Management of the Pediatric Airway
Paul W. Sheeran, MD
Dept of Pediatrics
Division of Critical Care
Dept of Anesthesiology &
Pain Management
UTSW Medical Center
Outline
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Differences in pulmonary physiology and airway
anatomy
Mask ventilation and intubation techniques
Evaluation of the upper airway
Pediatric laryngoscope blades
Sizing of ETT and depth of ETT
Predictors of difficult intubation
Management of the difficult airway
Pulmonary Physiology Differences
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Compliant chest wall
 Airway collapse at low lung volumes
 Low FRC (desaturate quickly)
 High oxygen consumption (6-10 cc
O2/kg/min)
 TV same; minute ventilation increased
Airway Anatomy Differences
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Relatively larger head and tongue
 More cephalad larynx (C3-4 vs. C5-6)
 “More anterior larynx”
 Narrowest part of the airway: cricoid cartilage
 Long epiglottis (floppy, omega shaped)
 Easily compressed trachea
Adult Glottis
Pediatric and Adult airways
Mask Ventilation Technique
Sizing of Oral Airway
Intubation Technique for Neonate
Induction Techniques
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Mask induction (most children):
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Place monitors
 8% sevoflurane in oxygen/nitrous oxide (5L/2L)
 When asleep: decrease sevoflurane to 4-6%, place
PIV, 100% O2, administer NMB, and intubate
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IV induction (RSI, adolescents, in situ PIV):
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Place monitors and pre-oxygenate
 Administer: Pentothal 6 mg/kg or propofol 3 mg/kg
and NMB
 Intubate
Upper Airway Evaluation
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Mouth opening
 Size of the jaw
 Thyromental distance
 Mallampati classification
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Class I: entire uvula visible
 Class II: part of uvula hidden by tongue
 Class III: only soft palate visible
 Class IV: only hard palate visible
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Neck range of motion (extension AO joint)
Mallampati Classification
Cormack and Lehane Grades
Miller laryngoscope blades
Phillips laryngoscope blades
Mac laryngoscope blades
Pediatric Laryngoscope Blades
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Types:
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Miller
Philips
Mac
Newborn: Miller 0
1 month - 1 year: Miller 1
1–3 years: Philips 1
4-8 years: Mac 2
>8 years: Mac 3, Philips 2, or Miller 2
Difficult Airway due to Dysmorphia
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Decreased mandibular space (limited mouth
opening)
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Micrognathia, retrognathia, mandibular hypoplasia
 Pierre- Robin, Treacher Collins
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Decreased head extension (RA, Klippel-Feil)
 Increased tongue size or space-occupying
lesion (e.g., cystic hygroma)
Guides for Proper ETT Sizing
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ETT size:
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Newborn: 3.5 mm
 4 months-1 year: 4.0 mm
 Older child: 4 + (age in years/4)
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Depth of ETT
Direct visualization (2nd notch)
 ETT ID X 3
 Loss of breath sounds (carina), pull out 2 cm
 Cuff palpable in sternal notch
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Treacher Collins Syndrome
Treacher Collins Syndrome
Klippel-Feil Syndrome
Hunter’s Syndrome
Hunter’s Syndrome
Other Indicators of Difficult Airway
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Burns to the face and neck
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A history of radiation to the head and neck
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A history of difficult intubation (i.e., read old
anesthesia records if available)
Other Causes of Difficult Intubation
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Oral bleeding and swelling (e.g., mucositis,
Steven’s Johnson Syndrome, or recent T&A)
 Copious oral secretions (e.g., RSV, ARDS,
pulmonary hemorrhage)
 Severe cardiac dysfunction (e.g., myocarditis,
sepsis)
Difficult Airway Management
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Anticipate problems:
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Call for help
Place PIV pre-op
Administer glycopyrolate (10 mcg/kg IV or IM) one hour
prior to intubation
Keep patient spontaneously breathing (no NMB)
Techniques
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Fiberoptic intubation (FOI)
LMA placement alone (no ETT)
LMA placement followed by FOI
Light wand-assisted oral intubation
Acquired Difficult Airway
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Epiglottitis/supraglottitis
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Croup
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Foreign body
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Trauma
Epiglottitis/supraglottitis
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Acute inflammation of the epiglottis,
aryepiglottic folds, arytenoids, and supraglotis
 School-aged child presents with high fever,
drooling, and inspiratory stridor
 Causes: bacteria or caustic ingestion
 Do not examine with a tongue blade
 Take to the OR
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Mask or IV induction without paralysis
 Rigid bronchoscopy by ENT
Croup
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Gradual onset of inspiratory stridor and
“barky” cough in young children (<3 years)
 Subglottic narrowing (steeple sign on CXR)
 Treatment:
 Cool
mist
 Nebulized racemic epinephrine
 Intubate if patient is in respiratory failure
(smaller ETT than expected is typically needed)
Foreign Body Aspiration
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Young child with either
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Acute h/o choking
Chronic h/o pneumonia or refractory wheezing/cough
Stable patients may be X-rayed
Unstable patients: intubated and then taken to the OR
For esophageal FB: RSI, intubation, and
esophagoscopy
For laryngeal FB:
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Mask or IV induction (without NMB)
Rigid bronchoscopy by ENT surgeon
Upper Airway Trauma
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Neck trauma may cause laryngeal and/or tracheal
injuries
Presenting symptoms: SQ air, neck swelling, hypoxia
If the patient is in extremis in the E.R.
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IV ketamine and glycopyrolate
Intubate orally
Confirm ETT location prior to NMB
If the patient is stable, then take to the O.R.
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Mask or IV induction without paralysis
Tracheotomy by ENT
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Oral intubation is controversial
Summary
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Pediatric patients have a small FRC and increased
O2 consumption: pre-oxygenate with CPAP
It is imperative to evaluate the airway prior to
administering paralytic agents
Difficult intubation associated with micrognathia,
decreased head extension, and a large tongue
Problems with patients with a difficult airway
should be expected: “Don’t go down alone”