Management of the infant and pediatric airway can pose unique challenges. Anatomic features of a child's head, neck, and airway, as well as physiologic differences between children and adults, must be considered. Recognizing and addressing these pediatric-specific attributes are important in equipment selection, patient positioning, and airway management technique.
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 "Emergent endotracheal intubation in children" and "Rapid sequence intubation (RSI) in children".)
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. 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 [1,2].