17/06/2026
#*THE PEDIATRIC AIRWAY*
Children present unique problems in airway management. By age 8, the anatomy and physiology of the pediatric respiratory system are similar to those of adults. In younger children, the high metabolic rate and body surface area (compared with body mass) result in increased oxygen utilization rates. These rates, coupled with a relatively low functional residual capacity in the unconscious or anesthetized child, predispose younger children to relatively rapid oxygen desaturation..
The anatomy of the pediatric airway differs from that of adults in several particulars. Because of a prominent occiput, infants and small children, when lying supine, tend towards neck flexion, and thus the “sniffing” position recommended in adults is not necessary. A small head ring or “doughnut” to stabilize the head may be beneficial. The tongue is proportionally large in small children, and has a propensity to obstruct ventilation, as does the hypertrophied tonsillar tissue. The nares are small in infants, and adenoidal tissue often partially obstructs the nasopharynx. Nasal airways are seldom used during mask ventilation, in order to avoid epistaxis and injury to the adenoidal tonsils, but correctly sized oral airways are frequently useful. Due to the distensibility and pliability of soft tissues and cartilages of children, it is relatively easy to compress the airway during mask ventilation. For this reason, the practitioner should be careful to confine his/her fingers to the boney mandible during mask ventilation.
The larynx tends to lie higher in the pediatric neck, at the C4 level, as opposed to the C6 level in adults. The epiglottis is longer and inclined toward the glottic opening, which can make it more difficult to elevate during laryngoscopy, particularly with a curved blade. For this reason, straight blades are preferentially used in infants and toddlers. After age 2, airway management is more amenable to the use of curved blades. Because the cricoid cartilage is the narrowest portion of the pediatric airway, and tight seals with inflated cuffs may contribute to mucosal injury with edema, uncuffed tubes have been the mainstay of tracheal intubation in young children. However, cuffed tubes may be used safely, if tight seals are avoided. Ideally, a small leak should be detected when 20 cm H2O of airway pressure is applied. Endotracheal tubes (ETT) in children can be chosen to correspond to the size of the small finger, or, more quantitatively, with the following equation:
The trachea is relatively short in young children, measuring only 5 cm at birth. It is relatively easy to intubate the mainstem bronchus, and therefore one should be mindful of appropriate endotracheal tube lengths for different pediatric age groups. One equation that helps predict these lengths for orotracheal intubation is:
During mask ventilation of a pediatric patient (Fig), airway obstruction is common. Oral airways and a tight-fitting mask, along with appropriate hand position on the mask and jaw usually overcome this readily. In light planes of unconsciousness, laryngospasm is a frequent occurrence in infants and small children. This is best managed with positive pressure by face mask, while a triple airway maneuver is performed. If it proves refractory, a small dose of succinylcholine (0.15 mg/kg) is usually effective in allowing mask ventilation until the process resolves. When all else fails, emergent induction, muscle relaxation with full-dose succinylcholine, and reintubation are necessary.
When direct laryngoscopy is attempted in infants and toddlers, the larynx often appears quite anterior. Attention should be paid to placing the head in extension (extreme cervical flexion causes obstruction, and may worsen the view) and keeping the large tongue displaced to the left, out of the field of vision (Fig). External laryngeal pressure, applied by the fingers of the right hand, or even the small finger of the left hand during laryngoscopy, can improve the laryngoscopic grade. Loose deciduous teeth are common, and if possible, their existence should be noted before the procedure
Very loose teeth should be extracted after loss of consciousness, to avoid displacement into the airway during laryngoscopy. Confirmation of tube position is similar to that in adults, with special attention paid to the depth of the ETT in the trachea. Once established as appropriate, this should be noted, since even small degrees of cervical flexion or extension can result in 2 cm to 3 cm of ETT motion, with endobronchial intubation an ever-present danger.
The epiglottis of an infant; note cord apposition secondary to laryngospasm in right-hand image.(Fig)
Direct laryngoscopy with a MacIntosh blade in a pediatric patient. (Fig)
Ref: Atlas of Airway Management: Techniques and Tools, 1st Edition.
