Airway assessment and basic airway management: Case

This unconscious toddler presents with airway obstruction from the tongue and soft tissues, signalled by snoring, minimal chest movement, pallor, and a low oxygen saturation. The first priority is to open and ventilate the airway within the first minute, because most paediatric arrests are respiratory, and an airway opened early can prevent progression to cardiac arrest altogether. [1]

Clinical findings

The key findings are the snoring, which localises the obstruction to the tongue falling back against the posterior pharynx as pharyngeal tone is lost, the minimal chest movement that confirms inadequate ventilation, and the pallor and low saturation. The large occiput has flexed the neck in the supine position, worsening the obstruction, and the copious secretions further threaten the airway. [2]

The candidate should assess the airway with look, listen, and feel over about five seconds, and recognise that the child is unconscious with no gag reflex, which determines the choice of adjunct. They should also note that the absence of trauma means a head tilt and chin lift is the appropriate opening manoeuvre, and they should be alert to the pre-terminal signs of softening noise and falling effort should the child tire further. [1]

Management

The immediate management is to open the airway with a head tilt and chin lift, suction the secretions under direct vision, and insert a correctly sized oropharyngeal airway because the child is deeply unconscious with no gag reflex. The oropharyngeal airway is sized from the corner of the mouth to the angle of the jaw or the earlobe, validated by the GUEDEL-I magnetic resonance imaging study, and an over-long device that pushes the epiglottis down must be avoided. [3]

Because breathing remains inadequate, ventilate with a two-person bag-valve-mask technique, one rescuer holding the mask with a two-hand E-C grip and the other squeezing the bag, at one breath every two to three seconds with only enough volume for normal chest rise. Call for senior anaesthetic and intensive care help early, because difficult mask ventilation in children tracks with difficult intubation, and prepare a supraglottic airway and tracheal intubation equipment while ventilation continues. [1]

Complications and follow-up

The complications to avoid are those of mis-applied basic technique: an oropharyngeal airway in a child with a gag reflex causing vomiting and aspiration, a one-person bag-valve-mask technique with a poor seal causing gastric insufflation, and hyperventilation causing gastric distension and reduced cardiac output. The candidate should state that persisting with failing basic technique instead of escalating delays the definitive airway, which is the gravest error. [1]

Once the airway is secured and the child stabilises, the candidate should seek and treat the underlying cause of the seizure, apply continuous monitoring with pulse oximetry and end-tidal carbon dioxide, and give the family a clear safety-net to return if noisy breathing, colour change, drowsiness, or breathing difficulty recur. A child who obstructed once may obstruct again, and identifying and treating the cause, together with reliable monitoring, completes the care. [2]