Airway Management and Ventilation
Pediatric airway anatomy drives technique: relatively large occiput, small mouth, large tongue, a floppy omega-shaped epiglottis, a larynx that is funnel-shaped and narrowest at the cricoid in infants, and a short trachea that makes tube malposition easy. Position to align the ear canal with the sternum - often a shoulder roll for infants, sniffing position for older children. Use head-tilt/chin-lift without trauma and jaw thrust with in-line immobilization when trauma is suspected.
Size an oropharyngeal airway from the corner of the mouth to the angle of the mandible; a nasopharyngeal airway is better tolerated when gag reflexes are intact. Bag-mask ventilation is a two-person skill: one rescuer holds the mask with a two-handed E-C technique while the other squeezes the bag. Deliver each breath over about 1 second, with only enough volume to see the chest rise.
Tube sizing: uncuffed = (age in years / 4) + 4; cuffed = (age / 4) + 3.5. Depth at the lip is roughly 3 × tube internal diameter. Confirm placement with continuous waveform capnography plus chest rise, equal breath sounds, and improving heart rate and saturation.
Traps: hyperventilation, which raises intrathoracic pressure, reduces venous return, and lowers cerebral perfusion; interpreting a flat capnography trace as equipment failure instead of esophageal intubation; and continuing to bag an obstructed airway instead of relieving the obstruction. For severe foreign body obstruction, give an infant 5 back blows then 5 chest thrusts, a child abdominal thrusts, and begin CPR if the child becomes unresponsive.
Worked example: a 4-year-old gets a cuffed 4.5 mm tube, secured at 13.5 cm at the lip.