Case: No time, no visible larynx

You are seeing a patient in the hallway when suddenly a mother rushes in with a pallid blue lifeless infant. The nurses start CPR and bag mask ventilation as you grab a Miller blade and 4.0 tube. Your first look is all secretions. After using the adult Yankauer suction you clear that out fast and look again….esophagus. You pull back but still the larynx is nowhere to be seen. What do you do next?

Neonatal airway is a difficult airway

Success rates for pediatric emergency airway, as published, are limited. Pediatric senior residents had a 40% success rate, 47% with more experience, and 68% for fellows.(Leone 2005) Among emergency physicians, success on first attempt was 60%.(Sagarin 2002) This is markedly different from adults, where success rates are commonly well above 90%. Why is it so low? Can we prevent this?

Kids are little adults? Sniffing position

I have heard dozens of lectures on how kids are anatomically different, so we make interventions to address that. Then at the bedside I see that taken to extremes. An example is the idea that they have big heads so we need a towel behind the shoulders, and pretty soon intubation is being performed with distorted anatomy. Infants need the sniffing position just like adults. Richard Levitan recommends aligning the ear canal to the sternum as a more universal standard that applies to children, adults, and the obese. A ramp of towels behind both the shoulders and head can achieve good sniffing position.


I have had cases where the respiratory therapist hands me the floppy small endotracheal suction. That usually doesn’t work. Use the adult Yankauer suction, and get those secretions out.

Back to the case

In this case you place towels behind the head and neck, extend the head slightly, and suction with Yankauer. Your next look is all tongue, but a gentle sweep to the left shows the arytenoids and you pass the tube just anteriorly. Capnography turns yellow through 6 tidal breaths, confirming success. You proceed with resuscitation.

Take home points:

-Neonates, like adults, need the sniffing position

-Neonatal secretions, like adult secretions, are best removed with Yankauer suction


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