Pediatric Airway Management Considerations

Anatomy

Physiology

BLS

ALS

HEAD

Large Occiput

PHARYNX

Floppy and omega-shaped epiglottis

LARYNX

vocal cords are slanted anteriorly & pink rather than white

short neck

Increases difficulty to visualize cords

tongue is large relative to the mouth

LUNGS

Lung tissues are sensitive to large tidal volume or increased pressure

Small residual volume

Higher metabolic rate

ETT sizing

Crocoid cartilage is easily distorted with too much pressure

BURP should be done gently and with 1 forefinger instead of 2

Head movements can make a significant difference in ETT depth (2cm) - can cause inadvertent extubation or going right mainstem

Suction pressures need to be lower (See ALS section)

Deep suction

Cricoid cartilage is the narrowest part of airway

FBAOs are more likely to be subglottic

padding is required under shoulders to align ear with sternal notch

The epiglottis is hard to pick up. Miller blade is used to pull back the entire structure rather than insertion into valecula

Adapt by rotating the tube to the right or left to pass the anterior commissure and pass the cords

Be careful to ventilate at 5-7mL/kg or risk causing barotrauma/pneumothorax

= (Age/4) + 3.5 OR diameter of little finger OR Broselow tape

Infants: 60-80mmHg

Children: 80-100mmHg

Suction catheter size < 1/2 internal diameter of ETT

Airway and breathing are central to resuscitation

Troubleshooting

Good airwaymanagement is key, NOT necessarily intubation

The responder with the most pediatric airway experience should be on airway

Smaller ETTs are more likely to kink

Ventilations become exponentially more difficult with narrower lumen, so deep suction to maintain patency is even more important

Ventilate >1 min in between intubation attempts

Become bradycardic with hypoxia

worsens hypoperfusion to myocardium and can lead to cardiac arrest