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DOI: 10.4103/2229-5151.128015
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Pediatric airway management


Jeff Harless, Ramesh Ramaiah, Sanjay M Bhananker

ABSTRACT Department of Anesthesiology and Pain


Medicine, University of Washington
Securing an airway is a vital task for the anesthesiologist. The pediatric patients have School of Medicine, Seattle, Washington,
significant anatomical and physiological differences compared with adults, which impact USA
on the techniques and tools that the anesthesiologist might choose to provide safe Address for correspondence:
and effective control of the airway. Furthermore, there are a number of pathological Dr.Sanjay M Bhananker,
processes, typically seen in the pediatric population, which present unique anatomical Box359724, Harborview Medical Center,
or functional difficulties in airway management. The presence of one of these syndromes 325 Ninth Avenue, Seattle, Washington,
98104, USA.
or conditions can predict a difficult airway. Many instruments and devices are currently Email:sbhanank@uw.edu
available which have been designed to aid in airway management. Some of these have
been adapted from adult designs, but in many cases require alterations in technique to
account for the anatomical and physiological differences of the pediatric patient. This
review focuses on assessment and management of pediatric airway and highlights the
unique challenges encountered in children.
Key Words: Airway anatomy, congenital syndromes, difficult intubation, pediatric airway

INTRODUCTION most pronounced at birth and the most unfamiliar


(nonadult like) airway is encountered in neonates and
One of the fundamental skills of an anesthesiologist is infants under 1year of age. Observational data bears
management of the airway. To be successful at this task, out this point as laryngoscopy is more likely to yield
it is important for the provider to have knowledge of the suboptimal views in this age group.[1]
important anatomical, physiological, and pathological
features related to the airway as well as knowledge of The first anatomical difference between the pediatric
the various tools and methods that have been developed and adult patient becomes important when positioning
for this purpose. In this vein most anesthetic providers the child prior to or immediately after the induction
are very familiar and skilled at managing the adult of anesthesia. The head of a pediatric patient is larger
airway successfully. However, children are not merely relative to body size, with a prominent occiput. This
small adults. There are important differences that predisposes to airway obstruction in asleep children,
occur during development that require a different because the neck is in flexed when they lie on a flat
approach or technique. Forewarned is forearmed. surface. Afolded towel is often required as a shoulder
Therefore, this review article will highlight some of the roll to achieve a neutral position of the neck and open
important anatomical and physiological differences up the airway. This is demonstrated visually in Figure1.
and their implication. It will then briefly describe some The larger occiput combined with a shorter neck makes
of the pathological conditions which present particular laryngoscopy relatively more difficult by providing
concern for airway management. Finally, an overview of obstacles to the alignment of the oral, laryngeal, and
techniques and tools for managing the pediatric airway tracheal axes.[2]
will be discussed.
The tongue is larger and the mandible shorter in the
young child. In infancy, the child is an obligate nasal
AIRWAY ANATOMY breather until 5months of age. Prominent adenoids and
tonsils are frequently found in preschool age children
The airway of the pediatric patient differs in many and are a frequent reason to present for elective ENT
ways which impact the anesthesiologists management surgery.[3] These factors all contribute to loss of upper
of the airway. Predictably, these differences are airway space which can lead to difficulty with mask

International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014 65
Harless, etal.: Pediatric airway management

ventilation, obstruction during spontaneous ventilation, The hyoid bone is the first airway structure to ossify.
and can make laryngoscopy more difficult. In addition, The cartilaginous portions of the airway are soft and
sedatives, hypnotic, and anesthetic drugs cause loss of compliant. Calcification of the larynx and trachea
tone of upper airway muscles which can itself result in typically does not occur until the teenage years. [7] The
potential upper airway obstruction.[4] flexible cartilaginous rings of the trachea can predispose to
dynamic obstruction with negative pressure ventilation,
The hypopharynx of the pediatric patient is relatively especially when any partial airway obstruction exists.[6,8]
shorter in height and narrower in width. On cross section,
the airway of an adult is more elliptical than that of the Based on cadaveric studies, it has been a commonly held
child. [5] This has implication for supraglottic airway belief that the pediatric airway is funnelshaped with the
placement. narrowest portion of the airway being found at the level
of the cricoid. This was contrasted to the adult airway,
The larynx is relatively higher in the neck in children. where the narrowest portion is the glottis and the airway
In some positions, the mandible may lie in line with is described as cylindrical. These refer to the more rigid
the upper glottic structures. The cricoid ring is located structures of the larynx as outlined by the laryngeal
approximately at the level of the C4 vertebrae at and tracheal cartilages.[6] Recent invivo measurements
taking into account the functional location of the softer
birth, C5 at age 6, and C6 as adult. [6] Vocal cords
tissues, specifically the vocal folds present a somewhat
are not typically found at a right angle(90) to the
different picture. Measurements of the size of the airway
trachea. They are angled in an anteriorinferior to
of children using bronchoscopic images as well as
posteriorsuperior fashion.[2] While this typically does
magnetic resonance imaging images were consistently
not affect laryngoscopic view, it can make insertion of the
found to have glottic openings smaller than at the cricoid.
endotracheal tube more challenging or more traumatic. [911]
However, the distensibilty of the glottic tissues and
Especially in suboptimal views or with indirect video the relatively nondistensible cricoid cartilage may still
laryngoscopy, the endotracheal tube will have a higher lead to the effect of the cricoid being functionally the
tendency to collide with or become obstructed on the narrowest part of the airway. This cartilaginous ring is
anterior commissure of the vocal folds. the only circumferential complete structure in the airway
and an endotracheal tube that passes easily though the
The epiglottis in children is more U shaped(compared vocal cords may not pass through the cricoid ring. The
to flat in adults) and it is less in line with the trachea and cricoid ring in an infant is elliptical, not circular, being
may lie across the glottic opening.[6] This feature makes oflarger diameter in the Antero-posterior dimension.[12]
many anesthesiologists prefer semistraight laryngoscope This affects the seal of cuffed and uncuffed endotracheal
blades such as a Miller which are designed to directly lift tubes and may guide selection of tracheal tubes.
the epiglottis out of view compared to a curved Macintosh
blade which relies on ligamentous connection from the
vallecula with the epiglottis to lift it out of view[Figure2]. PHYSIOLOGY

The pediatric patient has a number of physiological


challenges which can predispose him/her to hypoxemia.
Oxygen consumption of an infant is relatively greater
than an adult with some authors quoting differences at
rest of 6mL/kg/min vs. 3mL/kg/min.[8] This combined
with a somewhat lower functional residual capacity
can lead to rapid desaturation during apnea, such as
a during laryngoscopy or a rapid sequence induction,

b
Figure1: Artistic rendering of infant airway.(a) In image a note the large occiput
which has caused flexion of the head and subsequently caused the base of the
a b
tongue to obstruct the upper airway. This obstruction has been relieved(b) by
placing a towel under the shoulders and neck allowing more extension of the Figure2: Artistic rendering demonstrating proper technique of Macintosh(a) and
head and an opening of the upper airway Miller(b) laryngoscope blades

66 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Harless, etal.: Pediatric airway management

despite best efforts at preoxygenation. CO2 production Table1: List of possible factors complicating airway management
is likewise increased, on the order of 100-150mL/kg/min in a number of congenital syndromes
compared to the 60mL/kg/min of an adult. Since the Syndrome Airway implication
tidal volume(per kg body weight) is relatively consistent Pierre robin sequence Micrognathia, glossoptosis, cleft palate
with that of an adult, the respiratory rate in children is Goldenhar syndrome Micrognathia(unilateral), cervical
dysfunction
higher to achieve this need for higher minute ventilation Treacher Collins syndrome Micrognathia, small oral opening,
to eliminate the CO2.[13] zygomatic hypoplasia
Apert syndrome Limited cervical motion, macroglossia,
micrognathia, midface hypoplasia
The resistance to flow in the airway is governed by Hunter and Hurler syndromes Cervical dysfunction, macroglossia
Poiseulles law: R=8L/r 4. The resistance to flow is BeckwithWiedemann Macroglossia
inversely related to the radius of the airway raised to syndrome
FreemanSheldon syndrome Circumoral fibrosis, microstomia, limit
the fourth power, a small amount of narrowing (due to cervical motion
edema, inflammation, etc.,) in the already small pediatric Down syndrome Atlantooccipital abnormalities, small
airway could have severe consequences on respiratory oral cavity, macroglossia
KlippelFeil syndrome Cervical fusion
function. Anumber of disease processes that could result HallermannStreiff syndrome Microstomia
in such narrowing of the airway include growths within Arthrogryposis Cervical dysfunction
Criduchat syndrome Micrognathia, laryngomalacia
the airway such as hemangiomas or papillomas, aberrant Edwards syndrome Micrognathia
embryological development such as tracheomalacia, Fibrodysplasia ossificans Limited cervical motion
laryngomalacia, and laryngeal clefts, iatrogenic causes progressiva
like vocal cord paralysis and subglottic stenosis, or
compression of the airway structures by a mass located mandible length and lip to chin distance being associated
outside the airway.[14] The management of these processes with Cormack and Lehane view classification.[17] In one
is unique to the disease itself but common themes exist, study, bilateral microtia was associated with a 42%
such as the desire to avoid further trauma to the tissues of incidence of difficult laryngoscopy. [18] However, even
the airway in order to avoid edema and further narrowing if no specific diagnosis is known severity of disease or
of the already compromised airway. certain types of surgery are associated with increased
risk for airway management complications. In one large
case series the rate of difficult laryngoscopy, as defined
AIRWAY ASSESSMENT
as Cormack and Lehane gradeIII or IV, was found to be
1.35%. Some factors that increased likelihood of difficult
The initial airway assessment starts with a good history.
visualization included age<1year, cardiac surgery, ASA
Questions are directed toward eliciting indications of
status III and IV, Mallampati III or IV, and low body
a potentially difficult airway. This would include any
mass index.[1]
complications of birth or delivery, any history of prior
trauma or surgery to the airway or adjacent structures,
or of prior anesthetics. Additionally, one should inquire MANAGEMENT TOOLS AND TECHNIQUES
about current or recent symptoms suggesting upper
respiratory infection(URI), difficulty in speaking, The fundamental maneuver in airway management
difficulty breathing, difficulty feeding, hoarseness, and is properly performed mask ventilation. As in adults,
noisy breathing. Questions such as a history of snoring, there are oneand twohand techniques. Upper airway
day time drowsiness, or stopping breathing during sleep, obstruction which may be encountered during simple
may help to identify children with obstructive sleep mask ventilation is often relieved by head tilt, chin lift,
apnea. Many syndromes are associated with potentially jaw thrust, and the application of continuous positive
difficult airway management. Anonexhaustive list airway pressure.[19] Additionally, the lateral position
of syndromes with potential airway complications is may also improve airway patency, particularly when
summarized in Table1.[12,15] combined with chin lift and jaw thrust. This has been
demonstrated in children undergoing surgery for
Many physical exam findings which may be wellknown adenotonsillary hypertrophy, a group that is more prone
in the adult difficult airway literature also apply to to upper airway obstruction.[20] It is important to note that
children. Limited head extension, reduced mandibular face mask ventilation increases dead space compared to
space, and increased tongue thickness have been ventilation via an endotracheal tube. In smaller children,
shown to be the most reliable predictors of difficult this increase in volume becomes more significant due to
intubation.[16] Some studies have attempted to use scores the low absolute volumes of ventilation.[13]
calculated from various facial measurements to predict
difficult laryngoscopic views. However, these scoring The use of an oral airway during spontaneous or positive
systems can be difficult to use in clinical practice. Some pressure ventilation with a face mask helps to relieve the
series of cases have demonstrated a relationship between obstruction that may be caused by posterior displacement

International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014 67
Harless, etal.: Pediatric airway management

of the tongue in the anesthetized child. The appropriate blade styles and sizes from which to choose. Many
size of airway can be approximated by the distance from anesthesiologists prefer the Macintosh blade, adapted
the anterior gum line to the angle of the mandible.[13] from adult sizes, for older children. This blade is designed
to be utilized with an indirect elevation of the epiglottis by
Nasopharyngeal airways may also be used to relive placing the tip of the blade in the vallecula. Though this
upper airway obstruction during mask ventilation. Their blade was originally envisioned as a device to facilitate
use has also been described as a means of providing laryngoscopy in the preneuromuscular blocking drug
anesthetic gas, oxygen, and End tidal CO2 monitoring era in more lightly anesthetized patients, its popularity
while performing fiber optic tracheal intubation in the has continued to this day. [29] As mentioned before, in
child with a difficult airway.[21] younger children the orientation of the epiglottis in a
more anteriorposterior plane this indirect method of
A relatively recent advancement is the development of elevating the epiglottis may be less effective. Therefore,
the supraglottic airway. Many devices exist. The specifics many anesthesiologists prefer the use of a straight or
of each device provide a unique set of pros and cons for semicurved blade designed to directly elevate the
each device. The variables to consider includematerial of epiglottis in patients under the age of 4 or 5years.[6,30]
construction, ability to adjust seal pressure, reusability,
gastric port, ability to use as intubating conduit, and It is increasingly common to use cuffed endotracheal
ease of insertion among other factors. Two of the more tubes in neonates, infants, and young children. Whereas
popular supraglottic devices, the classic laryngeal mask historically uncuffed endotracheal tubes were used in
airway(LMA) and proseal LMA have good data in this population in an effort to minimize resistance of
the pediatric population to support their safety and the endotracheal tube while also minimizing pressure
efficacy.[22] The classic LMA has a 95%98% success rate trauma to the subglottis, it is now believed that cuffed
in achieving adequate ventilation in children.[23] When tubes can provide better ventilating conditions while also
studied in a series of 1400patients, there is also reported minimizing trauma to the delicate airway of pediatric
a low overall rate of problems(11.5%) with none of the patients. The elliptical shape of the cricoid leads to the
problems resulting in major morbidity.[24] Some authors possibility that an uncuffed tube with an acceptable leak
report successful use of proseal LMAs for laparoscopic pressure may still be causing pressure trauma to the
procedures in children age 6months to 8years.[25] subglottic mucosa.[12] Additionally, the use of uncuffed
endotracheal tubes may be associated with a higher
The supraglottic airway may hold some advantages over incidence of laryngospasm.[12,31]
endotracheal intubation for anesthesia in children with
recent URI. In one randomized trial comparing LMA The utility of using an audible air leak at an airway
to endotracheal tube, the LMA group had significantly pressure of less than 20cm H 2O has been called into
fewer respiratory complications compared to the question as being inadequate to prevent over inflation
endotracheal tube group.[26] However, the LMA is still of endotracheal tube cuffs. In one observational study
associated with an increased incidence of respiratory median cuff pressures were found to be 4060cm H2O,
complications when used in children with a recent URI exceeding the commonly accepted limit of 20-30cm
as compared to healthy children.[27] H2O.[28]

It has been recommended that a manometer be used to There are multiple options for induction of anesthesia in
gauge the inflation pressure of the cuff of the LMA. In one the anticipated difficult intubation. The use of inhalational
observational study following routine insertion of proseal induction tends to maintain spontaneous respirations
or classic LMAs using slight elevation of the device as but also depresses upper airway musculature and may
a clinical endpoint guiding inflation, inflation pressures worsen upper airway obstruction.[4,32] Remifentanil has
significantly exceeded the 60cm H 2O recommended the advantage of being shortacting opioid which can
by the manufacturer. Higher intracuff pressure may produce reasonable intubating conditions, while muscle
expose the patient to increased risk for mucosal damage relaxant rocuroniumhas the advantage of being reversible
by exceeding mucosal perfusion pressures.[28] Once a by sugammadex. Experience with sugammadex is limited
supraglottic airway has been chosen and inserted, it however and has limitations of not reversing anesthetic
is recommended that the inflation pressure be kept agents, and may not be sufficient for a patient to regain
to less than 40cm H2O. This appears to improve the upper airway muscular tone in a failed airway situation
oropharyngeal leak pressure and reduce the incidence due to potential trauma and edema of the attempted
of throat pain postoperatively.[12] airway as is suggested by a recent case report.[33] In adults,
awake fiberoptic intubation is often considered the gold
There are dozens of tools to facilitate tracheal intubation. standard method for the known or predicted difficult
The gold standard is still direct laryngoscopy. Within this airway. It allows for the maintenance of spontaneous
practice, there are a multitude of different laryngoscope respirations until the trachea is intubated. [12] In the

68 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Harless, etal.: Pediatric airway management

pediatric population, this option is usually not feasible is some suggestion that a direct surgical approach to
due to the need for significant cooperation on the part cricothyroidotomy is likely to be more successful.[40]
of the patient. In one survey of pediatric anesthesiologist However, there are a number of anatomical differences
in Canada, the use of inhalational induction was the in the pediatric airway which complicate any potential
preferred method approaching a predicted difficult transcutaneous approach to the airway. First of all the
airway.[34] neonatal cricothyroid membrane is small, measuring
only 3mm wide and 2.6mm tall.[41] Second, in infants,
Many techniques for managing the challenging airway the hyoid bone by overlap the usually prominent thyroid
take advantage of the relatively good positioning of a cartilage, thereby making identification of crucial
supraglottic device above the glottic opening. One method anatomy more difficult.[42] Some experts have, therefore,
is to place a supraglotic airway and then use a fiberoptic suggested that in these youngest patients the preferred
bronchoscope through an airway exchange catheter to approach may be direct puncture of the trachea below
intubate the trachea. The fiberscope and the supraglottic the level of the cricoid.[42]
airway are then removed and an endotracheal tube can
be advanced over the exchange catheter. [35] Another
method involves placement of the supraglottic airway, CONCLUSION
followed by introduction of the fiberscope into the trachea
through the supraglottic airway. Once the fiberscope is in Airway management is a key skill for the anesthesiologist.
the trachea a Jwire can be placed through the operating The airway of the pediatric patient has a number of
port of the scope. The scope can then be removed and significant differences when compared to the adult
an airway exchange catheter advanced over the wire. airway and presents some unique challenges. Awareness
Following the removal of the wire and supraglottic device of anatomical and physiological differences, important
an endotracheal tube can be advanced over the exchange pathological conditions affecting children, and a
catheter.[36] More recently, supraglottic devices have been knowledge of the available airway techniques and tools
designed specifically for use as conduits for intubation. will allow the anesthesiologist to formulate and execute
These devices do not have fenestrations and allow for safe and effective management of the pediatric airway.
direct placement of endotracheal tubes through the
supraglottic airway.[37] In cases series, excellent success
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28. Ong M, Chambers NA, Hullet B, Erb TO, von UngernSternberg BS. Cite this article as: Harless J, Ramaiah R, Bhananker SM. Pediatric
Laryngeal mask airway and tracheal tube cuff pressures in children: airway management. Int J Crit Illn Inj Sci 2014;4:65-70.
Are clinical endpoints valuable for guiding inflation? Anaesthesia Source of Support: Nil, Conflict of Interest: No.
2008;63:73844.

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