0749-5161/02/1802-0108

Vol. 18, No. 2

Printed in U.S.A.

PEDIATRIC EMERGENCY CARE

Copyright 2002 by Lippincott Williams & Wilkins, Inc.

EDITORS NOTE: This article is the second of six that will be published in 2002 for which a total of up to 6 Category
1 CME credits can be earned. Instructions for how credits can be earned appear on the last page of the Table of Contents.

CME REVIEW ARTICLE

Securing the childs airway in the emergency

department
KEVIN J. SULLIVAN, MD,* NIRANJAN KISSOON, MBBS

4. Be familiar with alternative techniques for the difficult airway,

including blind nasotracheal intubation, lighted stylet, laryngeal
mask airway, exible beroptic laryngoscope, retrograde intubation, and needle cricothyrotomy.

Airway management is an important aspect of pediatric

emergency care. Prompt, effective airway access can mean the
difference between a good outcome and disability or death. Optimal management requires an understanding of the differences between children and adults with respect to airway
anatomy and physiology and response to medications to facilitate airway access. In most cases, the emergency physician is
called to secure a childs airway with little forewarning. This
review details a logical and practical approach to the uncomplicated pediatric airway. Emphasis is also placed on recognition of the difficult airway and methods to render the difficulty
less daunting. Good judgment and the appropriate skills are
the prerequisites for success.

INTRODUCTION
Good airway management in the pediatric emergency department (ED) can mean the difference between an acceptable outcome and permanent disability or death. Airway management in
the critically ill child is a challenge for several reasons: it occurs
rarely, is often unanticipated, and must be achieved with little time
to plan in children with limited respiratory reserve. Moreover, the
emergency physician must sometimes provide airway management without the benet of fully knowing the extent of the patients injuries or medical conditions. Antecedent conditions (eg,
full stomach, shock, elevated intracranial pressure, and cardiovascular disease) complicate management and may not be immediately evident. As a consequence, the emergency physician must
choose strategies that are likely to succeed with few potential
complications.
Patients in the ED who require urgent or emergent airway management usually present with little advance warning; hence, there is
limited opportunity to mobilize specialized personnel and equipment before the patients arrival. This is different from the operating room where an anesthesiologist faced with a difficult airway can
usually get help from several anesthesiologists and has an array of
airway adjuncts. Elective surgical cases complicated by airway difculty can be managed by canceling surgery until well-planned alternative techniques are available. The emergency physician usually
cannot return at another time with a better strategy.
Optimal outcomes with pediatric airway management require a
thorough understanding of the physiologic, pharmacodynamic, and
anatomic differences between children and adults. Additionally,
good preparation, difficult airway recognition, and familiarity with
back-up plans for airway management are essential. This review is
intended for emergency physicians and, thus, will focus on devices
and techniques easily obtained and used in the ED.

TARGET AUDIENCE
This CME activity is intended for physicians, nurses, nurse practitioners, physician assistants, and paramedics who care for children in respiratory distress or cardiopulmonary arrest. Specialists
including pediatricians, emergency physicians, pediatric emergency physicians, anesthesiologists, and trauma surgeons will nd
this information particularly useful.

LEARNING OBJECTIVES
After completion of this article, the reader will
1. Be able to recognize the difficult airway and make the preparations necessary for the clinical scenario.
2. Be able to discuss the role of neuromuscular blocking agents
and induction drugs in airway management.
3. Be able to describe the management of the uncomplicated airway using manual ventilation with a bag and mask or direct
laryngoscopy.
*Pediatric Anesthesiologist and Intensivist, Departments of Pediatric
Anesthesia and Critical Care, Nemours Childrens Clinic, and Professor and
Chief, Division of Critical Care Medicine, University of Florida, Jacksonville,
Florida.
Address for reprints: Niranjan Kissoon, MBBS, Professor and Chief, Division of Critical Care Medicine, University of Florida Health Sciences
Center, 820 Prudential Drive, Suite 203, Howard Building, Jacksonville,
FL 32207; e-mail: niranjan.kissoon@jax.u.edu
Key Words: Airway management, intubation, emergency resuscitation,
respiratory failure

PREPARATION
The rst step toward success in securing a childs airway is appreciation of the unique physiologic and anatomic differences between

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SECURING THE CHILDS AIRWAY IN THE ED

adults and children. Infants and children are likely to experience

arterial oxygen desaturation more rapidly than adults for several reasons (Table 1). With pulmonary disease or short periods of apnea, the
rate of desaturation can be considerably shorter (1) because of increased rate of oxygen consumption and the inability of the child to
preserve functional residual capacity (FRC).
Oxygen Consumption and Metabolic Rate. On average,
adults consume a total of 2 to 3 cc/kg/min of oxygen under basal conditions. As a result of factors related to growth and higher basal metabolic rate, infants and children may consume 2 to 3 times as much
oxygen per kilogram of body weight under basal conditions (2).
Therefore, even if physiologic oxygen stores were identical, the
child would likely experience desaturation during even short periods of apnea.
Diminished Pulmonary Reserve. The FRC, a reservoir for gas
exchange, represents a similar percentage of total lung capacity in
awake children as in adults but not in anesthetized or paralyzed children (3, 4). The diminished outward chest recoil of the infant causes
the FRC to plummet when some of the compensatory, active mechanisms for FRC preservation are abolished by the administration of
neuromuscular blocking and sedative medications. The net result of
the infants higher oxygen consumption and diminished oxygen reserves is a tendency toward more rapid arterial oxygen desaturation
that is accelerated with coexistent lung disease.
Anatomic Differences. The anatomic differences pertinent to
airway management are outlined in Table 2. The infants prominent
occiput pushes the head into a exed position, which causes airway
obstruction when the child is placed on the back. This can be overcome by placing a towel roll under the shoulders. Care must be
taken to avoid excessive neck extension, because this, too, can result in airway obstruction.
The relatively large tongue of the infant, along with the relatively small nares, causes increased resistance to airow from a
facemask. Care must be taken to prevent the ngers holding the
mask hand from compressing the soft tissue structures of the oor
of the mouth. This can be avoided by making sure that all of the
digits of the hand are on bones of the chin, mandible, and mask itself. Additionally, early use of oropharyngeal or nasopharyngeal
airways (when not contraindicated) is encouraged.
Endotracheal intubation is complicated by the presence of smaller
airway structures with the larynx located higher in the neck (C4 vs
C6), which gives it an anterior and cephalad appearance. The epiglottis is longer and omega shaped, and it is positioned in a shorter neck
close to prominent adenoid and tonsillar tissue. The trachea is short
and has a greater potential for inadvertent endobronchial intubation.
Finally, the cricoid cartilage ring is the narrowest part of the airway
as opposed to the glottis in adults. Attention to these anatomic differences can help to prevent unnecessary postextubation stridor and
subglottic stenosis.
Because pediatric patients are prone to rapid arterial oxygen desaturation and may be difficult to mask ventilate or intubate, it is
essential to have all airway equipment readily available and in
working order. It is also prudent to have a back-up plan and equipment available for situations in which standard mask ventilation

TABLE 1
Respiratory physiologic differences between children and adults
Increased respiratory rate
Increased chest wall compliance
Decreased lung elastic recoil (lower lung compliance)
Diminished functional residual capacity
Increased rate of oxygen consumption

109
TABLE 2

Anatomic differences between pediatric and adult airways

More prominent occiput
Tongue occupies relatively larger proportion of oral cavity
Small nasal passages
Hypertrophied lymphoid tissue
Short trachea
Long epiglottis
Larynx appears more anterior and cephalad

and intubation are difficult or impossible. This is particularly relevant to the ED, where the clinician may not have the luxury of a
thorough airway assessment.
Recognition of the Difficult Airway. It is critical to recognize
the difficult airway before using induction agents and neuromuscular blockade, because failure to do so can result in a life-threatening
situation in which ventilation and intubation are impossible. Choosing alternative awake, asleep, or spontaneously breathing techniques for airway management in children with difficult airways can
be the difference between a smooth intubation and a fatal airway
ail.
In the absence of specic anatomic markers of airway abnormality, facial and upper airway trauma, or inammation, it is exceedingly unlikely to be surprised by a difficult airway. A history
of difficult airway in the patient can be identied from Medic-Alert
bracelets or from the caretakers of children with conditions known
to predispose to airway difficulty. A prior history of airway treachery is a red ag to heed, particularly if the difficulties occurred in
the hands of clinicians who are experienced in the airway management of children. Physical ndings that predict airway difficulty
are summarized in Table 3 and are discussed below.
Oropharyngeal Examination. The oropharyngeal examination
is the rst step in assessing the airway. The patients oral cavity is
examined with his or her mouth open and the tongue maximally
protruded. The degree of mouth opening and the size of the tongue
relative to the oral cavity are assessed. Mallampati et al. (5) classied airways on the basis of the degree of visualization of the faucial pillars, soft palate, and uvula. The ability to see a large part of
these structures predicts a high probability of adequate laryngeal
visualization in adults. Whether the Mallampati et al. score can successfully predict the degree of difficulty with endotracheal intubation in small children is not known.
Macroglossia, an absolute or relative enlargement of the tongue
in relation to the oral cavity, is a prominent feature of Down and
Beckwith-Wiedemann syndromes and is associated with airway
difficulty. Inltration or crowding of the tongue and airway structures is commonly seen in mucopolysaccharidosis, morbid obesity,
cystic hygroma, edema, and cellulitis. The presence of a high,
arched palate is also associated with airway difficulty.

TABLE 3
Findings that predict the presence of a difficult airway
Limited mouth opening
Cervical spine immobility (immobilization, trauma, degenerative
processes)
Small mouth
Prominent central incisors
Short mandible
Short neck
Large tongue (relative or absolute)
Obese patients
Laryngeal edema (infection, inhalation thermal injury)
Mandibular, midface, and facial trauma

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PEDIATRIC EMERGENCY CARE

Neck Extension. Neck extension is often necessary during

laryngoscopy to create a direct, straight line of vision from the
mouth to the glottic structures. Successful laryngoscopy can be performed without neck extension, as is often necessary in the setting
of known or suspected cervical spine trauma. However, inability to
extend the neck as a result of trauma or congenital cervical spine
abnormalities (eg, trisomy 21, Goldenhar and Klippel-Feil syndromes), juvenile rheumatoid arthritis, or prior cervical spine xation is a predictor of difficult intubation and ventilation.
Mandible Length. The mandible length refers to the distance
from the thyroid cartilage to the chin and is normally greater than
1.5 cm in infants (6). Patients who have a short mandible present
greater difficulty in lining up the pharyngeal, laryngotracheal, and
oral axes. These patients are said to have an anterior larynx because
the line of vision during laryngoscopy falls posterior to the airway
structures. Children with short mandibles must also compress more
tongue and oral structures into a small space, which often results in
difficulty with mask ventilation. Micrognathia is a salient feature of
Treacher-Collins and Pierre Robin syndromes.
The degree of airway abnormality, prior history of airway misadventure(s), and the ability of the patient to physiologically tolerate the proposed airway procedure are factors that must be considered when deciding on an airway strategy. It is imperative to
carefully consider these factors before attempting to control the airway in the spontaneously breathing child. When presented with the
profoundly compromised or apneic child, these criteria are useful
to predict airway compromise and allow for ancillary personnel
and techniques while the clinician initiates simultaneous airway
support.
Monitoring. Monitoring of the electrocardiogram, pulse oximeter, and noninvasive blood pressure is important for several reasons. This allows the clinician to assess the patients response to induction drugs, ventilation, brief periods of apnea, and the detection
of unsuspected problems such as ongoing internal bleeding, pericardial tamponade, tension pneumothorax, and increased intracranial pressure.
It is also essential to monitor of end-tidal carbon dioxide
(ETCO2). Detection of ETCO2 after endotracheal intubation is a
very sensitive and specic method to conrm endotracheal placement of the tube. Despite proper tube placement, there may be little or no carbon dioxide detected with the markedly diminished
pulmonary blood ow seen during cardiac arrest and profound hypovolemia (7). It is also possible to have a few weak signals of carbon dioxide if the endotracheal tube is in the esophagus and an
ETCO2 signal if the endotracheal tube is in the pharynx, above the
vocal cords (8, 9). Despite these pitfalls, ETCO2 detection and visualization of the endotracheal tube as it passes through the glottis
is the most reliable way to prevent inadvertent esophageal intubation. Additionally, the trend in ETCO2 is a guide to assessing the
response of the patient to cardiopulmonary resuscitation, uid therapy, inotropic agents, and the adequacy of ventilation (10, 11). It
can also rapidly detect inadvertent extubation during transport and
endotracheal tube repositioning.
Equipment for Airway Management. The equipment available for emergency airway management is listed in Table 4. Selfinating resuscitation bags are the simplest and most commonly
used items in the ED. They require a high liter ow of oxygen and
an inspiratory manifold and reservoir to maximize inspired oxygen
concentration (1214). Self-inating resuscitation bags offer the advantage of allowing ventilation of the patient with room air if the
oxygen source becomes exhausted or disconnected. However, spontaneous ventilation through the inspiratory valve may be difficult.

TABLE 4
Suggested airway cart equipment for the emergency department
Laryngoscope blades of all sizes and styles and Magill forceps
Endotracheal tubes of all sizes, cuffed and uncuffed
CO2 detector (adult and pediatric)
Facemasks (neonate to adult)
All sizes of naso- and oropharyngeal airways
Suction equipment and catheters
Self-inating resuscitation bags
Endotracheal tube guides
Semi-rigid intubating stylet (some hollow variants facilitate jet
ventilation)
Light wand
Flexible beroptic intubation equipment
Emergency nonsurgical ventilation
Transtracheal jet ventilation
Laryngeal mask airway
Tracheoesophageal combitube
Emergency surgical airway access
Cricothyrotomy equipment
Needle (14-gauge catheter over needle, 3.0 ID endotracheal tube
adapter)
Seldinger kits available for children younger than 910 years
The expertise and experience of the ED clinician should dictate the contents of the airway cart.
Adapted from Practice guidelines for management of the difficult airway:
a report by the American Society of Anesthesiologists Task Force on the
Management of the Difficult Airway. Anesthesiology 1993; 78:597602.

Rebreathing of carbon dioxide is not possible, irrespective of the

rate of fresh gas ow into the apparatus as a result of the presence of
unidirectional exhalation valves. Positive end-expiratory pressure
(PEEP) can be administered through manipulation of built-in popoff
valves or through the addition of extraneous PEEP valves.
The use of Mapleson D ventilation bags allows for easy spontaneous ventilation and allows the clinician to easily adjust levels of
PEEP without the addition of extraneous valves. Unlike self-lling
bags, Mapleson circuits require a continuous oxygen supply to
function, because they cannot entrain room air. It is also necessary
to ensure a fresh gas ow at least 2 to 3 times the minute ventilation for spontaneous ventilation and 1 to 2 times the minute ventilation for controlled ventilation to prevent rebreathing of carbon
dioxide (15).
As a general rule, the airway cart should contain at least one alternative for the difficult airway. The rescue device should allow
for the restoration of ventilation and oxygenation in the event that
endotracheal intubation is not possible and mask ventilation is marginal or not possible. This category includes nonsurgical and surgical approaches as outlined in Table 4.
Medications. Medications are used to attenuate deleterious reex autonomic responses to airway manipulation and to render the
patient unconscious and amnesic. Neuromuscular blockade is provided to optimize laryngeal visualization and to prevent coughing.
Emergency clinicians should be intimately familiar with the commonly used medications, side effects, routes of elimination, and
pharmacokinetic proles. The Broselow-Luten tape (Armstrong
Medical Industries, Lincolnshire, IL) allows for accurate dosing for
patients if their weight is not known or if the clinician cannot immediately recall the dose (16).
Premedication. Premedication may be conveniently grouped
into 4 categories and remembered by the acronym LOAD (17).
Lidocaine is most commonly used as an intravenous medication
for the purpose of suppressing reex autonomic and airway responses to laryngoscopy and endotracheal intubation. Lidocaine attenuates increases in intracranial pressure during laryngoscopy in

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SECURING THE CHILDS AIRWAY IN THE ED

children with intracranial hypertension. It is given as an intravenous bolus of 1 to 2 mg/kg 2 to 3 minutes before laryngoscopy,
and it has direct anesthetic properties on the central nervous system
(17). Lidocaine can also be nebulized or sprayed onto airway structures or into the trachea to diminish the patients response to laryngoscopy and intubation. Concentrations of 1%, 2%, and 4% can be
given in volumes calculated to keep the total dose below the toxic
limit of 5 mg/kg.
Opioids and benzodiazepines do not reliably produce unconsciousness unless they are administered in large quantities. In such
doses, they often also produce apnea. As such, these medications
are best used as adjunct therapies for amnesia and analgesia with
other induction drugs. Additionally, these medications may be used
for conscious sedation in the spontaneously breathing patient who
is to be kept awake and responsive during endotracheal intubation.
Opioids produce sedation and blunt the response to noxious airway
stimuli, whereas benzodiazepines induce sedation and amnesia.
After adequate topical anesthesia of the airways, short-acting medications such as midazolam in 0.05 to 0.1 mg/kg increments and
fentanyl in 1 to 2
g/kg increments can be given to render the patient less anxious and more comfortable.
Synergistic respiratory depression results from concomitant administration of opioids and benzodiazepines; however, with careful
titration of these medications, it is possible to avoid respiratory depression. Should respiratory depression or excessive somnolence
occur, these are the only medications for which reliable and rapid
antagonists exist and allow reversal if spontaneous ventilation is
threatened. Slow titration of these agents will allow the clinician to
avoid excessive respiratory depression and the chest wall rigidity
that has been described with the rapid administration of large quantities of fentanyl to children (18). Owing to differences in drug protein binding, central nervous system perfusion and permeability,
and receptor affinity, the risk for respiratory depression and apnea
is greater in neonates (1921).
Anticholinergic medications including glycopyrrolate, scopolamine, and atropine have several applications in the management
of the difficult pediatric airway. They cause tachycardia and drying
of oral secretions, and scopolamine also causes amnesia. Neonates
have a tendency to respond to laryngoscopy or hypoxemia with a
dramatic slowing of the heart rate as a result of parasympathetic
nervous system activation. Because stroke volume cannot be augmented appreciably in neonates, cardiac output is dependent on
heart rates that are neither excessively fast nor slow (22). Neonates
are, therefore, good candidates for premedication with anticholinergic medications, especially when succinylcholine is used. Many
investigators recommend premedication with atropine for all children younger than 10 years (17). Atropine sulfate in an intravenous
dose of 0.02 mg/kg with a minimum dose of 0.1 mg can be given
to prevent bradycardia during airway management. Atropine sulfate can also be given intramuscularly in a dose of 0.04 mg/kg. The
site of intramuscular injection affects the rate of response to atropine, with lingual injection producing faster response than deltoid or vastus lateralis injection (23). Anticholinergic medications,
such as glycopyrrolate (0.01 mg/kg), are given to dry oropharyngeal secretions to optimize visualization during beroptic techniques of airway management. This is optimally given 30 minutes
before airway management is attempted and, therefore, may be of
limited use in emergency airway management. Scopolamine is also
a potent antisialagogue and has the added benet of producing sedation and amnesia.
Defasciculating doses of nondepolarizing neuromuscular blockers (NMBs) are administered to patients for two reasons. Before

111

widespread availability of rapidly acting, nondepolarizing NMBs,

this priming dose of neuromuscular blocker would allow for
much more rapid onset of paralysis if the patient received one tenth
of the usual intubating dose (ie, pancuronium) 3 to 5 minutes before administration of the customary intubating dose (24). This is a
less common concern today with the availability of medications
such as mivacurium, rocuronium, and rapacuronium.
The second reason to administer a fraction of the usual dose of a
nondepolarizing NMB is to attenuate the fasciculations commonly
seen with the administration of succinylcholine. Although the
mechanism is not clear, elevations in intracranial and intraocular
pressure occur contemporaneously with fasciculations and may be
attenuated by prior administration of a defasciculating dose of nondepolarizing NMBs (17, 25). Some patients may experience
diplopia, muscle weakness, and a sense of difficulty breathing resulted from the weakness induced by this dose. It is therefore prudent to try to render the patient amnesic to preintubation events and
to be prepared to quickly secure the airway should these symptoms
become problematic.
Other medications useful for airway management include a topical vasoconstrictor to minimize the risk of epistaxis during nasal approaches. Naloxone, 12
g/kg intravenously repeated as needed to
restore adequate respiratory drive without excessively reversing sedation, and umazenil (0.0050.01 mg/kg) are useful for reversing
excessive respiratory depression caused by benzodiazepines and opioids when used in awake attempts at airway management during
spontaneous ventilation (26). Repeated doses may be needed to treat
recurrent respiratory depression, because the half-lives of these antagonists are generally shorter than the drugs they are designed to
antagonize.
NEUROMUSCULAR BLOCKERS. The purpose of NMBs is to
provide complete muscle relaxation to facilitate endotracheal intubation. These drugs differ in their onset times, duration of action, side effects, and routes of metabolism. Succinylcholine, mivacurium, and rocuronium provide alternatives for all situations
in the ED.
DEPOLARIZING NEUROMUSCULAR BLOCKADE. Succinylcholine is
a depolarizing NMB that produces reliable intubating conditions in
the shortest amount of time. In children, an intravenous dose of 2
mg/kg (45 mg/kg intramuscularly) produces intubating conditions
within 30 to 45 seconds (46 min after intramuscular injection) (24).
In older children, the onset of paralysis is heralded by skeletal muscle fasciculation, which is usually not seen in infants. The principal
benet of neuromuscular blockade is that most patients will recover
from it in approximately 5 to 7 minutes. Thus, neuromuscular blockade is ideal for rapid sequence intubation (RSI) and for use in the difcult airway.
In emergencies where succinylcholine is believed to be the best
drug for airway management, there should little reservation about
using it. However, there are relative contraindications to its use,
which are outlined in Table 5. The tendency to elevate serum
potassium levels is of little clinical relevance in most patients.
However, patients with burns, denervating nerve injuries (eg,
stroke, spinal cord injury), crush injury, intra-abdominal abscess,
and myopathy are at risk for marked elevations in serum potassium that can result in cardiac arrest (2729). Hyperkalemia does
not seem to be problematic in patients with cerebral palsy or
myelomeningocele (30, 31). For acquired risk factors (eg, burns,
denervating injuries), it is recommended that succinylcholine be
avoided for the period between 1 and 2 days to 6 months to 2
years after the injury (32).
There is also concern that succinylcholine administration will ex-

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PEDIATRIC EMERGENCY CARE

TABLE 5
Selected potential deleterious effects
associated with the use of succinylcholine
Hyperkalemia
Myopathy
History of malignant hyperthermia
Denervating injury or disease process ( 23 d, lasting for 36 mo or
longer)
Recent burns (more than 24 h and less than 6 mo since injuryrisk
believed to decrease with healing)
Crush injuries
Abdominal abscesses
Arrythmias
Increased intracranial pressure
Increased intraocular pressure
Myalgias
Increased intragastric pressure

acerbate intracranial hypertension or elevate intraocular pressure in

patients with an open eye injury. Elevations in intraocular and intracranial pressure occur contemporaneously with the skeletal muscle fasciculations that follow succinylcholine administration, but the
mechanism of pressure elevation is not known. It is also unclear
whether small children (younger than 6 to 8 years) possess adequate
muscle mass to produce substantial fasciculations, and substantial
fasciculations are not commonly seen in infants (24). Despite this,
many clinicians believe that administration of a defasciculating dose
of a nondepolarizing NMB (10% of the usual intubating dose) may
help to attenuate these deleterious effects (17, 25). It is reasonable
to administer this nondepolarizing NMB dose 1 to 3 minutes before
succinylcholine administration if intracranial hypertension or intraocular pressure is of concern.
Succinylcholine may also cause arrhythmias in children, particularly bradyarrhythmias, after intravenous injection. Succinylcholine
structurally resembles two acetylcholine molecules bonded together,
and it has a tendency to act as a muscarinic surge at the parasympathetic receptors on the heart. Children are particularly prone to the
vagal effects of succinylcholine, and this drug should probably always be preceded by intravenous atropine in children in the ED (33).
Atropine premedication may be less critical when succinylcholine is
administered intramuscularly (34).
NONDEPOLARIZING NEUROMUSCULAR BLOCKADE. Mivacurium
is a nondepolarizing NMB that represents a reasonable compromise between succinylcholine and other NMBs. Mivacurium in
an intravenous dose of 0.3 mg/kg provides muscle relaxation (albeit sometimes weak relaxation) in 60 to 90 seconds and provides
clinical relaxation for 8 to 15 minutes in the absence of pharmacologic antagonism. Recovery to 25% of baseline twitch height is
evident in 6 minutes in infants and in 10 minutes in children (35,
36). Like succinylcholine, mivacurium is dependent on plasma
cholinesterase for elimination, but, unlike succinylcholine, it can
be antagonized with neostigmine. Rapid administration causes
histamine release. The intensity of neuromuscular blockade with
this drug has been somewhat variable and less complete than succinylcholine.
Rocuronium is a nondepolarizing NMB that produces strong
muscle relaxation in 30 to 45 seconds to just over 1 minute when
administered in a dose of 0.6 to 1.2 mg/kg intravenously (higher
doses for RSI conditions). Rocuronium is similar to succinylcholine in its ability to produce favorable RSI conditions (37);
likewise, it is of rapid onset, but its duration of effect tends to be
about 30 to 45 minutes. The return of the rst twitch in the train of

April 2002

four returns in approximately 17 minutes and can be pharmacologically antagonized with neostigmine if necessary (37). Like succinylcholine, rocuronium can be administered intramuscularly in
the absence of intravenous access (38). In high doses, it sometimes
causes tachycardia. Rocuronium is best used for RSI when there is
a reason to avoid succinylcholine, and the airway is not anticipated
to be difficult. Rocuronium is metabolized and excreted by the liver
and can be antagonized by neostigmine.
SEDATIVE AND INDUCTION DRUGS. Sedative and induction drugs
produce unconsciousness and amnesia and facilitate endotracheal
intubation. A detailed discussion of the pharmacodynamics and
pharmacokinetics of the induction agents is beyond the scope of
this report, but the salient features are reviewed briey. Sodium
thiopental (STP) reliably produces unconsciousness, amnesia, and
apnea in induction doses of 4 to 7 mg/kg intravenously (40).
Lower doses are required in neonates because of decreased protein
binding (41). The clinical effects of STP dissipate rapidly because
of redistribution from the central nervous system to fat and muscle, which explains why a medication with an elimination half-life
of 3 to 10 hours in children is clinically effective for only 20 minutes (42). After repeated doses of STP are administered, saturation
of muscle and fat sites occurs and redistribution no longer takes
place.
Induction doses of STP lower intracranial pressure more than
mean arterial pressure (43). Thus, cerebral perfusion pressure is preserved or improved, whereas the medication decreases the cerebral
rate of oxygen consumption (43). STP is also a potent antiepileptic
drug even in small doses, but it is of short duration because of redistribution. STP is a direct myocardial depressant, causing tachycardia
by a central vagolytic mechanism, venous capacitance vessel pooling of blood, and reduced cardiac output (43). Patients with cardiomyopathy, profound hypovolemia, and insufficient baroreceptor
reexes can experience profound hypotension from customary induction doses of STP. Therefore, if STP is to be used in these circumstances, smaller doses should be titrated cautiously.
Ketamine can be considered to be the opposite of STP with respect to its hemodynamic prole. Its usual intravenous dose of 1 to
2 mg/kg increments produces dissociative analgesia and amnesia.
Intramuscular administration is unpredictable, but an intramuscular
dose of 4 to 6 mg/kg is usually sufficient. Ketamine increases heart
rate, blood pressure, and cardiac output through its stimulation of
central sympathetic nervous system outow (26). It is a direct myocardial depressant (44) and must be used with caution in patients
with depleted catecholamine reserves (severe end-stage shock) in
whom deleterious hemodynamic effects may be observed. As opposed to all of the other induction drugs, respiratory drive is relatively preserved with ketamine (26), although intact laryngeal reexes cannot be presumed to be present. Patients ventilate
spontaneously, which makes this an attractive sedative for procedures in unintubated patients in whom it is preferable to maintain
spontaneous ventilation. However, preservation of spontaneous
ventilation cannot be assured in neonates receiving ketamine or in
older children who are premedicated with large doses of opioid
medications. Ketamine is a potent bronchodilator and may be the
drug of choice for intubation of the severe asthmatic. As a potent
sialogogue, however, concomitant administration of an anticholinergic medication should be considered to prevent copious airway
and salivary secretions. In contrast to STP, the central nervous system effects of ketamine include increased cerebral metabolic rate,
intracranial pressure, and cerebral blood ow (43). As such, it is a
poor choice for the patient with increased intracranial pressure.
Emergence delirium is less common in children than adults. How-

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SECURING THE CHILDS AIRWAY IN THE ED

ever, premedication with a benzodiazepine is an effective way to

attenuate this side effect.
Etomidate incorporates the best of STP and ketamine. Etomidate,
in an induction dose of 0.3 to 0.4 mg/kg intravenously, preserves cardiovascular stability (45, 46), producing minimal changes in blood
pressure, cardiac output, or systemic vascular resistance. It results in
less respiratory depression than barbiturates, and it decreases cerebral metabolic rate of oxygen, intracranial pressure, cerebral blood
ow, and maintains cerebral perfusion pressure (43). Etomidate may
potentiate seizure foci in patients with seizure disorders (47, 48). Previous investigators have demonstrated increased mortality among
patients receiving prolonged infusions of etomidate for sedation (49).
Etomidate transiently inhibits the enzymes responsible for the synthesis of adrenal steroids (49), and both induction doses and longterm infusions may cause reversible adrenal insufficiency (50, 51).
However, this is not likely to be of clinical signicance during use in
the ED. Etomidate is a good choice for induction of anesthesia in patients who are critically ill with unknown circulatory or central nervous system disease.
Benzodiazepines, including midazolam, diazepam, and lorazepam, are commonly used in the ED to provide sedation and amnesia during airway management. Benzodiazepines are attractive because of their antiepileptic properties and the relative hemodynamic
stability that they provide. One should be cautious, however, when
they are used with opioids or other sedative hypnotic medications,
because this may produce synergistic respiratory depression.

BASIC AIRWAY MANAGEMENT

Schematic approaches to the pediatric airway are outlined in Figure 1. For practical purposes, the pediatric airway in the ED can be
classied into three categories: the uncomplicated airway, the obviously difficult airway, and the difficult airway that is not anticipated.
Any approach to securing the childs airway must be simple and
likely to be successful on rst attempt. Individual practitioner preference, familiarity, and condence should dictate the options available in a given ED. Although it is necessary to be familiar with all
of the approaches, it is critical to be particularly adept at a few.
Figure 1A depicts a global approach to the pediatric airway and
emphasizes the importance of recognition of the difficult airway
(dened as an airway predicted to be difficult to mask ventilate and
intubate) before administering sedating or paralyzing drugs. Figure
1B outlines the approach to the straightforward pediatric airway
and advocates rapid sequence induction or modied rapid sequence
induction for most pediatric patients with uncomplicated airways.
It also provides escape arms for lost airways (unable to mask ventilate or intubate) and the unrecognized difficult airway (able to
mask, unable to intubate).
The difficult airway algorithm (Fig. 1C) provides some recommendations for an approach to the airway that is known to be difficult. It emphasizes the importance of maintaining spontaneous ventilation if the patient is fairly stable. The patient can remain
conscious and breathing spontaneously, or sedatives can be titrated
to help manage the less cooperative patient. The sedatives used
should be easily reversible if drug-induced respiratory compromise
occurs.
The lost airway algorithm (Fig. 1D) provides some recommendations for airway management if bag-mask ventilation or intubation is
not possible, and spontaneous ventilation is inadequate or absent.
This algorithm recognizes the difficulty in pediatric transtracheal
techniques and offers the clinician the opportunity to decide whether

113

airow obstruction during mask ventilation can be bypassed by introducing a laryngeal mask airway (LMA) or Combitube (Kendall,
Manseld, MA) (for larger children). If this is unsuccessful or unavailable, the next step is to proceed immediately to invasive airway
management. For the profoundly hypoxemic patient who is in extremis, the clinician should proceed directly to needle cricothyrotomy in children, because this is the technique that is most likely to be
rapidly successful.
The nal algorithm, the crash airway algorithm (Fig. 1E), provides some recommendations for airway management in the patient
who is critically ill or unstable. It acknowledges that it may not be
necessary to provide pharmacologic assistance for the patient who
is already moribund and unlikely to react to or recall the airway intervention. We advocate immediate initiation of bag-mask ventilation before the rst attempt at endotracheal intubation. This may
restore some physiologic stability and prevent or forestall cardiovascular collapse. Likewise, for the patient with intracranial hypertension, mask ventilation is the most effective in rapidly lowering
intracranial pressure and improving cerebral blood ow. We suggest using STP or etomidate plus lidocaine and a muscle relaxant if
the patient is moribund and intracranial hypertension is present. For
other patients, laryngoscopy and intubation can be performed without pharmacologic assistance.
It should be emphasized that algorithms are helpful; however,
clinical judgment, experience, and expertise should guide the individual approach. Maintaining spontaneous ventilation (if it is physiologically adequate) in the difficult airway scenario is critical. Finally, it is important to recognize when airway interventions are
ineffective. At this point, failure to proceed to another translaryngeal or transtracheal form of support may result in an adverse patient outcome.
The single most valuable asset available to the clinician is prociency at bag-mask ventilation. This is the technique that will buy
time and preserve life while other airway equipment, personnel, and
techniques can be mobilized. Poor technique results in hypoventilation, gastric insufflation with air, and subsequent aspiration of gastric contents. Good technique involves preserving good maskface
seal, inating the chest with the minimal required pressure, maintaining the optimal patency of the upper airway through manipulation of the mandible and cervical spine (when not contraindicated),
and insertion of oropharyngeal or nasopharyngeal airways (when
not contraindicated) to maintain patency of the upper airway. Good
mask technique, positioning, and gentle cricoid pressure are required to help minimize the risks of gastric aspiration. Cricoid pressure must be applied gently (depress the trachea 12 cm) in infants,
because the pliable trachea can be completely occluded by the Sellick maneuver if performed with too much pressure.
In most children, placement of the endotracheal tube under direct
visualization with the RSI technique is all that is needed. All attempts at direct laryngoscopy should be gentle and brief. Failure to
do so will result in further airway bleeding and edema and may exacerbate intracranial hypertension. Indeed, the most common scenario leading to severe injury in lost airway scenarios is progressive
airway compromise as a result of repeated iatrogenic trauma and
failure to abandon a technique that has proven to be ineffective.
The Uncomplicated Pediatric Airway. Patients in the ED
can generally be assumed to have a full stomach. Rapid sequence
induction is an airway strategy that is designed to minimize the risk
of aspiration of gastric contents. In this scenario, the patient is preoxygenated by breathing spontaneously, and induction drugs and
paralytics are injected in rapid sequence. The patient is allowed to
become apneic without ventilating with positive pressure. As soon

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PEDIATRIC EMERGENCY CARE

April 2002

B
FIG. 1. A, Global algorithm for pediatric airway management in the emergency department. B, Management of the straightforward pediatric airway. (continued)

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SECURING THE CHILDS AIRWAY IN THE ED

115

D
FIG. 1. (Continued ) C, Difficult airway algorithm. Options for endotracheal tube placement while the patient is breathing spontaneously include, but are not
limited to, awake direct laryngoscopy, blind nasal (children 10 y), beroptic methods (Bullard, exible bronchoscope), intubating laryngeal mask airway, light
wand, retrograde techniques. D, Lost airway algorithm. (continued )

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PEDIATRIC EMERGENCY CARE

April 2002

E
FIG. 1. (Continued ) E, Crash airway algorithm. Adapted from Walls RW. The emergency airway algorithms. In: Manual of emergency airway management.
Philadelphia: Lippincott Williams & Wilkins, 2000;1626.

as the patient is paralyzed and sedated, the clinician performs direct

laryngoscopy and places the endotracheal tube under direct visualization while an assistant provides gentle cricoid pressure (Sellick
maneuver). This technique provides optimal conditions for endotracheal intubation and minimizes the risk of gastric aspiration. It
should be the technique most commonly used in the ED.
Rapid sequence induction may require modication when applied to younger children, especially infants and those with severe
lung pathology, because they are likely to desaturate quickly. In this
setting, a modied rapid sequence induction is selected. After preoxygenation, a sedative and paralytic medication is given intravenously as cricoid pressure is gently applied. The airway is gently
ventilated with positive pressure until laryngoscopy and endotracheal intubation. This prevents, or minimizes, the arterial oxygen
desaturation associated with brief periods of apnea in the sick infant.
The Obviously Difficult Airway. The child with a history or
physical ndings suggestive of a difficult airway presents the clinician with the opportunity to avoid the pitfalls associated with a situation in which intubation and ventilation are impossible. Patients
with obviously difficult airways include those with syndromes associated with abnormal airway anatomy and those with abnormal
airways resulting from trauma or airway inammation (eg, epiglottitis, caustic ingestion, or thermal injury). The approach to airway
management is dictated by the urgency of the patients condition
and the perceived difficulty the airway presents.
If it is likely that bag-valve-mask ventilation will be successful,
drugs that will abolish respiratory drive or paralyze the respiratory
muscles should not be given. In such instances, it is preferable to
secure the airway with the patient breathing spontaneously. Op-

tions for accomplishing this include generous topical airway anesthesia followed by awake laryngoscopy, beroptic bronchoscopy,
blind nasotracheal intubation, light wand intubation, and retrograde
techniques. The choice of technique will depend on the preference
and condence level of the practitioner, age and degree of cooperation of the child, and the specic clinical circumstances. It may
also be appropriate to involve other health care professionals
skilled in airway access to assist if time permits.
For patients who are likely to be easy to bag-mask ventilate, but difcult to intubate endotracheally, other approaches are possible. In this
situation, the risk of gastric aspiration during airway manipulations
must be weighed against the increased cooperation gained by administering sedatives and/or paralytic agents. In agitated and uncooperative patients, the risk benet ratio may favor sedation and/or paralysis. The favorable conditions gained may more than offset the risk of
aspiration. In addition to the techniques described previously, the
spontaneously breathing patient can also be taken to the operating
room and intubated while spontaneously inhaling volatile anesthetics.
In the ED there will be patients with difficult airways and limited
physiological reserve who are in need of immediate airway access.
Approaches in such a setting include the quick conrmation that
one can neither mask ventilate nor endotracheally intubate the
patient. If neither can be done, it is appropriate to place a temporizing airway (eg, LMA, Combitube) or proceed directly to an invasive airway technique.
Options for invasive airway management in children in the ED include needle cricothyrotomy and/or placement of a larger cricothyroid tube via the Seldinger technique. Needle cricothyroidotomy is
the easiest and safest technique for temporary ventilatory support in

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SECURING THE CHILDS AIRWAY IN THE ED

the ED and should be considered the technique of choice. The technique for gas exchange is dictated by patient age. Bag ventilation or
transtracheal jet ventilation (TTJV) with the pressure regulator set to
a low pounds per square inch (PSI) can be used to temporarily restore
oxygenation while a more denitive airway is pursued (52). However, TTJV should be used only by those who are skilled and comfortable with the technique.
Despite all of the opinions and reviews written on this subject,
few clinicians actually have experience applying technique in children. The cricothyroid membrane is small and may be difficult to
palpate in infants and smaller children. In such instances, it is appropriate to place an intravenous catheter through the trachea in the
region of the cricothyroid membrane. Oxygenation and lifesustaining levels of ventilation can be sustained for an hour or more
in dogs with nearly complete upper airway obstruction. Gas exchange was provided by low-ow oxygen in spontaneously breathing animals and by positive pressure ventilation with a self-lling
bag in paralyzed animals (53).
Needle cricothyrotomy in children is a temporary measure and
is used to preserve oxygenation until a denitive airway can be obtained. Although oxygenation may be preserved at life-sustaining
levels with this technique, ventilation is often marginally adequate
for a nite time period, and careful attention must be paid to the
rise and fall of the chest and oxygenation. Complete, or high-grade
proximal airway obstruction, can result in inadequate exhalation
and air trapping, leading to barotrauma and pneumothoraces.
Complications from errant placement of the needle and catheter
include pneumothorax, subcutaneous emphysema resulting in the
loss of favorable conditions for subsequent attempts at correct
catheter placement, mediastinal emphysema, esophageal injury,
and bleeding. In addition, ventilation with a self-lling resuscitation bag may be difficult because of the high resistance imposed
by the small intravenous catheter in the airway. It may be necessary to disable the pop-off valve on the self-lling bag to optimize
ventilation. Finally, TTJV requires the use of specialized equipment and may cause injury if used improperly (54). Careful monitoring of the rise and fall of the chest, oxygen saturations, and
carbon dioxide tensions on blood gases is mandatory. Tracheostomy (with surgical consultation in ED or operating room) or
translaryngeal endotracheal intubation from above can then be attempted after oxygenation is ensured by needle cricothyrotomy.
Commercial kits are available for needle cricothyrotomy with subsequent passage of a guidewire into the trachea, passage of serial
dilators, and placement of a cricothyrotomy tube. The wider bore
cricothyrotomy tube is much more able to facilitate ventilation
than the needle catheter; however, such kits exist only for children
older than 10 years.
The Unanticipated Difficult Airway. Despite attempts to
screen for and predict airway difficulties, the difficult airway may
be rst recognized during the laryngoscopy phase of RSI. The next
step is to immediately determine whether the patient can be ventilated with bag and mask. If the patient can be ventilated, the techniques available include optimizing the position and allowing the
most skilled individual present to repeat laryngoscopy. If the patient cannot be intubated, alternative techniques of airway management include beroptic intubation, Bullard laryngoscopy, light
wand, retrograde techniques, and placement of LMA with blind or
beroptic placement of an endotracheal tube through the LMA.
Other options are needle cricothyrotomy with bag or transtracheal
jet ventilation or the placement of a cricothyrotomy tube via the
Seldinger technique (patient age and size permitting).
If the patient cannot be ventilated, urgent action is needed to es-

117

tablish ventilation. In rapid succession, this includes calling for

help, placement of oral and nasal airways (when not contraindicated), and two-hand mask grip with optimization of sniffing position and forward mandible displacement (observing c-spine precautions when indicated) while an assistant squeezes the resuscitation
bag. If air cannot be moved effectively, the clinician must quickly
decide whether the airway obstruction can be remedied with LMA
placement or tracheoesophageal Combitube placement (if the patient is an appropriate candidate for this device). Generally speaking, pathology at the level of the supraglottis or below may not be
bypassed with these modalities, and it may be more prudent to proceed immediately to needle cricothyrotomy. Alternatively, older
children can be managed with placement of a cricothyrotomy tube
via Seldinger technique. For speed and simplicity, needle cricothyrotomy is probably the procedure that is most familiar to ED physicians.
Review of Specic Techniques. Needle cricothyrotomy is
performed when anatomic injury prevents the movement of gas
from the upper airway into the trachea and the trachea cannot be intubated via the translaryngeal route. A 14-gauge catheter over a
needle is introduced into the trachea in the region of the cricothyroid membrane. A syringe is attached to the needle and aspirated
for free ow of air indicating entry into the trachea. With the
catheter rmly held in the trachea, the catheter is directly attached
to the endotracheal tube adapter from a 3.0 endotracheal tube. A resuscitation bag can then be attached to the catheter adapter assembly, and oxygen can be insufflated into the lungs. Alternatively, the
barrel of a 3-cc syringe can be placed in the hub of the catheter, and
an endotracheal tube adapter from a 7.0 endotracheal tube can complete the assembly for resuscitation bag attachment. An alternative
method for insufflating gas into the trachea is to connect a highpressure wall source (50 PSI) to the catheter via a hand-operated jet
injector with a pressure regulator gauge apparatus to prevent barotrauma. For children younger than 5 years, needle cricothyrotomy
with bag ventilation is the technique of choice (55). For children
between the ages of 5 and 10 years, options include needle cricothyrotomy with bag ventilation or TTJV with the pressure regulator set to a low PSI that is sufficient to inate the chest. For children older than 10 years, the patients size may allow the clinician
to place a larger bore cricothyroid tube from commercially available kits, such as TTJV catheters or Seldinger cricothyroid sets
(Cook Critical Care, Bloomington, IN) (52).
The LMA is a recent addition to the difficult airway algorithm
presented by the American Society of Anesthesiologists (55) and
has recently been suggested for pediatric advanced life support by
the American Heart Association (56). The LMA consists of a wide
bore tube with a standard 15-mm adapter at the proximal end for attachment to a breathing circuit or resuscitation bag. The distal end
is an elliptical mask that is inated through a pilot balloon and conforms to the shape of the larynx. It provides a low-pressure seal for
mask ventilation at the level of the larynx (Fig. 2).
The advantage of the LMA is that it can effectively bypass the
supraglottic structures and can free the clinicians hands for further
airway endeavors. It also serves as an effective conduit for placement
of a beroptic bronchoscope into the trachea, because the LMA
opening is at the entrance of the glottis. LMAs come in varying sizes
and can be used in the smallest of pediatric patients (Table 6). LMAs
designed to facilitate beroptic intubation through the LMA are now
available with a modied laryngeal aperture with a movable ange
designed to lift the epiglottis from the path of the bronchoscope.
The LMA provides no more airway protection than a simple facemask. Patients may aspirate gastric contents, and the low-pressure

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PEDIATRIC EMERGENCY CARE

TABLE 6
Suggested sizes for laryngeal mask airways in children
Mask size
1
2
2.5
3
4

Patient size

Weight (kg)

Cuff volume (mL)

Infant
Child
Child
Small adult
Normal and large adult

6.5
6.520
2030
30

2 to 4
10
15
20
30

Reprinted with permission from Morgan GE Jr, Mikhail MS. Airway

management. In: Clinical anesthesiology, ed 2. Stamford, CT: Appleton
and Lange, 1996; 5072.

vice should end up in the trachea as it is passed blindly through the

mouth. There other lumen (blue) has a sealed distal end and proximal
fenestrations to allow air to be delivered to the region of the glottis
by bag mask. A proximal balloon is inated in the hypopharynx to
provide an adequate airway seal to permit ventilation. With the device placed blindly into the espohagus it serves the function of an
LMA, and the endotracheal tube lumen (white) can be used to facilitate passage of a nasogastric tube to evacuate the stomach (Fig. 3).
The Combitube has the disadvantage of being available in only one
size and is, therefore, helpful only in adolescents (patients older than
15 years and 5 ft tall) and has the potential to cause esophageal injury in patients with esophageal pathology.
Although patients sometimes cannot be ventilated by mask or

B
FIG. 2. A, Laryngeal mask airways (LMA) of different sizes. B,
Schematic drawing of proper placement of LMA: side view of LMA (A),
insertion of LMA with head in sniffing position while pressing device
along hard palate (B), advancement of LMA against posterior pharynx until seated (C), correctly seated LMA (D). Reprinted with permission from
Morgan GE Jr, Mikhail MS. Airway management. In: Clinical anesthesiology, ed 2. Stamford, CT: Appleton-Lange, 1996; 56.

seal may make ventilation difficult in patients who require elevated

inating pressures because of obesity or intrinsic lung disease.
Placement of the LMA requires more sedation or anesthesia than
placement of an oral or nasal airway, and practice is required to be
procient at proper placement and use of this instrument. Inability
to ventilate through the LMA is either a result of downfolding of the
epiglottis over the glottis during LMA placement or obstruction below the level of the glottis.
The tracheoesophageal Combitube can be very helpful in allowing
ventilation and oxygenation to be preserved when mask ventilation
is difficult. The Combitube is a cylindrical device with two separate
lumens and two separate 15-mm airway adapters at the proximal end.
One of the lumens (white) serves as an endotracheal tube if the de-

FIG. 3. Tracheoesophageal Combitube placed in esophagus or trachea

can provide emergency ventilation. A, The tracheoesophageal Combitube
has two lumens and two cuffs. B, If placed in the esophagus, ventilation
through the blind tube will force gas out the side perforations and into the
larynx. C, If placed in the trachea, ventilation through the patent clear tube
will direct gas into the trachea. Reprinted with permission from Morgan GE
Jr, Mikhail MS. Airway management. In: Clinical anesthesiology, ed 2.
Stamford, CT: Appleton-Lange, 1996;59.

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SECURING THE CHILDS AIRWAY IN THE ED

LMA, it is more likely that the patient can be ventilated to some degree but cannot be intubated by the translaryngeal route under direct visualization. This is common in patients with cervical spine
trauma, cervical spine fusion, limited mouth opening, and other
anatomic reasons contributing to the clinicians inability to align
the oral, pharyngeal, and laryngeal axes. In this situation, translaryngeal tracheal intubation is possible via the blind or indirect visualization techniques.
Indirect visualization techniques allow the clinician to see the
larynx indirectly using flexible fiberoptic bronchoscopy or a
Bullard laryngoscope. The Bullard laryngoscope is available in
adult and pediatric sizes (Fig. 4) and consists essentially of a
fiberoptic apparatus mounted on a handheld, L-shaped frame. It is
inserted into the oropharynx and allows the airway structures to
be directly visualized while the preloaded endotracheal tube is
passed off a wire stylet through the glottis under indirect visualization. This can be done when the patient is awake (with topical
anesthesia) or asleep with either spontaneous or positive pressure
mask ventilation (asleep and paralyzed). Flexible fiberoptic intubation entails the use of a variety of sizes (outer diameter and
length) of fiberoptic bronchoscopes over which an endotracheal
tube has been loaded. The bronchoscope can be introduced into
the airway via the oral or nasal routes and, likewise, can be done
when the patient is awake, asleep and breathing spontaneously, or
asleep and paralyzed. This can be accomplished via intermittent
attempts between mask ventilation with periods of apnea or it can
be performed through specialized facemasks that allow for continuous ventilation while flexible fiberoptic bronchoscopy is performed.
Blind techniques are methods in which the endotracheal tube is
placed into the trachea without direct or indirect visualization.
These techniques essentially include blind nasal techniques as well
as light wand intubations. Blind nasal intubation is easier in a spontaneously breathing patient. This technique involves the introduction of an endotracheal tube into the nasopharynx of the patient and
the advancement of the tube as the breath sounds in the endotracheal tube become louder. Commercially available endotracheal
tubes that incorporate a guiding ring and cable in the wall of the endotracheal tube make it easy to direct the tube in an anterior direction for easier insertion. This technique is not advisable in patients

119

with potential basilar skull fracture. Techniques to facilitate sedation with spontaneous ventilation include light benzodiazepineopioid sedation with topical airway anesthesia, inhalation anesthesia, or ketamine-benzodiazepine methods. Blind nasal intubation is
not likely to be successful in small children because of the anterior
location of the glottis and the small laryngeal aperture that is obscured by the epiglottis. This technique is not recommended for
routine use in children younger than 10 years (55).
Light wand techniques involve passing an endotracheal tube
from an illuminated intubating stylet into the trachea without direct
or indirect visualization. The light wand has a very bright light on
its tip that is blindly passed through the glottic aperture. Placement
is attempted when a very bright light is visible through the skin
overlying the thyroid and cricoid cartilage. The main pitfall of this
technique is that, even with esophageal placement of the stylet, a
very bright light can sometimes still be seen through the anterior
neck. It is important to practice this technique to be able to reliably
distinguish between correct and incorrect stylet positions so as to
pass the endotracheal tube without displacing the stylet. This technique works better in anesthetized patients.
The nal methods for translaryngeal intubation are collectively
referred to as retrograde techniques. This term encompasses a wide
variety of permutations of maneuvers but in its distilled form refers
to the placement of a guidewire into the airway via the cricothyroid
membrane or trachea. The wire is passed proximally through the
laryngeal aperture and retrieved from the oropharynx. The wire is
passed through the Murphy eye of the endotracheal tube, and the
endotracheal tube is advanced into the trachea over the guidewire.
Alternatively, the guidewire can be passed through the working port
of a bronchoscope over which an endotracheal tube has already been
loaded. The bronchoscope and endotracheal tube combination is advanced over the guidewire and placed in the trachea under indirect
visualization. These techniques work best with generous topical airway anesthesia or after the induction of anesthesia.

CONCLUSIONS
Proper airway management requires practice and judgment in
addition to an appreciation of the anatomic, pharmacologic, and
physiologic differences that separate infants and children from
adults. It is prudent to become procient at techniques for airway
management beyond simple direct laryngoscopy and endotracheal
intubation, even though most cases will require nothing more. The
clinician should strive to be familiar with many techniques, but
should become very adept at only a few.

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FIG. 4. Bullard laryngoscope. The Bullard laryngoscope is a metal

frame with beroptic components that is inserted into the airway and allows
the operator to insert the endotracheal tube under indirect visualization. Unlike a conventional laryngoscope, it is not necessary to align the oral, pharyngeal, and tracheal axes.

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