patients with high airway resistance (e.g., severe asthma, ARDS).

Clinical Application:

  • Useful as a temporary rescue airway in difficult intubations.
  • Can be used as a bridge to endotracheal intubation if needed.

Endotracheal Intubation (ET) for Pediatrics

Endotracheal intubation (ETI) is the gold standard for securing an airway, allowing for mechanical ventilation, oxygenation, and airway protection.

When to Perform Endotracheal Intubation:

  • Respiratory failure (inability to maintain oxygenation/ventilation)
  • Airway protection (e.g., altered mental status, severe trauma)
  • Cardiac arrest requiring prolonged ventilation
  • Severe shock or multi-organ failure requiring controlled respiration

Steps for Pediatric Endotracheal Intubation:

  • Prepare Equipment:
    • ETT size (uncuffed): (Age ÷ 4) + 4
    • ETT size (cuffed): (Age ÷ 4) + 3.5
    • ETT depth: ETT size × 3 = approximate depth in cm at the lips
    • Ensure suction, BMV, and backup airways are available
  • Positioning:
    • Sniffing position for optimal visualization
    • Manual inline stabilization if cervical spine injury is suspected
  • Preoxygenate: 100% oxygen for 30–60 seconds before intubation
  • Rapid Sequence Intubation (if indicated): Consider sedation and neuromuscular blockade
  • Intubation Procedure:
    • Use Miller blade (neonates/infants) or Mac blade (older children)
    • Visualize cords and advance ETT
  • Confirm Placement:
    • Capnography (ETCO₂)
    • Bilateral breath sounds
    • Symmetrical chest rise
    • No gastric inflation
  • Secure the Tube: Tape or ET holder; confirm with chest X-ray (tip at T2–T3)

Precautions:

  • Do not attempt multiple intubations—risk of hypoxia and bradycardia
  • Correct tube size is critical—oversize = trauma, undersize = leaks
  • Always have a backup plan (LMA, BMV)

Clinical Application:

  • Definitive airway in critical pediatric patients
  • Used when long-term mechanical ventilation is required

Choosing the Right Airway Management Technique

Technique Best For Contraindications
LMA Difficult intubation, short procedures High aspiration risk, complete airway obstruction
ETT Prolonged ventilation, airway protection Failed intubation (consider LMA or BMV)

Summary: Why Advanced Airway Management Matters

  • LMA is a quick, supraglottic rescue airway that is easy to insert but does not protect against aspiration.
  • Endotracheal intubation (ETI) provides a definitive airway, ensuring full control of oxygenation and ventilation.

Takeaway: Advanced airway management must be performed quickly and correctly to prevent hypoxia and cardiac arrest. Knowing when to use LMA vs. ETI can make the difference between life and death.