Airway is the first assessment in the systematic ABCDE approach to patient assessment: A = airway (c spine), B = breathing, C = circulation, D = disability, E = exposure. All aspects of the systematic approach require continuous review. The primary objective of airway assessment is to confirm an open and patent airway. Red flags are signs that warrant immediate medical review.

The basic anatomical structures which make up the upper airway are: the nose, the pharynx, the epiglottis, the larynx, the cricoid and the trachea.

Children will predominantly present in respiratory arrest as a primary event unless there is an underlying medical condition. This respiratory response is due to the compensatory processes of children’s bodies through cell oxygenation and the development of major organs, such as the heart (left ventricle) and the kidneys.

Airway needs to be simultaneously assessed with the general discriminator AVPU – Alert, Verbal, Pain, Unresponsive. This may involve waking up a sleeping child. A lowered conscious state automatically places a child’s airway at risk. Understanding how the anatomy of a child’s airway changes from birth to 11 years will provide the rationale for your practice. It will help to identify red flags and other key presentations that place a child at risk. The common causes of upper airway obstruction in the under-4 age group are viral illness such as croup and ingestion of foreign bodies. Additional presentations include smoke and chemical inhalation.

From birth to 6 months, babies are obligate nasal breathers which means they breathe through the nose. This is thought to be due to several structural features which are developing in this age group. The first are skeletal structures, which are a short neck and large occiput (back of head). The second are internal structures of the airway. A baby’s tongue is proportionally larger than the internal surface area of their mouth. Together with a smaller pharynx, this places their tongue closer to the palate and oral airway, essentially blocking the oral airway, causing the baby to breathe through the nose. Putting all of these structures together for nursing practice, correctly positioning a baby’s airway and head in a neutral position for airway is paramount. A large occiput naturally flexes the baby’s head forward, causing airway occlusion. Hyper-extension will also cause occlusion. The correct placement of oxygen masks is equally fundamental to prevent compression of the external nares (nostrils).

Continuing down the airway of a small child, the epiglottis is larger and floppier than that of an adult. The larynx is higher up and more anterior and superior in position (at the front of the throat extending towards the base). This makes the airway funnel-shaped with the narrowest point at the cricoid. The trachea (windpipe) is less rigid in structure and more compliant. The adult airway in comparison is straight with better integrity. In plain terms, the airway of a small child is more at risk of collapse and obstruction than that of an adult.

Understanding the development of children’s airway will help to you to differentiate between a normal physiological function such as drooling in the under-6 months and drooling as sign of potential airway obstruction.

As referenced, babies under 6 months old are obligate nasal breathers therefore mouth breathing in this age group signifies moderate to severe distress. Mouth breathing accompanied by drooling is a red flag for any aged child as it indicates partial airway occlusion. Drooling means that the child is unable to swallow their secretions. Supporting your practice for airway assessment are other algorithms such as the Westerly score used in the assessment of croup. It helps to determine the severity of croup and provides guidelines for treatment.

Children under the age of 8 years are termed diaphragmatic breathers due to using the diaphragm muscle to alter the thoracic pressure for ventilation. Up to this stage of development the rib cage in a small child is highly compliant and horizontal in structure, which means that thoracic movement does effectively change lung pressure.

Your assessment must include establishing respiratory effort and air entry. While the respiration rate is an important observation to monitor, the most definitive clinical indicator for a child’s respiratory status is work of breathing. Is the child shallow breathing or splinting?

A child who is alert with a patent airway and normal respiratory effort will essentially have quiet breathing. It is important to know that complete airway occlusion will also present as quiet breathing, again reiterating the need to assess a child’s conscious status.

Normal effort in the under-6-month age group is nasal breathing with soft abdominal effort. Nasal flaring is therefore an alert. This is the physiological response by the body to attempt to increase positive pressure and ventilation through the nares. Placing the baby’s head in a neutral position will expose the suprasternal notch to allow assessment for a tracheal tug.

A simple method to examine the chest in a child of any age is to ask the parent or carer to expose their trunk. Obviously this will involve respecting the privacy and dignity of the patient. Full observation of the chest and abdomen can be made. Red flags for a child of any age are sternal recession and see-saw effort (opposite chest to abdominal rise). Placing the child in a side profile can also help to visualize the rib margins better to assess intercostal recession – drawing in air, which in isolation is termed mild-to-moderate effort.

Completing this section is physical examination. Auscultation with a stethoscope is recommended for full assessment of the upper and lower airway. But this is recognized as an advanced competence. Your assessment may include hearing an audible wheeze (heard on expiration) or stridor (heard on inspiration).

For verbal children, an easy technique is to ask them to speak a full sentence. Speech is formed through the larynx and vocal cords on expiration. A child who struggles to speak one to three words is showing airway compromise.

To conclude, the red flag or severe respiratory effort in the under-6-month age group is head bobbing – the physiological attempt to increase positive pressure using the clavicular muscles. With gross motor development, this form of respiratory distress in self-supporting children presents as the tripod position.