1. New Orleans EMS Airway Lecture Series: Lecture 4 The Pediatric Airway
Jeffrey M. Elder, M.D.
Deputy Medical Director

2. Challenges of the Pediatric Airway
Age related dosing and equipment
Anatomical Variations based on age
Anxiety of a sick child

3. Pediatric Airway Anatomy

4. Tongue Located completely in the oral cavity until 2 years old
No portion makes up the upper/anterior pharyngeal wall
Potential site of airway obstruction
Difficult ventilation

5. Occiput
A child’s head/occiput are proportionately larger than and adult’s
Neck flexion while supine
Leads to obstruction
Overcome with the sniffing position (want EAC just anterior to the shoulders)
Roll placed under back(infant)
None – small child
Roll placed under occiput

6. Positioning

7. Sniffing Position

8. Nasal Passage Increased mucosa and lymphoid tissue
Nasal airway is primary pathway for normal breathing in the infant
Warming, humidification, particle filtration
Compromised breathing with increased secretions, NGT placement, nasal congestion

9. Larynx
Newborns
Larynx at the base of the occiput/C1 to C4
Enables epiglottis to lock the larynx into the nasopharynx by passing up behind the soft palate
Provides a direct air channel from the nares to the lungs, allowing liquids to pass on the sides into the esophagus

10. Larynx Two separate anatomic pathways Large Tongue High Glottis
Respiratory tract from the nose to the lungs
Digestive tract from the mouth to the stomach
Large Tongue
Entirely within the oral cavity
High Glottis
Difficult line of vision from mouth to the larynx during laryngoscopy
Anterior Airway

11. Anatomic Changes in Childhood
Occurs after the second year of life
Posterior 1/3 of tongue descends into the neck, forming upper anterior pharyngeal wall
By 7 years, the larynx lies between C3 and C6
In adulthood, the larynx lies between C4 – C7
Now loose the two separate pathways

12. Anatomy In adults, the vocal cords and trachea are of equal dimensions
In newborns, the narrowest portion of the airway is the cricoid ring
Tight ET tubes may lead to cricoid damage, subglottic stenosis

13. Functional Issues Children easily obstruct the airway
Racemic epinephrine can have dramatic results in the smallest areas of the airway (croup –cricoid ring)
Larger airway calibers do not see such dramatic results (epiglotitis) – forced nebs can lead to dynamic upper airway obstruction
Noxious stimuli can lead to dynamic obstruction and respiratory arrest
Crying child increases work of breathing 32-fold – “leave them alone”
BMV may bridge through an obstruction
i.e. Epiglotitis
Increased inspiratory effort may collapse the airway – (extrathoracic trachea)
PPV can stent the airway open are relieve the obstruction

14. Physiology
Basal Oxygen consumption is approximately twice that of adults
Children have a decreased functional residual capacity (FRC) to body weight ratio
Desaturate much more quickly!!
Even given equivalent duration of preoxygenation
Be prepared to provide supplemental oxygen by BMV if oxygen saturation drops below 90%

15. Airway Management

16. Evaluation History Observation PMHx, Prematurity, Previous Intubations
Tachypnea
Accessory Muscle Use
Nasal Flaring
Tripoding

17. Evaluation Position of comfort Grunting Cyanosis Drooling Wheezing
Rales

18. Signs of Respiratory Failure
Decreased level of consciousness
Grunting and increased work of breathing
Poor Air Entry / Decreased breath sounds
Bradycardia
Apnea/Slow Respiratory Rate

19. Reasons to Intubate Failure to Oxygenate Failure to Ventilate
Expected Clinical Course

20. Airway Management

21. The 7 P’s of RSI Preparation Preoxygenation Pretreatment
Paralysis with induction
Positioning
Placement with proof
Postintubation management

22. Airway Equipment Suction Device Oxygen source Bag Valve Mask ET Tube
1 size smaller and larger
Laryngoscope blade & Handle
EtCO2 Detector
Tube Holder
Alternate Airway Equipment
OPA, Combitube, LMA, cric. kit
RSI Medications

23. Equipment Sizes ET Tube Diameter = (age/4) + 4
Width of child’s 5th fingernail
Depth = Tube Size x 3
Uncuffed Tube for less than 8 years old
Laryngoscope Blade
Be careful of size 0 and 00
Based on Broselow Tape

24. Bag Valve Mask Ventilation
Must fit over the nose, cheeks, mouth, and chin
Place in sniffing position
In line stabilization
Jaw thrust
OPA/NPA
From ear to mouth
Inspect for foreign body
Cricoid pressure

25. Bag Valve Mask Ventilation
Pediatric/Adult Size bag
Pop off valve cm of water
A skill that needs practice!
1 or 2 person ventilation

26. Rapid Sequence Induction
Etomidate 0.3 mg/kg
Succinylcholine 2 mg/kg
faster metabolism than adults
Still first line for full-stomach or emergency intubation
Rocuronium 1 mg/kg
Atropine 0.02 mg/kg min. 0.1mg
Lidocaine 1mg/kg
SCh --Hyperkalemic cardiac arrest secondary to unDx neuromuscular disease

27. Endotracheal Intubation
Usually after airway control and ventilation/oxygenation
Preoxygenation
Don’t bag – 3 minutes of 100% oxygen via BVM
Pick the right equipment!
Most effective and reliable airway management/protection
Always a clinical decision

28. Endotracheal Intubation
Attempts should not last over 30 seconds
Straight or Curved blade
Miller – picks up epiglottis
Straight blades preferred in small children
Picks of epiglottis directly and tongue/mandible more easily elevated from field of vision
Macintosh – enter the vallecula

29. Post Intubation Management
Verification of Tube Placement
Visualization
ETC02
Auscultation
Secure the tube with tape or commercial device
Head/neck immobilization in small children to avoid neck movement and dislodgement

30. Post Intubation Management
Place NG tube after ETI
Decompress the stomach
Avoid micro aspiration in mechanically ventilated patients

31. Contraindications to RSI
Major Laryngeal trauma
Upper Airway Obstructions
Distorted Facial/Airway Anatomy
Operator Concern of Difficult Airway

32. The Difficult Airway

33. The Difficult Airway Direct Examination Large Tongue
Mental-Hyoid Distance
Upper-Lower Incisor Distance
Large Tongue
Blood, swelling, secretions
Limited C spine mobility/scoliosis
Limited mandibular ROM
Maxillofacial/ Larynx trauma
*Angoiedema
*Anaphylaxis
*Epiglottitis
*Croup
Morbid Obesity
Micrognathia
Burns
Foreign Body

34. Adjunct Airways Combitube
Only if > 4 feet tall
Rescue Airway Device

35. Adjunct Airways LMA Rescue option in the failed airway
May cause partial airway obstruction in infants (rotational placement)
Loss of seal/movement
Contraindicated in FB aspiration obstruction

36. Adjunct Airways LMA

37. Adjunct Airways Cricothyroidotomy
Contraindicated < 10 yrs
Needle Cric <10 yrs
14g needle, 5cc syringe, 3mm ETT adapter, BVM
Can’t intubate, Can’t ventilate
Trauma, angioedema, epigolttitis

38. Adjunct Airways Cricothyroidotomy

40. References
Trauma Reports Volume 8, No. 1. Jan/Feb AHC Media, LLC.
Managing the Pediatric Airway in the ED, Pediatric Emergency Medicine Practice. Volume 3, No. 1. January 2006
Manual of Emergency Airway Management, 3rd Edition. Walls, R. and Murphy, M