Airway assessment and basic airway management: Viva

Branch 1: Recognising the obstruction and opening the airway

The candidate should recognise at once that the snoring, minimal chest movement, and low saturation mean the unconscious child's airway is obstructed by the tongue and soft tissues, and that this is the proximate threat to life. The first action is to open the airway with a head tilt and chin lift, because there is no suggestion of trauma, and to suction any secretions, then reassess for chest movement and air at the mouth. [1]

The examiner may probe why the child obstructs so readily. The candidate should explain the paediatric airway differences that make tongue obstruction common and dangerous: a large occiput that flexes the neck supine, a tongue that is large relative to the oral cavity and falls back when tone is lost, and the physics by which resistance rises with the inverse of the radius to the fourth power, so a small child obstructs rapidly. The key teaching point is that the narrowest point of the child's airway is the cricoid cartilage, not the vocal cords. [2]

Branch 2: Choosing and sizing the adjunct

The examiner may ask which adjunct to use. The candidate should state that because the child is deeply unconscious with lost pharyngeal tone and no gag reflex, an oropharyngeal airway is the correct adjunct, and that it must be sized from the corner of the mouth to the angle of the jaw or the earlobe. They should explain that an oropharyngeal airway is contraindicated in a child with a preserved gag reflex because it provokes vomiting and aspiration, in which case a nasopharyngeal airway, sized from the nostril to the tragus, is preferred. [1]

If the examiner pivots to a child with suspected cervical spine injury, the candidate should switch the opening manoeuvre to a jaw thrust without head tilt, with manual in-line stabilisation, and state that the airway always comes first and the small risk of spinal injury never justifies leaving it obstructed. They should also know to avoid a nasopharyngeal airway in suspected basilar skull fracture or coagulopathy. [1]

Branch 3: Bag-valve-mask ventilation and escalation

If breathing remains inadequate, the candidate should describe a two-person bag-valve-mask technique: one rescuer holds the mask with a two-hand E-C or thenar eminence grip while the other squeezes the bag, ventilating with one breath every two to three seconds and only enough volume for normal chest rise. They should justify the two-person technique on the evidence that it gives a superior seal and ventilation compared with the one-hand technique, and warn that excessive force or rate causes gastric insufflation, regurgitation, and aspiration. [3]

The examiner should test the escalation logic. The candidate should state that the triggers for escalation are failure to achieve adequate chest rise and oxygenation despite a correct two-person technique, recurrent obstruction, or any deterioration, and that because difficult mask ventilation tracks with difficult intubation in children, the responder should summon senior anaesthetic and intensive care help early rather than persisting alone. They should frame bag-valve-mask ventilation as the bridge that keeps the child alive while the definitive airway is assembled. [1]