#410: Postoperative Pediatric Airway Emergencies

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Pediatric airway emergencies in the postoperative setting are high-impact events that can quickly escalate to cardiac arrest, so it’s vital you recognize and act on them immediately. For an overview of pediatric respiratory distress, review this article here.

In this article, you’ll review:

• Unique features of the pediatric airway 
• Risk factors for postoperative respiratory complications in children
• Performing a focused pediatric respiratory assessment
• Signs of respiratory distress in children
• Common postoperative respiratory complications including desaturation, upper airway obstruction, laryngospasm, bronchospasm, and oversedation/loss of ventilation

Differences between pediatric and adult airways

The first thing to understand about the pediatric airway is that it is drastically different from the adult airway. Some of the many differences are:

• Size – smaller in diameter and length, making even small obstructions and mild edema extremely dangerous
  • Newborn =  2.5 mm internal tracheal diameter
  • 1-year old = 4.5 mm internal tracheal diameter
  • 6-year old = 6 mm internal tracheal diameter
  • ~14 years to adult = 8 mm internal tracheal diameter
• Position – the larynx is higher and more anterior than in adults, which can make intubation more difficult
• Shape – the airway narrows at the cricoid ring, whereas in adults it’s more narrow at the vocal cords
• Tongue size – the pediatric tongue is larger relative to the oropharynx making occlusion more likely and intubation more difficult
• Mandible size – the smaller mandible increases risk for airway obstruction
• Head size – the large occiput of pediatric patients flexes the neck when the child is on a flat surface, which can lead to airway obstruction (more pronounced in infants)
• Large tonsils and adenoids – large anatomical structures impede on airway space

Risk factors for respiratory complications in PACU

Postoperative respiratory complications (PRCs) are some of the most common events occurring in pediatric patients undergoing surgery. In fact, estimates predict that of all post-op complications, 75% are related to the respiratory system. Articles in the Journal of Perianesthesia nursing and Journal of Clinical Medicine outline the many factors that predisposes pediatric patients to postoperative respiratory complications. These include:

Respiratory conditions – Upper respiratory infections, reactive airway disease, asthma, pneumonia, chronic lung disease, smoking or exposure to second-hand smoke, OSA, pulmonary bronchiole dysplasia 

Cardiac conditions – Congenital heart disease, arrhythmias, murmurs

Neurological conditions – Seizures, AVMs, neuromuscular disease (such as cerebral palsy)

Physical abnormalities – Tracheal malacia, micrognathia with glossoptosis (small jaw with large tongue placed backward)

Genetic disorders – Cystic fibrosis, Down syndrome, Apert syndrome

Other – Obesity, eczema (linked to asthma), African American ethnicity (due to more narrow airway), anemia

Surgery-related factors – Longer or more complex surgical procedures, use of long-acting NMBAs, difficult intubation, and specific types of surgery including adenotonsillectomy, surgeries of the head and neck, and surgery for pyloric stenosis (among others).

Age – Preemies, infants and young children are at higher risk than older children

ASA score – The ASA score is utilized by anesthesiologists to classify patients based on their medical history. These scores range from 1 to 6, with 1 being a healthy patient and 6 being a patient who has been declared brain dead. 

Note that perioperative complications can occur in any child. In fact, a study conducted in Singapore looked at 297 critical incidents and found that 80% of them occurred in healthy patients scheduled for elective surgery. Of those, most were respiratory-related events, with laryngospasm being the most common.

Focused pediatric respiratory assessment

To quickly determine if the child is in need of respiratory intervention, your focused respiratory assessment will look at a few key components:

• Behavior –This will vary depending on the phase of recovery the child is in. Immediately after surgery the child will be unconscious or very drowsy. As the child wakes, watch for a return to normal behavior. A child who is agitated and restless could be exhibiting this behavior due to hypoxia and respiratory distress. Of course, it could also be due to pain, which is why further assessment is necessary. A listless child who is not interacting with their environment is showing signs of distress. In addition, if the child is drooling, this may be related to a partial or complete airway obstruction.
• Gaze – If the child has an absent stare this could be due to hypoxia and altered mentation.
• Speech and cry – In children able to talk, pay attention to their speech. If they are unable to speak in full sentences or speak at all, the child is showing signs of respiratory distress. A child who has a weak or absent cry is experiencing distress.
• Posture – Initially, the child will be sedated. Just as with behavior, watch for normal posture once the child is awake. If the child is assuming a tripod position or lethargic beyond what is expected for their stage of recovery, these are signs of respiratory distress. The tripod position is described as sitting upright, leaning slightly forward with mouth open and jaw/neck thrust forward to open the airway.
• Work of breathing – Observe the child for increased work of breathing, as evidenced by accessory muscle use, nasal flaring, grunting, and/or head bobbing. These are all signs the child is struggling to breathe.
• Respiratory rate – Tachypnea may be due to anxiety and pain, but significant tachypnea or tachypnea with accessory muscle use is a sign of respiratory distress. Children are great at compensating, but only for a short period of time. Once they start to lose the ability to compensate, they can deteriorate very quickly. A child who is breathing too slowly is likely not able to compensate any longer and is in serious trouble. In addition, periods of apnea are also signs the child needs immediate intervention.
• Sounds – Abnormal findings can include wheezing, stridor, rales, and diminished breath sounds. A “silent chest” indicates little to no gas exchange is occurring and indicates respiratory arrest is imminent.
  • Wheezing – air moving through narrow or collapsed airways
  • Rales or crackles – associated with fluid accumulating in the alveoli
  • Stridor – high-pitched sound due to turbulent airflow through a narrow upper airway
  • Diminished sounds – may be due to obstruction and airway narrowing
• Skin color – A child having respiratory difficulty may appear pale or cyanotic. Pallor and cyanosis are most easily observed around the mouth and at the nailbeds.
• Heart rate – The heart rate will increase to compensate for the low SpO2. As this compensatory mechanism fails, bradycardia or arrhythmias ensue and signify impending cardiac arrest.
• SpO2 – A low oxygen saturation level is a sign of respiratory compromise.

Nursing interventions for pediatric respiratory complications

The leading cause of cardiac arrest in children is respiratory failure, so it’s vital that nurses work to restore respiratory function as quickly as possible. In this section you’ll review the key nursing interventions for common postoperative respiratory compilations. Note that in many cases, respiratory complications occur as the child is emerging from anesthesia in the recovery room, so very close monitoring is essential.

Desaturation (hypoxemia)

Common causes of postoperative hypoxemia include the residual effects of medications used in anesthesia, inadequate reversal of anesthetic agents, opioids, airway obstruction and laryngospasm. Another very common and avoidable cause of hypoxemia in pediatric patients is transport from the OR to the PACU without oxygen. Even short trips can cause the child to drop their oxygen saturation level. 

An SpO2 < 94 is considered hypoxemia in a pediatric patient and oxygen therapy should be increased or initiated. Utilize the oxygen delivery device that is best tolerated by the child and address any other causative factors. For example, if the desaturation is due to airway obstruction or bronchospasm, you’d want to address those as well. Speaking of airway obstruction…

Soft tissue airway obstruction

Soft tissue airway obstruction occurs due to posterior movement of the tongue and loss of upper airway tone secondary to anesthetic medications. In most cases, airway obstruction can be managed with manual airway maneuvers or an adjunct (OPA or NPA). When utilizing an OPA with a child, note that the device is inserted with the tip pointing down while the tongue is held out of the way by a tongue depressor. Twisting or turning the OPA in a child’s mouth can damage the soft palate. If the airway is obstructed by thick secretions or blood, clearing the airway is indicated.

Laryngospasm

Laryngospasm is another common cause of airway obstruction in the postoperative period. It occurs as the child emerges from anesthesia and involves an exaggerated protective vocal cord closure reflex. Other causes of laryngospasm include severe hypocalcemia, vitamin D deficiency, and gastroesophageal reflux. 

Laryngospasm can be partial or complete and is considered a life-threatening emergency that can result in hypoxia, bradycardia and cardiac arrest.

• S/S partial laryngospasm – inspiratory stridor, suprasternal and supraclavicular retractions, flailing of lower ribs, minimal air entry
• S/S complete laryngospasm – no breath sounds, paradoxical chest movement (chest wall moves in on inspiration and out on expiration), hypoxia, bradycardia, no air entry

Risk factors for laryngospasm include:

• Volatile anesthetics such as desflurane, isoflurane, halothane, sevoflurane
• Vocal cord irritation by blood, mucus, secretions 
• Multiple intubation attempts
• Stimulation of the airway while under light anesthesia or while emerging from anesthesia
• Age – infants and younger children are at higher risk
• Asthma – up to 10x more likely to experience laryngospasm
• Recent upper airway infection
• Second hand smoke exposure
• OSA, GERD
• Presence of airway anomaly
• Tonsillectomy and adenoidectomy
• Bronchoscopy, endoscopy

Laryngospasm treatment

• Removal of the irritating stimulus if possible
• Positive airway pressure with 100% FiO2 – utilize a face mask with a tight seal and closed expiratory valve. A BVM and CPAP may also be utilized.
• Vigorous jaw thrust – lifts the epiglottis away from the glottic opening, moves the larynx forward, and creates a gap between the vocal cords 
• Larson’s maneuver – performed by putting pressure on the mastoid process behind the posterior ramus of the mandible (aka: laryngospasm notch)
• Medications – Propofol and succinylcholine may be used to break the spasm. When succinylcholine is used, an anticholinergic such as atropine or glycopyrrolate is utilized to prevent bradycardia and cardiac arrest

Bronchospasm

Bronchospasm can occur due to stimulation of the airway from a device (such as an endotracheal tube), underlying reactive airway disease, an anaphylactic reaction, and aspiration. Bronchospasm can lead to respiratory deterioration due to airflow obstruction and should be treated promptly. 

Signs and symptoms of bronchospasm include wheezing, frequent coughing, extended expiration, and general signs of respiratory distress such as labored breathing and accessory muscle use.

The treatment for postoperative bronchospasm can include:

• Administration of bronchodilators such as albuterol
• Glucocorticoids
• High-flow humidified oxygen

Oversedation and loss of ventilation

In cases where an opioid, benzodiazepine, or inadequate anesthesia reversal lead to a loss of ventilatory effort, quick action is needed to prevent bradycardia and impending cardiac arrest. 

Any patient without respiratory effort must receive assisted ventilation and a quick way to do that at the bedside is with a BVM and 100% FiO2. Recall that rescue breathing for a child is one breath every 2 to 3 seconds.

The next key intervention is to reverse the medication. If it’s an opioid, the reversal is narcan. If it’s a benzodiazepine, the reversal is flumazenil. In cases where the child isn’t adequately reversed from anesthesia, additional reversal medication will be administered by the anesthesiologist.

Want to learn more about pediatric nursing?

First off, thank you for your dedication to taking care of children! Pediatric nurses are true angels and I love being able to provide resources that can help you in your practice. To get more pediatric articles, just click this link. See you there!

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References:

ACLS Training Center. (2023, June 27). Pediatric respiratory emergencies algorithm. ACLS Training Center. https://www.acls.net/pals-algo-respiratory-emergencies.htm

Agbim, C., Wang, N. E., & Lee, M. (2018). Respiratory distress in pediatric patients. Pediatric Emergency Medicine Reports. https://www.reliasmedia.com/articles/142390-respiratory-distress-in-pediatric-patients

American Heart Association. (2016). Pediatric Advanced Life Support Provider Manual.

Budi, I., & Simic, D. (2004). Risk factors for respiratory adverse events during general anesthesia in children. Facta Universitatis, 11(3), 118–122. https://www.researchgate.net/publication/228714597_Risk_factors_for_respiratory_adverse_events_during_general_anesthesia_in_children

Castro, D., & Freeman, L. A. (2025). Oropharyngeal Airway. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470198/

Challands, J., & Brooks, K. (2019). Paediatric respiratory distress. British Journal of Anaesthesia Education, 19. https://bjaed.org/article/S2058-5349(19)30124-6/pdf

Cheifetz, I. (2011). Pediatric acute respiratory distress syndrome. Respiratory Care, 56(10), 1589–1599. https://doi.org/10.4187/respcare.01515

Children’s Hospital of Philadelphia. (n.d.). Signs of Respiratory Distress in Children. Children’s Hospital of Philadelphia. https://www.chop.edu/conditions-diseases/signs-respiratory-distress-children

Edwards, L. R., & Borger, J. (2025). Pediatric Bronchospasm. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK546685/

Egbuta, C., & Mason, K. P. (2020). Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient. Journal of Clinical Medicine, 9(6), 1942. https://doi.org/10.3390/jcm9061942

EMS World Staff. (2018, March 2). Recognizing Pediatric Respiratory Distress. EMS World. https://www.emsworld.com/article/219976/recognizing-pediatric-respiratory-distress

Fleming, S., Thomson, M., Stevens, R., & et al. (2011). Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: A systematic review of observational studies. Lancet, 377(9770), 1011–1018. https://pubmed.ncbi.nlm.nih.gov/21411136/

Harless, J., Ramaiah, R., & Bhananker, S. M. (2014). Pediatric airway management. International Journal of Critical Illness and Injury Science, 4(1), 65–70. https://doi.org/10.4103/2229-5151.128015

Horwood, L., Nguyen, L. H. P., Brown, K., Paci, P., & Constantin, E. (2013). African American ethnicity as a risk factor for respiratory complications following adenotonsillectomy. JAMA Otolaryngology– Head & Neck Surgery, 139(2), 147–152. https://doi.org/10.1001/jamaoto.2013.1321

Jagannathan, N., Burjek, N., & rowland, M. (2024). Complications of pediatric airway management for anesthesia. UpToDate. https://www.uptodate.com/contents/complications-of-pediatric-airway-management-for-anesthesia?search=laryngospasm%20children&source=search_result&selectedTitle=1%7E122&usage_type=default&display_rank=1

Li, H., Zhang, Y., Cai, J., Wang, H., & Wei, R. (2023). Risk Factors of Hypoxemia in the Postanesthesia Care Unit After General Anesthesia in Children. Journal of PeriAnesthesia Nursing, 38(5), 799–803. https://doi.org/10.1016/j.jopan.2023.02.003

Lippincott Williams & Wilkins. (2008). Effective Reversal of Moderate Rocuronium- or Vecuronium-Induced Neuromuscular Block With Sugammadex, a Selective Relaxant Binding Agent. Survey of Anesthesiology, 52(4), 187–188. https://doi.org/10.1097/SA.0b013e31817c5bb0

Mamaril, M. E. (2020). Preoperative risk factors associated with PACU pediatric respiratory complications: An Integrative review. Journal of PeriAnesthesia Nursing, 35(2), 125–134. https://doi.org/10.1016/j.jopan.2019.09.002

openanesthesia. (2023, January 13). Laryngospasm. OpenAnesthesia. https://www.openanesthesia.org/keywords/laryngospasm/

Pawar, D. (2012). Common post-operative complications in children. Indian Journal of Anaesthesia, 56(5), 496–501. https://doi.org/10.4103/0019-5049.103970

Queensland Paediatric Emergency Care. (2022). Respiratory Assessment. Children’s Health Queensland Hospital and Health Service. https://www.childrens.health.qld.gov.au/__data/assets/pdf_file/0032/179717/respiratory-assessment-in-children.pdf

Shah, U., & Jacobs, I. (1999). Pediatric Angioedema: Ten Years’ Experience. JAMA Otolaryngology – Head & Neck Surgery, 125(7), 791–795. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/509568

Silva, C. R., Pereira, T., Henriques, D., & Lanca, F. (2020). Comprehensive Review of Laryngospasm. World Federation of Societies of Anaesthesiologists. https://resources.wfsahq.org/wp-content/uploads/New-Update-35-Laryngospasm.pdf

Tay, C. l. m., Tan, G. m., & Ng, S. b. a. (2001). Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore. Pediatric Anesthesia, 11(6), 711–718. https://doi.org/10.1046/j.1460-9592.2001.00767.x

Trachsel, D., Erb, T. O., Hammer, J., & von Ungern‐Sternberg, B. S. (2022). Developmental respiratory physiology. Paediatric Anaesthesia, 32(2), 108–117. https://doi.org/10.1111/pan.14362

Tyler, D. C., Woodham, M., Stocks, J., Leary, A., & Lloyd-Thomas, A. (1995). Oxygen saturation in children in the postoperative period. Anesthesia and Analgesia, 80(1), 14–19. https://doi.org/10.1097/00000539-199501000-00004

Villines, Z. (2021, November 30). What to know about the triad of asthma, eczema, and allergies. Medical News Today. https://www.medicalnewstoday.com/articles/asthma-triad

Weiner, D., Neuman, M., & Wiley, J. (2024a). Acute respiratory distress in children: Emergency evaluation and initial stabilization. UpToDate. https://www.uptodate.com/contents/acute-respiratory-distress-in-children-emergency-evaluation-and-initial-stabilization

Weiner, D., Neuman, M., & Wiley, J. (2024b). Causes of acute respiratory distress in children. UpToDate. https://www.uptodate.com/contents/causes-of-acute-respiratory-distress-in-children

Westhorpe, R. N. (1987). The Position of the Larynx in Children and its Relationship to the Ease of Intubation. Anaesthesia and Intensive Care, 15(4), 384–388. https://doi.org/10.1177/0310057X8701500405

Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2024). Postpartum Hemorrhage. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499988/

Wueensland Paediatric Emergency Care. (2023). Oropharyngeal Airway. Children’s Health Queensland Hospital and Health Service. https://www.childrens.health.qld.gov.au/__data/assets/pdf_file/0033/179718/oropharyngeal-airway.pdf

Yartsev, A. (2023, December 18). Neonatal respiratory physiology | Deranged Physiology [Deranged Physiology]. https://derangedphysiology.com/main/cicm-primary-exam/respiratory-system/Chapter-926/neonatal-respiratory-physiology

Zar, H., & McCollum, E. (2023). Pulse oximetry to detect paediatric hypoxaemia—the fifth vital sign. The Lancet Global Health, 11(11), E1684–E1685. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00380-7/fulltext

Last Updated on January 6, 2026 by Maureen Osuna, MSN, RN