Paediatric Airway

Reviewed and revised 20 April 2014

OVERVIEW

• The paediatric airway differs from that of adults in terms of anatomy, and there are important management implications

ANATOMICAL DIFFERENCES FROM ADULTS

• smaller
• small mandible
• large head (neck already flexed)
• tongue large
• larynx high
• funnelled shaped with anterior angulation
• epiglottis long and stiff
• vocal cords angled
• narrowest portion = circoid cartilage
• small diameter of airways -> higher resistance to air flow.
• highly compliant -> kink
• trachea short & in line with right bronchus.
• increased chance of airway blockage

MANAGEMENT

• may require small towel under body and shoulder to straighten airway out
• use formula ETT size = age/4 + 4 (age > 1 years) or Braslow measurement or approximate size of little finger (-1 if cuffed tube)
• depth from lower lip = age/2 =+ 12
• often use uncuffed tubes because of increased concern about laryngeal stenosis however, high volume low pressure cuffed ETTs are increasing used in children due to the low risk of problems)
• requires small, straight blade to lift epiglottis out of the laryngeal inlet
• important to fix tubes securely because of ease of dislodgement
• circuit/mechanics to minimise WOB
• difficult to perform a tracheostomy
• nasogastric tube placement is useful to decompress the stomach and improve ventilation

VIDEO

Key issues and approach according to Reuben Strayer:

Neonatal intubation:

References and Links

Journal articles

• Green SM. A is for airway: a pediatric emergency department challenge. Ann Emerg Med. 2012 Sep;60(3):261-3. doi: 10.1016/j.annemergmed.2012.03.019. Epub 2012 Apr 19. PubMed PMID: 22520991.
• Harless J, Ramaiah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci [serial online] 2014 [cited 2014 Apr 19];4:65-70. Available from: http://www.ijciis.org/text.asp?2014/4/1/65/128015
• Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med. 2012 Sep;60(3):251-9. doi: 10.1016/j.annemergmed.2012.02.013. Epub 2012 Mar 15. PubMed PMID: 22424653; PubMed Central PMCID: PMC3400706.
• Sims C, von Ungern-Sternberg BS. The normal and the challenging pediatric airway. Paediatr Anaesth. 2012 Jun;22(6):521-6. doi: 10.1111/j.1460-9592.2012.03858.x. Review. PubMed PMID: 22594404.

FOAM and web resources

• PEMED podcast — Pediatric Airway 101 (2012)
• PEMED podcast — Pediatric Airway – The Advanced Course (2012)
• FET — Ghazela Sharieff: Pitfalls in Pediatric Airway Management (2010)