Emergency airway management in children: Unique pediatric considerations
- Joshua Nagler, MD
Joshua Nagler, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Section Editor
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The anatomic structures and physiologic processes that affect the assessment and management of the airway in children will be reviewed here as will the challenge of achieving proficiency for practitioners who infrequently perform pediatric airway management. Specifics regarding airway management techniques are discussed separately. (See "Basic airway management in children" and "Emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) outside the operating room in children: Approach".)
There are several anatomic features in infants and children that may impact advanced airway management. Here we discuss the relevant structures and their effect on airway management.
Prominent occiput — The proportionally larger occiput in infants and younger children causes varying degrees of neck flexion in the supine position. This can result in anatomic airway obstruction or interfere with attempts to visualize the glottic opening during laryngoscopy [1-3]. Placing a towel roll under the shoulders can improve airway alignment (picture 1). This approach is in contrast to placing a pad under the occiput in adults.
Large tongue — Infants and young children have large tongues relative to the size of the oral cavity. Therefore, inadequate control and displacement of the tongue may impede visualization of the deeper airway during direct laryngoscopy. In addition, the tongue becomes a common source of upper airway obstruction, particularly in patients with depressed mental status and concomitant loss of intrinsic airway tone. Retroglossal obstruction occurs in approximately half of obstructions in infants, compared with adults where the vast majority of intrinsic airway obstruction occurs at the level of the soft palate [4,5].
Larger tonsils and adenoids — Children more commonly have larger tonsils and adenoids than adults. Studies utilizing magnetic resonance imaging (MRI) have confirmed that this increased mass of lymphoid tissue contributes to airway obstruction in children . In addition, adenoidal bleeding can occur with placement of a nasopharyngeal airway or attempts at nasotracheal intubation. Resultant blood in the naso- and hypopharynx can lead to aspiration and make glottic visualization challenging.
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- ANATOMIC CONSIDERATIONS
- Prominent occiput
- Large tongue
- Larger tonsils and adenoids
- Superior laryngeal position
- Weaker hyoepiglottic ligament
- Large, floppy epiglottis
- Shorter trachea
- Narrow trachea
- Anatomic subglottic narrowing
- Compliant chest wall
- PHYSIOLOGIC CONSIDERATIONS
- Age-related respiratory rate
- Preferential nasal breathing
- Smaller tidal volumes
- Lower functional residual capacity
- Higher oxygen metabolism
- Prone to respiratory fatigue
- Higher vagal tone
- LIMITED OPPORTUNITY TO GAIN PROFICIENCY