Paediatric Airway
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 neck 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:
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
LITFL
- 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. 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
- DFTB — The needle or the damage done (2016)
- PEMED podcast — Pediatric Airway 101 (2012)
- PEMED podcast — Pediatric Airway – The Advanced Course (2012)
- FET — Ghazela Sharieff: Pitfalls in Pediatric Airway Management (2010)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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