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Lesson

Pediatric Airway Differences

12 min Airway & Breathing Skip to quiz

Objective: Position the head before you bag a child. Use a small squeeze and the pediatric breath rate. A breathing problem causes collapse more often than a primary heart problem.

Why this matters

Adult airway habits on a toddler flex the neck, give a huge bag squeeze, and can cause the arrest you were trying to prevent. Breathing problems are the major cause of pediatric cardiac arrest. Support breathing early. Do not wait for the child to look like an adult cardiac arrest.

Verbalize
  • I put a roll under the shoulders, or I use a sniffing position. A large occiput, the back of the skull, flexes the neck if I do nothing.
  • I squeeze until I see chest rise. I do not give an adult-sized breath.
  • If they have a pulse and are not breathing well, I bag at about 20 to 30 breaths per minute, about 1 breath every 2 to 3 seconds.

Clinical sequence

  1. Position the head before you reach for a tube. A towel under the shoulders in infants, or a careful sniffing position, lines the ear up with the sternal notch.
  2. Use an adjunct and a jaw thrust. The tongue and soft tissue are relatively large. Do not tip the head too far back.
  3. Suction early. Children block with secretions and vomit.
  4. Bag with a modest squeeze and visible chest rise. Use a pediatric bag if your service stocks one, and a length-based tape for tubes and adjuncts. An adult bag on an infant fills the stomach unless you squeeze with control.
Infant airway compared with an adult airway An infant has a large occiput, a relatively large tongue, and a larynx that sits higher and farther forward. A pad goes under the shoulders. Do not tip the head far back, and do not put a pillow under the head. Infant Adult shoulder pad Large back of the head. Large tongue. Larynx higher, more forward. Smaller occiput. Smaller tongue. Larynx sits lower. Line the ear up with the sternal notch. Do not tip an infant's head far back. Do not put a pillow under the head. Squeeze only until the chest rises. With a pulse: about 20 to 30 breaths a minute. About 1 breath every 2–3 s.
An infant has a large occiput, a relatively large tongue, and a larynx that sits higher and farther forward than an adult larynx. A pad under the shoulders lines the ear canal up with the sternal notch. Do not put a pillow under the head, and do not tip the head far back. Squeeze the bag only until the chest rises. With a pulse, bag at about 20 to 30 breaths a minute, about one breath every 2 to 3 seconds. During CPR with an advanced airway, use that same rate. Do not copy the adult rate of about 10.

Why a Child Is Not a Small Adult

  • The larynx sits higher and farther forward. A straight view of the cords can be harder. Use video laryngoscopy if you have it and you are authorized.
  • The glottis is the tightest opening. The cricoid is a complete ring that does not expand, so a leak and cuff pressure matter. The old teaching that the airway is a funnel and must always be uncuffed is not current. Cuffed tubes are accepted when they are sized and inflated correctly. Follow your protocol. Do not invent a tube size from memory.
  • The oxygen reserve is small, and oxygen use is high. Functional residual capacity is the air left in the lungs after a normal breath. It is small in children. They desaturate within seconds once they stop breathing. Give oxygen before the look. Limit the look. Give oxygen again between attempts. See preoxygenation.

How Fast to Bag a Child

  • If a pulse is present and breathing is not adequate, bag at about 20 to 30 breaths per minute, about 1 breath every 2 to 3 seconds. Each breath should show chest rise.
  • During cardiopulmonary resuscitation (CPR) with an advanced airway, keep continuous compressions and the same 20 to 30 breaths per minute. Do not copy the adult rate of 10 breaths per minute onto a child.
  • If your protocol is silent, use that current pediatric rate, about 20 to 30 breaths per minute with an advanced airway. If your protocol still says 10 breaths per minute for every age, clarify that with medical direction before you use the adult rate on a child. Do not under-ventilate a child because the adult card is the one you memorized.
  • Two-rescuer CPR without an advanced airway is 15 compressions to 2 breaths. One rescuer is 30 compressions to 2 breaths.
  • For infant compressions, use one hand or the two-thumb encircling technique. Do not use two fingers on the sternum. The 2025 CPR guideline dropped the two-finger method because it did not reach the right depth.
  • A slow heart rate in a hypoxic child is often a breathing problem. Give oxygen and bag. Do not reach for epinephrine first if you have not bagged.

Teaching points

  • Fix the head before you pick up equipment.
  • A long look on a child who still has a pulse is how you lose the pulse.

Common errors

  • Tipping an infant’s head too far back to open the airway.
  • Using the adult rate of 10 breaths per minute on a child with an advanced airway.
  • Taking a long look on a child who still had a pulse when you started.

Practice

One-minute check

Partner: a 6-month-old is limp, with a slow pulse and poor chest rise. Say how you position the head, the breath rate, and whether you intubate now or ventilate now. Then name the 2025 infant compression method you would use if they lose the pulse: one hand or two thumbs, not two fingers.

Related: Effective BVM, FBAO, High-Quality CPR.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. A large occiput in an infant lying flat tends to:
2. Ventilation rate for an infant or child with a pulse who needs breaths, or during CPR with an advanced airway, is closest to:
3. A hypoxic child’s bradycardia is often:
4. Current infant chest-compression technique is:
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