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 — Adult and Pediatric Emergency Medicine
- Senior 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) 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 [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.
- Todres ID. Pediatric airway control and ventilation. Ann Emerg Med 1993; 22:440.
- Goetting MG. Mastering pediatric cardiopulmonary resuscitation. Pediatr Clin North Am 1994; 41:1147.
- RUBEN HM, ELAM JO, RUBEN AM, GREENE DG. Investigation of upper airway problems in resuscitation. 1. Studies of pharyngeal x-rays and performance by laymen. Anesthesiology 1961; 22:271.
- Don GW, Kirjavainen T, Broome C, et al. Site and mechanics of spontaneous, sleep-associated obstructive apnea in infants. J Appl Physiol (1985) 2000; 89:2453.
- Eastwood PR, Szollosi I, Platt PR, Hillman DR. Collapsibility of the upper airway during anesthesia with isoflurane. Anesthesiology 2002; 97:786.
- Arens R, McDonough JM, Costarino AT, et al. Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2001; 164:698.
- Westhorpe RN. The position of the larynx in children and its relationship to the ease of intubation. Anaesth Intensive Care 1987; 15:384.
- Schwartz DS, Keller MS. Maturational descent of the epiglottis. Arch Otolaryngol Head Neck Surg 1997; 123:627.
- John SD, Swischuk LE. Stridor and upper airway obstruction in infants and children. Radiographics 1992; 12:625.
- Fearon B, Whalen JS. Tracheal dimensions in the living infant (preliminary report). Ann Otol Rhinol Laryngol 1967; 76:965.
- Griscom NT, Wohl ME. Dimensions of the growing trachea related to age and gender. AJR Am J Roentgenol 1986; 146:233.
- Miller KA, Kimia A, Monuteaux MC, Nagler J. Factors Associated with Misplaced Endotracheal Tubes During Intubation in Pediatric Patients. J Emerg Med 2016; 51:9.
- Weiss M, Knirsch W, Kretschmar O, et al. Tracheal tube-tip displacement in children during head-neck movement--a radiological assessment. Br J Anaesth 2006; 96:486.
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
- ECKENHOFF JE. Some anatomic considerations of the infant larynx influencing endotracheal anesthesia. Anesthesiology 1951; 12:401.
- Litman RS, Weissend EE, Shibata D, Westesson PL. Developmental changes of laryngeal dimensions in unparalyzed, sedated children. Anesthesiology 2003; 98:41.
- Dalal PG, Murray D, Messner AH, et al. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg 2009; 108:1475.
- Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S876.
- Papastamelos C, Panitch HB, England SE, Allen JL. Developmental changes in chest wall compliance in infancy and early childhood. J Appl Physiol (1985) 1995; 78:179.
- Kelly DH, Stellwagen LM, Kaitz E, Shannon DC. Apnea and periodic breathing in normal full-term infants during the first twelve months. Pediatr Pulmonol 1985; 1:215.
- Swift PG, Emery JL. Clinical observations on response to nasal occlusion in infancy. Arch Dis Child 1973; 48:947.
- Miller MJ, Martin RJ, Carlo WA, et al. Oral breathing in newborn infants. J Pediatr 1985; 107:465.
- Rodenstein DO, Perlmutter N, Stănescu DC. Infants are not obligatory nasal breathers. Am Rev Respir Dis 1985; 131:343.
- Stocks J, Godfrey S. Nasal resistance during infancy. Respir Physiol 1978; 34:233.
- Gerhardt T, Reifenberg L, Hehre D, et al. Functional residual capacity in normal neonates and children up to 5 years of age determined by a N2 washout method. Pediatr Res 1986; 20:668.
- Stocks J, Quanjer PH. Reference values for residual volume, functional residual capacity and total lung capacity. ATS Workshop on Lung Volume Measurements. Official Statement of The European Respiratory Society. Eur Respir J 1995; 8:492.
- Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and the onset of desaturation in apnoeic children. Can J Anaesth 1994; 41:771.
- Rinderknecht AS, Mittiga MR, Meinzen-Derr J, et al. Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data. Acad Emerg Med 2015; 22:431.
- Keens TG, Bryan AC, Levison H, Ianuzzo CD. Developmental pattern of muscle fiber types in human ventilatory muscles. J Appl Physiol Respir Environ Exerc Physiol 1978; 44:909.
- Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46:328.
- Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002; 18:417.
- Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J Pediatr 2005; 146:638.
- Kerrey BT, Rinderknecht AS, Geis GL, et al. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med 2012; 60:251.
- Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86:635.
- Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic intubation: learning and performance. Anesthesiology 2003; 98:23.
- Losek JD, Olson LR, Dobson JV, Glaeser PW. Tracheal intubation practice and maintaining skill competency: survey of pediatric emergency department medical directors. Pediatr Emerg Care 2008; 24:294.
- Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med 2004; 44:307.
- Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325.
- Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Crit Care Med 2014; 42:169.
- Chen L, Hsiao AL. Randomized trial of endotracheal tube versus laryngeal mask airway in simulated prehospital pediatric arrest. Pediatrics 2008; 122:e294.
- Davis DP, Valentine C, Ochs M, et al. The Combitube as a salvage airway device for paramedic rapid sequence intubation. Ann Emerg Med 2003; 42:697.
- Guyette FX, Roth KR, LaCovey DC, Rittenberger JC. Feasibility of laryngeal mask airway use by prehospital personnel in simulated pediatric respiratory arrest. Prehosp Emerg Care 2007; 11:245.
- Kette F, Reffo I, Giordani G, et al. The use of laryngeal tube by nurses in out-of-hospital emergencies: preliminary experience. Resuscitation 2005; 66:21.
- Kurola J, Pere P, Niemi-Murola L, et al. Comparison of airway management with the intubating laryngeal mask, laryngeal tube and CobraPLA by paramedical students in anaesthetized patients. Acta Anaesthesiol Scand 2006; 50:40.
- Kurola JO, Turunen MJ, Laakso JP, et al. A comparison of the laryngeal tube and bag-valve mask ventilation by emergency medical technicians: a feasibility study in anesthetized patients. Anesth Analg 2005; 101:1477.
- Russi CS, Miller L, Hartley MJ. A comparison of the King-LT to endotracheal intubation and Combitube in a simulated difficult airway. Prehosp Emerg Care 2008; 12:35.
- Russi CS, Wilcox CL, House HR. The laryngeal tube device: a simple and timely adjunct to airway management. Am J Emerg Med 2007; 25:263.
- 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