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:
- 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
- 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
- consider atropine 20 mcg/kg IV (to prevent bradycardia from intubation/ suxamethonium)
Key issues and approach according to Reuben Strayer:
References and Links
- CCC — Paediatric anaesthesia equipment
- CCC – Paediatric Rapid Sequence Intubation
- Time to tighten those sphincters! (case-based Q&A on paediatric upper airway obstruction)
- 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)