Paediatric Airway

Reviewed and revised [last-modified]

OVERVIEW

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

ANATOMICAL DIFFERENCES FROM ADULTS

Features of the paediatric airway:

smaller
small mandible
large head (neck already flexed)
tongue large
larynx high
funneled shaped larynx with anterior angulation
epiglottis long and stiff
vocal cords angled
narrowest portion is the cricoid cartilage (rather than the vocal cords)
small diameter of airways results in higher resistance to air flow and increased chance of airway obstruction
highly compliant trachea (risks ‘kinking’)
trachea is short and in line with right bronchus
Larger occiput. This results in the nexk being flexed when a child is lying supine.

MANAGEMENT

Specific issues in the management of the pediatric airway

Positioning
- Infants (up to one year old) have a large occiput, which flexes the neck when the infant lies supine on a flat surface. To achieve a neutral position, place 1-2 folded towels under the trunk, from buttocks to shoulders. This allows the occiput to be 1-2 cm lower than the back, and allows the head to rest in a neutral position.
Formulae for endotracheal tubes
- endotracheal tube size size = age/4 + 4 (age > 1 years) or Broselow measurement or approximate size of little finger (-1 if cuffed tube)
- depth from lower lip (cm) = age/2 + 12 (oral intubation)
- depth from nares (cm) = age/2 + 15 (nasal intubation)
- tube 0.5 mm ID smaller and 0.5 mm ID larger, should all be available on the child’s bed.
Cuffed versus uncuffed tubes
- traditionally uncuffed endotracheal tubes were used because of increased concern about laryngeal stenosis
- high volume low pressure cuffed endotracheal tubes are increasingly used in children due to the low risk of problems
requires small, straight blade (Miller laryngoscope blade) to lift epiglottis out of the laryngeal inlet
important to fix tubes securely because of ease of dislodgement
circuit/mechanics to minimise work of breathing
difficult to perform a tracheostomy
nasogastric tube placement is often useful to decompress the stomach and improve ventilation
drugs
- consider atropine 20 mcg/kg IV (to prevent bradycardia from intubation/ suxamethonium)

VIDEO

Key issues and approach according to Reuben Strayer:

Neonatal intubation:

Lifeinthefastlane.com

CCC — Paediatric anaesthesia equipment
Time to tighten those sphincters! (case-based Q&A on paediatric upper airway obstruction)

Journal articles

Coté CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Paediatric anaesthesia. 2009; 19 Suppl 1:66-76. [pubmed]
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