In Pediatric Advanced Life Support (PALS), the airway is assessed using a rapid, systematic approach that combines looking, listening, and feeling for signs of obstruction or compromise. The goal is to quickly classify the airway as clear, maintainable with simple interventions, or not maintainable, then act accordingly. This assessment happens within seconds and drives every decision that follows.
Why Pediatric Airways Need a Different Approach
Children are not small adults, and their airway anatomy creates unique vulnerabilities. An infant’s head is proportionally large compared to the body, and the prominent back of the skull (occiput) naturally flexes the neck forward when the child is lying on their back. That flexion alone can obstruct the airway in an unconscious infant.
The tongue is also relatively large in infants and young children, large enough that it can block the airway even at rest. Infants are preferential nasal breathers because the tongue takes up so much space in the mouth, which means nasal congestion or swelling can cause significant breathing difficulty in ways it wouldn’t for an older child or adult.
The narrowest point of a child’s airway sits lower than in adults. In adults, the tightest spot is at the vocal cords. In children, it’s at the ring of cartilage just below the vocal cords (the cricoid), giving the pediatric airway a funnel shape rather than a cylinder. This means swelling in that area narrows the airway more dramatically and more quickly than it would in an adult. The epiglottis in infants is also floppier and narrower, making it more prone to collapse.
The Look, Listen, and Feel Approach
PALS airway assessment starts the moment you see the child. You’re evaluating three things simultaneously: whether air is moving, how hard the child is working to breathe, and whether there are signs that the airway is partially or fully blocked.
What to Look For
Visual signs of airway compromise include nasal flaring, where the nostrils widen with each breath as the child tries to pull in more air. Retractions are another key finding: visible pulling inward of the skin at the collarbones (supraclavicular), between the ribs (intercostal), or below the breastbone (substernal). These retractions mean the child is using accessory muscles to breathe, which signals significant respiratory distress. In infants, head bobbing with each breath is an ominous sign of the same struggle.
Chest movement matters too. You’re looking for whether the chest rises symmetrically, whether it rises at all, and whether abdominal breathing has taken over. A child whose belly moves but whose chest doesn’t may have an upper airway obstruction or severe respiratory fatigue.
What to Listen For
Abnormal airway sounds tell you where the problem is. Stridor, a high-pitched sound heard mainly during breathing in, points to an obstruction in the upper airway near the vocal cords or above. Snoring suggests the tongue or soft tissues in the throat are partially blocking airflow. Gurgling indicates fluid, blood, or secretions in the airway. Wheezing, a whistling sound during breathing out, localizes the problem to the lower airways.
The quality of a child’s cry or speech also matters. A strong, loud cry is reassuring. A weak, hoarse, or muffled voice suggests upper airway swelling or obstruction. Complete silence in a child who appears to be trying to breathe is the most concerning finding of all, pointing to a totally blocked airway.
What to Feel For
Placing your cheek or hand near the child’s mouth and nose lets you detect air movement directly. You’re checking whether air is flowing, how forceful it is, and whether it’s consistent with each breath. Feeling the chest wall can also reveal asymmetric expansion or the absence of movement on one side.
Classifying the Airway
Once you’ve gathered these findings, the airway falls into one of three categories, and each one leads to a different set of actions.
A clear airway means air moves freely without abnormal sounds, visible distress, or extra effort. The child breathes comfortably, the chest rises normally, and no intervention is needed beyond continued monitoring.
A maintainable airway is one that’s compromised but can be opened and kept open with basic techniques. This includes repositioning the head, clearing visible obstructions, or using simple airway devices. Most children with partial obstructions from tongue displacement or mild soft tissue collapse fall into this category.
A not maintainable airway is one that cannot be kept open with basic maneuvers. This requires advanced interventions like placing a breathing tube. Severe swelling, structural damage, or foreign bodies lodged deep in the airway can all create this situation.
Opening the Airway Manually
Two primary maneuvers are used to open a child’s airway, and the choice between them depends on whether a spine injury is possible.
The head-tilt chin-lift is the standard technique for an unconscious child with no suspected neck injury. One hand tilts the forehead back gently while the fingers of the other hand lift the chin forward. In infants, the tilt should be mild (a “sniffing position”) because their airways are so flexible that over-extending the neck can actually kink and collapse it. Because infants have that large occiput pushing the head forward, placing a thin pad under the shoulders can help achieve a neutral position.
The jaw thrust is used when a cervical spine injury is a concern. Instead of tilting the head, you place your fingers behind the angles of the jaw on both sides and push the lower jaw forward. This moves the tongue away from the back of the throat without any neck movement. It’s harder to maintain than a head-tilt chin-lift, but it protects the spine.
Clearing the Airway With Suction
When fluid, blood, vomit, or secretions are blocking the airway, suctioning is the immediate intervention. In pediatric patients, suction pressure should stay below 120 mmHg to avoid damaging the delicate airway lining. Each suctioning attempt should last no longer than 15 seconds, because prolonged suctioning can cause oxygen levels to drop, heart rate changes, and bleeding from the airway tissue.
The size of the suction catheter matters too. If the child has a breathing tube in place, the catheter should block less than 50% of the tube’s opening. Using a catheter that’s too large creates excessive negative pressure inside the lungs and increases the risk of complications. Between suctioning attempts, the child should receive oxygen to recover.
Using Airway Adjuncts
When manual maneuvers alone aren’t enough to keep the airway open, simple airway devices bridge the gap.
An oropharyngeal airway (OPA) is a curved plastic device placed in the mouth to hold the tongue forward and off the back of the throat. It’s only appropriate for unconscious children with no gag reflex, because in a conscious or semi-conscious child it will trigger vomiting. To size an OPA, hold it against the side of the face: the correct size reaches from the corner of the mouth to the angle of the jaw.
A nasopharyngeal airway (NPA) is a soft, flexible tube inserted through the nostril to create an air channel past the tongue. It’s better tolerated in children who still have some level of consciousness. Sizing an NPA involves measuring from the nostril to the tragus of the ear (the small pointed flap in front of the ear canal). The tube’s diameter should be no wider than the child’s little finger. NPAs are generally avoided in children with facial fractures or suspected skull base injuries.
Foreign Body Airway Obstruction
The 2025 American Heart Association guidelines updated the approach to choking in children. For infants with a severe airway obstruction, the protocol calls for repeated cycles of 5 back blows alternating with 5 chest thrusts. Abdominal thrusts are not used in infants because of the risk of organ injury.
For children older than one year, the updated recommendation now starts with 5 back blows followed by 5 abdominal thrusts, repeated in cycles. This is a change from previous guidelines, which began with abdominal thrusts. The update was made to create consistency across age groups and simplify training, and pediatric data showed no disadvantage to starting with back blows.
Reassessing After Every Intervention
Airway assessment in PALS is never a one-time event. After every intervention, whether it’s repositioning the head, suctioning, placing an airway adjunct, or clearing a foreign body, the entire look-listen-feel cycle repeats. You check again for chest rise, air movement, abnormal sounds, and signs of distress. A child’s condition can change rapidly, and an airway that was maintainable five minutes ago may not be maintainable now. Each reassessment determines whether the current intervention is working or whether you need to escalate to the next level of airway management.