Health care professionals providing care to infant and/or pediatric populations during medical procedures involving sedation need to be aware of the inherent risks involved. Secondary to anatomical differences, children have a higher propensity to experience adverse events related to the upper airway when compared with adult populations. Arguably the most common of these events being respiratory insufficiency secondary to upper airway obstruction or respiratory failure secondary to apnea.

Anatomical features that predispose the pediatric upper airway to adverse events include:

• a larger occiput which forces the head in relation to the neck into flexion and upper airway obstruction when neurologically disinhibited

Figure 1: A) the large occiput of the child places them into neck flexion and airway obstruction.

B) extending the child's neck either by performing a head-tilt chin-lift maneuver or placing a towel-role under the shoulders is one way to alleviate upper airway obstruction caused by extreme neck flexion

• a larger tongue in relation to the oropharyngeal space can cause upper airway obstruction in the infant or child with decreased level of consciousness

• prominent adenoids and tonsils are frequently found in preschool age children and can decrease upper airway space which can lead to a difficulty with bag/mask ventilation

Physiological characteristics that can lead to decompensation of the infant or child when receiving procedural sedation includes:

• increased oxygen consumption, in combination with a lower functional residual capacity, can lead to rapid desaturations during apnea or periods of hypoventilation

• increased resistance to air flow in the upper airway secondary to a smaller diameter in a child can be further exacerbated by procedural sedation as the presence of a sedative can decrease upper airway muscle tone and lead to compression of that space.

Alleviating upper airway obstruction secondary to procedural sedation involves using techniques and appliances that move the base of the tongue anteriorly in relation to back of the oropharyngeal space. Going from the simplest techniques to more advanced, the process for managing upper airway obstruction consists of:

1. Head-tilt, chin-lift maneuver

The head-tilt, chin-lift maneuver is indicated for patients presenting with upper-airway obstruction secondary to poor mentation. The technique is carried out by placing the fingers of one hand under the mandible and lifting upward to move the chin anteriorly while at the same time, place the other hand on the child's forehead and gently tilt the head into the neutral position.

Figure 2: the head-tilt, chin-lift maneuver

Cautions when performing the head-tilt chin-lift maneuver- avoid closing the mouth, pushing on the soft tissues under the chin, or hyperextending the neck, because any of these actions can cause airway obstruction.

2. Jaw-thrust maneuver

The preferred method for opening the airway in infants and children when there is a concern for cervical spine injury. During airway management, in-line manual cervical spine stabilization should be considered during the airway maneuver. To perform the skill, place one hand at each side of the face, grasp the angles of the mandible and move the mandible anteriorly.

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3. Suctioning Figure 3: jaw-thrust maneuver

Is indicated in all infants and children who have copious oral secretions, bleeding, or vomiting and who are showing signs of airway obstruction (i.e., hypoxemia, respiratory distress, or poor air entry despite adequate chest wall movement) or cannot properly protect their airway (i.e., patients with altered mental status or swallowing abnormalities). The procedure involves suctioning the patient for brief intervals (i.e., less than 30 seconds) while taking into account their breathing and oxygenation. The yonker is the recommended instrument for clearing oral secretions. The posterior pharynx should be avoided in order to reduce the risk of gagging and vomiting. For suctioning the nasopharynx, use a suction catheter with a bore size that easily passes into the nasal passage but is also effective at clearing secretions.

Potential complications associated with suctioning includes vomiting and/or desaturations. If vomiting occurs, rapidly place the patient on their side or elevate the head of the bed and proceed to suction the oropharyngeal space. If significant oxygen desaturations occur, stop suctioning and provide supplemental oxygen as needed. Figure 4: oropharyngeal suctioning

Suctioning can be re-commenced as needed once the patient's oxygen saturation returns to baseline levels.

4. Oropharyngeal Airway

The oropharyngeal airway (OPA) is indicated in the unconscious infant or child to relieve upper airway obstruction caused by the tongue that is unresponsive to simple airway maneuvers (i.e, head-tilt/chin lift or jaw thrust). An OPA should never be placed in the conscious infant or child as it can stimulate gagging and or vomiting. Sizing the OPA involves holding it along the side of the face with the phalange at the corner of the mouth and the tip of the airway directed to the angle of the mandible. The procedure involves depressing the tongue to the floor of the mouth using a tongue depressor and gently inserting the OPA in-line with the curve of the mouth and pharynx. Avoid inserting and then 360-degrees rotating an OPA in an infant or smaller child as it may cause abrasion or injury to the tonsils or soft palate with bleeding.

Complications of incorrect sizing includes obstruction of the larynx, laryngeal injury, or laryngospasm (i.e., if too large) and obstruction of the airway by the tongue (i.e., if too small).

​ 5. Nasopharyngeal airway

The nasopharyngeal airway (NPA) maybe used in the conscious or unconscious infant or child to bypass airway obstruction caused by the tongue and pharyngeal soft tissues.

Figure 5: oropharyngeal airway sizing

It is particularly useful to relieve obstruction caused by macroglossia or tonsillar hypertrophy in infants and children with normal mentation and respiratory function. Sizing the NPA involves choosing a size where the length is equal to the distance between the nostril and tragus of the ear.

Complications associated with using an NPA that is too long include: bradycardia through vagal stimulation; laryngeal injury with airway bleeding or swelling; laryngospasm; vomiting with the risk of aspiration; pressure necrosis of the soft tissue and cartilage of the nose; and coughing. If the NPA is too small, it can become easily obstructed by nasal secretions and become ineffective.

6. Assisted ventilation

Indications for positive-pressure ventilation include: for the infant or child with ineffective spontaneous breathing (i.e., bradypnea, diminished chest expansion, minimal air entry) and supporting breathing during a cardiac arrest. When providing assisted ventilation using a positive pressure device, ensure that: you maintain an open airway with either proper positioning (i.e., head-tilt chin-lift/jaw-thrust) or airway adjuncts (i.e., OPA, NPT); you support breathing by delivering breaths for a respiratory rate (RR) of 20-30 breaths per minute (bpm) and delivering the breath over 1- second.

The EC-clamp technique is used by the clinician to provide positive-pressure breathing in situations where respiratory insufficiency or failure is evident. The purpose of the EC-clamp technique is to provide the clinician with a means of opening the upper airway while at the same time providing manual breaths to the patient. To perform the technique, the manual resuscitator's mask is applied to the patients face with the narrowest portion of the mask over the bridge of the nose. The mask is secured to the face by forming a "C" with the thumb and index finger while the remaining fingers of the same hand form an ''E" to move the mandible anteriorly and remove the tongue from obstructing the upper airway. The clinician's other hand is used to compress the bag and provide manual breaths at a rate of 20-30 breaths per minute or one breath every 2 to 3 seconds. Chest rise during positive pressure breathing is the gold standard for identifying effective ventilation in the absence of end-tidal carbon dioxide.

In the context where ventilation and/or oxygenation remains ineffective despite use of the E-C clamp technique, a two-person E-C clamp technique can be performed. This may be more common in patients with larger habitus or facial anomalies (i.e., Pierre-robin syndrome). To accomplish this, one rescuer uses two hands to create the E-C hand positions and maintain the airway while a second rescuer depresses the bag of the manual resuscitator.

Some basic strategies for trouble shooting ineffective manual ventilation include:

• Reopen the airway- with basic techniques (i.e., repositioning the head, suctioning, rechecking placement of an OPA or NPT)

• Treat foreign body upper-airway obstruction as per the algorithm

• Increase the ventilation pressures- by checking the bag-valve-mask device, including verifying appropriate mask size, ensuring a tight mask seal, or disabling a pop-off valve on the self-inflating bag

• Assess for and treat gastric insufflation- gastric insufflation can be prevented by using smaller tidal volumes, giving the breath over 1-second, and reducing the respiratory rate so that the patient has a longer time to exhale.

• Assess and treat for pneumothorax

If you have any questions regarding upper airway management during procedural sedation, contact out team at Gateway Resuscitation

Sincerely,

The Gateway Wellness Group team

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