Pediatric Alternative Airways: What You Need to Know and Where to Find It

Backup airways. Alternative airways. Rescue airways. Whatever we call them, we should know about them, have them, and use them. But do we know what we really need to know? In our ongoing experiences with both novice and experienced EMS practitioners, when it comes to alternative airways for pediatric patients, the answer too often is no. However, this is a potential shortfall in our education and training that can be easily remedied.

We spend hours and hours perfecting our craft in intubation, but how much time do we spend learning about backup airway devices? Have you ever actually looked at the package insert or viewed the instructions? In actual practice we commonly base our use of devices on our training, which doesn’t always reflect the manufacturer’s recommendations.

The truth is out there when it comes to these lifesaving devices. There is also much misinformation and many misconceptions that can be easily corrected, if one knows where to look. It would be nice if critical information like what size airway is suggested for what size patient and how much air should be used to inflate the balloon(s) were available in the same way with each type of device, but that’s not the case. So with that in mind, let’s review the essential questions that come up with the most commonly utilized pediatric emergency alternative airways. 

Standardized Colors

It’s crucial to remember that the colors of the tops of alternative airways do not correlate to the Broselow-Luten or Handtevy systems. Three veterans of pediatric care—Robert Luten, MD, cocreator of the Broselow-Luten system; Peter Antevy, MD, creator of the Handtevy system; and educator Scott DeBoer, lead author of this article—created charts based on manufacturers’ sizing recommendations that describe what color is for what size pediatric alternative airway (for Ambu’s King and AuraGain, Mercury Medical’s air-Q sp, Teleflex’s LMA Supreme, and Intersurgical’s i-gel).

These guides were provided to each of these manufacturers in the fall of 2017, and we hope in the future all manufacturers of alternative airways will embrace the inherent safety advantages of a standardized color-coded approach.

Verifying Placement

As with endotracheal tubes, it is always advisable to confirm proper placement of an airway adjunct. Short of having x-ray vision, the most reliable techniques involve assessing the presence of carbon dioxide in exhaled air. And do these colorimetric and capnographic devices work with a King airway, LMA, or i-gel? Absolutely!

Quite simply, air goes in and out of these airways (and hopefully your patient’s lungs) just like with an endotracheal tube. Confirming correct placement, both initially and on an ongoing basis, can be done with a colorimetric indicator or, preferably, waveform capnography. The standard of care is to monitor CO₂ with any endotracheal tube placement, so you can and should monitor exhaled carbon dioxide with any alternative airway to confirm placement as well.

Taking the Pressure

We know most ET tubes have an inflatable cuff to help secure placement and minimize air leakage. The same is true for many alternative airways. If a cuff is present, we want to inflate it with the recommended amount of air (more on where to find that in our next article).

In addition to inflating the cuff (if present) with the amount of air detailed in the manufacturer’s instructions, another common option, especially in the hospital, is the use of cuff pressure manometers. Commonly used in anesthesia and intensive care units to monitor endotracheal tube pressures, these are now becoming more utilized in critical transport and EMS as well, and with good reason: Research shows that, as a rule, providers tend to seriously overinflate the cuffs of endotracheal tubes. They may be even more likely to overinflate the balloons/masks of alternative airways to ensure a proper seal. However, published research details complications associated with overinflation, including the potential for damage and necrosis to surrounding airway tissues.

Inflation guidelines—i.e., the amounts of air listed on the tube or package—are just guidelines. Some patients’ airways need more, and of course some need less. The syringe size on the tube or package is a nice way to tailor what size syringe to use for inflation—i.e., don’t hook a 60-mL syringe to an infant-size King airway. Interestingly, the same manometers utilized in the hospital setting for endotracheal tubes can be used for monitoring alternative airways as well. It’s the same toy, just for different tubes!

In our next article we’ll look at where to find information on alternative airway devices.  

Scott DeBoer, RN, MSN, CPEN, CEN, CCRN, CFRN, EMT-P, is an international pediatric seminar leader and nurse consultant with more than 30 years of nursing experience. He retired from flight nursing in 2015 following more than 20 years with the University of Chicago Hospitals’ UCAN flight team. He is the founder and primary seminar leader for Pedi-Ed-Trics Emergency Medical Solutions. 

Michael Rushing, NRP, RN, BSN, CEN, CPEN, CFRN, TCRN, CCRN-CMC, is AHA coordinator for Baptist Health Care, Pensacola, Fla., and paramedic adjunct professor at Northwest Florida State College, Niceville, Fla.

Lisa DeBoer, CET, NREMT, PI, is president and cofounder of Pedi-Ed-Trics Emergency Medical Solutions. 

Michael Seaver, RN, BA, is a healthcare informatics consultant based in Chicago.