CICM SAQ 2014.2 Q5


Outline the important anatomic features that affect airway management in the paediatric airway and, where appropriate, strategies that may be used to overcome these.


Answer and interpretation
  • Prominent occiput – Causes some neck flexion in the supine position. This can interfere with attempts to visualize the glottic opening during laryngoscopy. Placing a towel roll under the shoulders can improve airway alignment.
  • Large tongue – Infants and young children have large tongues relative to the size of the oral cavity. Can cause airway obstruction and interfere with laryngoscopy.
  • Larger tonsils and adenoids – Can cause airway obstruction. Placement of nasal airway may cause bleeding and aspiration.
  • Superior laryngeal position – located opposite the C3 to C4 vertebrae, compared with the C4 to C5 in adults. Visualization of glottis more challenging.
  • Large, floppy epiglottis – the epiglottis projects into the airway and covers more of the glottis. A straight blade needed to directly lift the epiglottis for improved visualisation during direct laryngoscopy.
  • Short trachea – The short trachea predisposes to right endobronchial intubation or inadvertent extubation. Use of formula (age/2 +12 cm from lower lip) to estimate tube length. Special attention to fixation.
  • Narrow trachea – Small decreases in the airway size from secretions, oedema, or external compression will cause obstruction. The needle or surgical cricothyroidotomy technically challenging in infants and children. (0.5)
  • Anatomic subglottic narrowing – this narrowing can create an effective anatomic seal without the need for a cuffed ETT. Foreign bodies can become lodged below the cords.
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

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