Paediatric Airway


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


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 neck being flexed when a child is lying supine.


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)


Key issues and approach according to Reuben Strayer:

References and Links


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. PMID: 22520991.
  • Harless J, Ramaiah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci [serial online] 2014
  • 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.PMC3400706.
  • Sims C, von Ungern-Sternberg BS. The normal and the challenging pediatric airway. Paediatr Anaesth. 2012 Jun;22(6):521-6. PMID: 22594404.

FOAM and web resources

CCC 700 6

Critical Care


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.

| INTENSIVE | RAGE | Resuscitology | SMACC

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