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HLT-EMT39-04 · Lesson 9 · 22 clock hours · practice

Pediatric and Geriatric Airway Considerations

Objective. Students will adapt airway assessment and management techniques appropriately for the anatomical and physiological differences of pediatric patients and older adults, selecting correct equipment sizes and ventilation parameters.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Why Age Matters in Airway Management

Airway anatomy and physiology change significantly across the human lifespan. Techniques and equipment that work well for a healthy adult can fail — or cause harm — when applied without modification to an infant, child, or older adult. Understanding these differences is not optional; it is a core safety requirement for every EMT and paramedic.

Pediatric Airway Anatomy

Children are not simply small adults. Several anatomical features make their airways distinct:

Sizing pediatric equipment correctly is critical. An endotracheal tube that is too large can traumatize the subglottis; one that is too small will not ventilate effectively. The Broselow pediatric emergency tape is the standard field tool: lay it beside the patient from the top of the head to the heel, read the color zone, and use the listed equipment sizes. Always verify tube placement and use the smallest effective BVM that achieves visible chest rise without overinflation.

Infant and Child Ventilation Technique

For bag-valve-mask (BVM) ventilation in infants, use the E-C clamp technique and ensure only gentle pressure is applied. Visible chest rise — not a set pressure — is the endpoint. Avoid hyperextending the neck in infants; keep the head in a neutral sniffing position. In toddlers, slight extension is appropriate. Using a correctly sized OPA or NPA to maintain a patent airway before intubation attempts reduces hypoxia.

Geriatric Airway Anatomy and Physiology

Older adults present a different set of challenges:

Selecting the Right Equipment

For pediatric patients, the Broselow tape drives all sizing decisions in the field. For geriatric patients, use standard adult equipment but assess carefully before insertion — check for dentures, assess neck mobility, and position with padding under the shoulders if needed to achieve a neutral or slightly extended position without forcing the cervical spine.

Safety Priorities for Both Age Groups

1. Confirm chest rise with every ventilation — it is the primary indicator of adequate tidal volume.

2. Avoid gastric inflation in pediatrics by not over-ventilating.

3. Suction gently in older adults to prevent mucosal injury and vagal stimulation.

4. Document all equipment sizes used for both age groups so hospital staff can maintain continuity.

5. Communicate your findings during handoff, especially any modifications made to standard technique.

Key terms8

Broselow tapeA color-coded length-based resuscitation tape used in pediatric emergencies to estimate patient weight and guide selection of medication doses and equipment sizes based on the child's height.
Subglottic narrowingIn infants and young children, the cricoid ring is the narrowest part of the airway, making it especially vulnerable to obstruction from edema or an oversized endotracheal tube.
Sniffing positionThe head position that aligns the oral, pharyngeal, and tracheal axes to optimize visualization of the glottis during intubation; achieved by slight neck extension and head elevation.
Chest wall complianceThe ease with which the chest wall expands during ventilation; higher in infants and children (requiring less pressure) and lower in older adults due to calcification of costal cartilages.
Miller bladeA straight laryngoscope blade used to directly lift the epiglottis, preferred in infants and small children because of their long, floppy epiglottis anatomy.
Oxygen reserveThe functional residual capacity of oxygen in the lungs available during apnea; reduced in pediatric patients due to smaller lung volumes and in older adults due to decreased lung compliance.
Aspiration riskThe likelihood that foreign material (vomit, secretions, food) will enter the lower airway; elevated in older adults due to diminished protective reflexes such as gag and cough.
E-C clamp techniqueA one-provider BVM technique in which the third, fourth, and fifth fingers form an 'E' to hold the jaw and the thumb and index finger form a 'C' to seal the mask against the face.

Worked examples4

1. You place the Broselow tape alongside a child and the tape reads 85 cm, placing the child in the purple color zone. The tape indicates an ET tube size of 4.0 mm uncuffed. What blade size should you select if the tape indicates a size 2 straight blade?
  1. Step 1: Identify the color zone from the Broselow tape measurement — the child measures 85 cm, placing them in the purple zone.
  2. Step 2: Read the ET tube size from the tape for that color zone — 4.0 mm uncuffed is listed.
  3. Step 3: Read the laryngoscope blade size from the tape — a size 2 straight (Miller) blade is indicated.
  4. Step 4: Confirm both selections match the same color zone before preparing equipment.
Answer: Select a 4.0 mm uncuffed ET tube and a size 2 straight (Miller) laryngoscope blade, as both are indicated by the purple zone on the Broselow tape.
2. For BVM ventilation of an infant, you squeeze the bag and notice the abdomen rising but the chest barely moves. What two adjustments should you make?
  1. Step 1: Recognize that a rising abdomen with minimal chest rise indicates gastric inflation, meaning tidal volume is being directed into the stomach rather than the lungs — likely caused by excessive pressure or improper head position.
  2. Step 2: Reposition the infant's head to a neutral sniffing position (avoid hyperextension), ensuring airway alignment.
  3. Step 3: Reduce bag squeeze force — use only enough pressure to produce visible chest rise. In infants, this is a very small squeeze of the infant-sized BVM.
  4. Step 4: Verify mask seal and consider inserting a correctly sized OPA to maintain airway patency and reduce resistance.
Answer: Reposition the head to neutral sniffing position and reduce bag squeeze force until only visible chest rise is achieved, preventing further gastric inflation.
3. A Broselow tape places a child at 110 cm in the white color zone, indicating a 4.5 mm ET tube and size 2 blade. You prepare to insert an OPA. The tape indicates a size 70 mm OPA. How do you confirm the OPA size is appropriate before insertion?
  1. Step 1: Accept the Broselow tape size recommendation of 70 mm as your starting selection.
  2. Step 2: Perform a quick anatomical check: hold the OPA against the outside of the child's face — the flange should rest at the corner of the mouth and the tip should reach the angle of the jaw (earlobe).
  3. Step 3: Confirm the size is neither too long (which could push the epiglottis down and obstruct the airway) nor too short (which would fail to displace the tongue).
  4. Step 4: If the Broselow size matches the anatomical check, proceed with insertion using the tongue-jaw lift method with a tongue depressor, rotating the OPA into position — do not use the 180-degree rotation technique used in adults, as it can damage pediatric oral tissues.
Answer: Confirm the 70 mm OPA by checking that the flange sits at the corner of the mouth and the tip reaches the angle of the jaw, then insert using the tongue depressor technique appropriate for pediatric patients.
4. You are ventilating an elderly patient with a BVM. The patient has a partial upper denture that is loose. Should you remove the denture before or after achieving a mask seal?
  1. Step 1: Assess whether the denture is well-fitted or loose. A well-fitted denture can improve mask seal by maintaining facial contour; a loose denture is a foreign body hazard.
  2. Step 2: Because the denture is described as loose, it poses a risk of dislodging into the airway during ventilation or intubation.
  3. Step 3: Remove the loose partial denture before beginning BVM ventilation to eliminate the airway foreign body risk.
  4. Step 4: After removing the denture, note that the patient's cheeks may now be sunken, making mask seal harder. Compensate by using a two-provider BVM technique or applying gentle upward jaw thrust to improve seal.
Answer: Remove the loose partial denture before BVM ventilation to prevent airway foreign body risk, then use jaw thrust or a two-provider technique to maintain mask seal despite altered facial contour.
In class: Age-group anatomy comparison lecture and Q&A: instructor uses side-by-side anatomical models to highlight differences in tongue-to-oral-cavity ratio, epiglottis shape, trachea diameter, and chest wall compliance across infant, child, adult, and older-adult patients; students complete a comparison table. · Pediatric equipment sizing station: students use the Broselow tape on child manikins to select ET tube size, blade size, OPA, NPA, and appropriate oxygen delivery devices for three different simulated weights; findings are recorded on a sizing worksheet. · Geriatric airway scenario: students manage a simulated elderly patient with partial dentures, cervical spine stiffness (simulated by instructor coaching), and reduced oxygen reserve; partners debrief modifications made to standard technique.
Materials: Pediatric and infant manikins, Broselow pediatric emergency tape, pediatric and infant airway adjunct sets, pediatric BVM units, adult manikin with cervical collar to simulate limited mobility, sizing worksheets, anatomy comparison models
Check: Written sizing worksheet reviewed by instructor: all equipment selections for all three pediatric scenarios correct per Broselow tape guidance; pass requires 100% correct selections on critical sizing items (tube size, blade size).

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Airway Management
1. Which anatomical feature most directly explains why a straight (Miller) laryngoscope blade is preferred over a curved (Macintosh) blade when intubating an infant?
Airway Management
2. A provider delivers bag-valve-mask ventilations to a 2-year-old and notices the abdomen is visibly distending. What is the most likely cause and the priority corrective action?
Airway Management
3. You are using the Broselow tape on a child manikin at a sizing station. The tape places the child in a color zone that indicates a 5.0 mm cuffed ET tube. Which action best demonstrates correct use of this tool?
Airway Management
4. An elderly patient you are treating has cervical spine arthritis with severely limited neck mobility. Which modification to airway positioning is most appropriate?
Airway Management
5. Why do infants desaturate more rapidly than adults during an apneic episode?
Airway Management
6. A geriatric patient has a full upper denture that fits well. You need to ventilate the patient with a BVM. What is the most appropriate action regarding the denture?
Airway Management
7. Which of the following best describes the narrowest anatomical point of an infant's airway and its clinical significance?
Airway Management
8. During the geriatric airway scenario, a student does not suction the patient's oropharynx aggressively because the patient is an older adult. Which principle best supports this decision?
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