Pediatric airway management is one of the most stressful and fearful activities within the emergency department. We use these skills less often as compared with adults, and therefore the familiarity, mental and muscle memory are not as tuned. There is also a tremendous cognitive load during pediatric resuscitations determining the appropriate sized equipment and medication dosing, increasing the pressure.

There are numerous critical differences in managing the pediatric airway. There are anatomical differences, especially in children <2-years of age. The child’s head is much larger in proportion to their body than adults, with a large occiput which often requires position of padding behind the shoulders. The airway is also very anterior to what you are used to in adults. Given the small size of the airway, they tend to obstruct much easier, and the stimulation and pain of a resuscitation can lead to dynamic obstruction. There are physiologic differences. Child have a much higher base line oxygen consumption rate than adults and small proportional functional reserve capacity (FRC) which leads to quicker desaturations. Lastly, all medications require weight-based dosing.

While BVM ventilation, direct/video laryngoscopy (including the speciality pediatric blades) are foundation of managing the pediatric airway, the primary backup airway adjunct are the supraglottic devices. In some situations they may be useful for primary BVM ventilation.

Supraglottic airways (ie SGA, Laryngeal Mask Airway, LMA) are available in non-intubating and intubating pediatric sizes. They are sized by patient weight (which is on the device packaging) from newborn to adolescent. The reason for having both intubating and non-intubating SGAs is because both types have unique features that may be critical in a given situation. Below we will discuss which device to choose and why.

Non-intubating LMA Supreme

With infants, we can usually provide adequate Bag-Valve-Mask ventilation with an appropriately sized face mask easily. In a short time however, the stomach becomes insufflated which compresses the lungs and makes it difficult to provide adequate ventilation. This is the main problem we get into with infants.

When you are having trouble with face mask ventilation and/or the patient’s stomach is inflating during face mask ventilation, pick the non-intubating LMA Supreme and use the gastric port to empty the air out of the stomach as ventilation is ongoing. This approach allows us to ventilate through the LMA for a prolonged period without inflating the stomach. Simply remove the LMA when you have provided enough preoxygenation based on the oxygenation saturation level, and attempt your intubation. I think this is the greatest use for peds LMAs, so get used to this device. You can also use this device as the initial first-line ventilation device (instead of BVM ventilation) for newborns and infants, since it usually provides better ventilation than BMV.

They are available in sizes 1, 1½, 2, and 2½.

LMA Supreme Side View

LMA Supreme Oblique View

At the top of the LMA Supreme are two ports. There is a standard 15mm ID x 22mm OD adaptor that connects to a BVM or ventilator. There is also a separate channel for a suction catheter that leads to the esophagus.

LMA Supreme Suction Port View

The figure below shows a detailed view of the mask. At the tip of the mask you can see the exit port for the gastric suction catheter. Notice that the cross-section of the air exit port in post has an upside down U-shape to accommodate the channel for the suction catheter. This makes it difficult to pass a bougie or intubating catheter through.

LMA Supreme Mask Detail View

air-Q Intubating LMA

For a pediatric patient with difficult airway anatomy in which you want to intubate with a bronchoscope, then the preferred approach to use is the intubating air-Q LMA. This device has been tested head-