INTRODUCTION — 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" .)

ANATOMIC CONSIDERATIONS — 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 ].

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 [ 3 ]. 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.

Superior laryngeal position — The position of the larynx in infants and children is more
cephalad than in adults. It is located opposite the C3 to C4 vertebrae, compared with the C4 to
C5 in adults ( figure 1 and figure 2 ) [ 4,5 ]. This creates a more acute angle between the glottic
opening and the base of the tongue, which can make direct visualization more challenging.
Weaker hyoepiglottic ligament — The hyoepiglottic ligament runs at the base of the vallecula,
attaching the epiglottis to the base of the tongue. In young children, it has less tensile strength;
therefore curved blades designed for tip placement in the vallecula (eg, Macintosh) may not
elevate the epiglottis as effectively as in adults.

Large, floppy epiglottis — The epiglottis is relatively large and floppy in children, particularly
those younger than three years of age. It is also angled more acutely with respect to the axis of
the trachea. As a result, the epiglottis projects into the airway and covers more of the glottic
aperture ( figure 1 and figure 2 ). Effective mobilization of the epiglottis also favors the use of a
straight blade to directly lift the epiglottis for improved visualization during direct laryngoscopy
( figure 3 ).

Shorter trachea — The trachea increases in length with age, from approximately 5 cm in
neonates to 12 cm in adults [ 6,7 ]. The short trachea predisposes to right mainstem bronchus
intubation or inadvertent extubation, given the short segment within which an endotracheal tube
(ETT) can be correctly placed. This can occur at the time of intubation, or during unintentional
head movement, which has been shown to displace ETTs as much as 1 cm in neonates and 2 cm
in older children [ 8 ].

Narrow trachea — In addition to being shorter, the trachea in younger children is also narrow [
6,7 ]. Because airway resistance is inversely proportional to the lumen radius to the fourth power,
even small decreases in the airway size from secretions, edema, or external compression
(including cricoid pressure, in circumstances in which it is felt to be beneficial) will have
disproportionate effects on these smaller airways ( figure 4 ). The narrow tracheal lumen,
combined with the narrow space between tracheal rings and small size of the cricothyroid
membranes, makes needle or surgical cricothyroidotomy technically challenging in infants and
children [ 9 ]. (See "The difficult pediatric airway" .)

Anatomic subglottic narrowing — In adults, the vocal cords comprise the narrowest portion of
the airway. The cricoid ring has been identified as the narrowest portion of the pediatric airway
in historic cadaveric studies [ 10 ]. Newer data from anesthetized children suggest anatomic
narrowing may be greatest at the vocal cords though the elliptical cross sectional shape of the
subglottis and the non-distensible cricoid cartilage in the spontaneously breathing child still
make the subglottic region functionally the narrowest [ 11,12 ].

As a result of the subglottic narrowing, foreign bodies can become lodged below the cords, or the
endotracheal tube (ETT) may be small enough to pass through the cords but not beyond the
cricoid ring. Importantly, this narrowing can create an effective anatomic seal without the need
for a cuffed ETT. With the advent of newer, smaller profile, lower pressure cuffed tubes,
however, the American Heart Association now has approved cuffed ETTs for all pediatric
patients outside the newborn period, provided the cuff pressure can be maintained at less than 20
cm H20 [ 13 ]. In addition, use of a cuffed ETT in children is associated with a reduced need for
ETT exchanges and no increase in post-extubation morbidity when compared to uncuffed tubes.
(See "Emergent endotracheal intubation in children", section on 'Cuffed versus uncuffed' .)
Compliant chest wall — The thoracic skeleton in children is primarily cartilaginous and
therefore more compliant than the ossified bony structures in adults [ 14 ]. Intrinsic muscle tone
is required to maintain lung volumes and prevent chest wall distortion. Therefore, infants and
young children are more likely to experience respiratory muscle fatigue, atelectasis and
respiratory failure.

PHYSIOLOGIC CONSIDERATIONS — Age-specific physiologic features in infants and

children can also affect advanced airway management. Here we discuss those processes which
are different in children, and how they impact assessment and management of the pediatric
airway.

Age-related respiratory rate — Normative ranges for vital signs vary by age ( table 1 ). Variation
in patterns may also occur, such as periodic breathing which occurs commonly in the first six
months of life [ 15 ]. Discriminating normal from concerning vital sign values and trends is
paramount in assessing respiratory illness and response to therapy.

Preferential nasal breathing — Infants are commonly believed to be obligate nasal breathers.
Some data suggest that a subset of infants will fail to initiate mouth breathing within a prescribed
time after nasal occlusion [ 16 ]; however, others have shown infants can breathe through their
mouths spontaneously or following nasal airflow obstruction [ 17,18 ]. For the majority of
infants who are nasal breathers, the nares account for nearly half the total airway resistance [ 19
]. Therefore, obstruction by secretions, edema, or compression from non-flowing nasal cannula
or a misplaced face mask can lead to significant increase in the work of breathing.

Smaller tidal volumes — Infants and young children have small, relatively fixed tidal volumes
relative to body size (6 to 8 mL/kg). As a result, they are susceptible to iatrogenic barotrauma
from aggressive positive pressure ventilation. In addition, the limited ability to increase minute
ventilation with deeper breathing means that any compensatory response to physiologic demands
for increased minute volume is most likely to be manifest as tachypnea. Limited sustainability of
rapid respiratory rates predisposes young infants to respiratory failure.

Lower functional residual capacity — Functional residual capacity (FRC) increases with age
during childhood [ 20,21 ]. Therefore, young children have little intrapulmonary oxygen stores to
utilize during hypoventilatory or apneic periods. Apneic infants, in particular, have a more
precipitous decline in oxygen saturation, for example, when they undergo rapid sequence
intubation [ 22 ]. For this reason, children have a heightened need for preoxygenation and,
possibly, bag-mask ventilation during rapid sequence induction for intubation. (See "Rapid
sequence intubation (RSI) in children", section on 'Preoxygenation' .)

Higher oxygen metabolism — Infants have a higher metabolic rate and consume oxygen at a
rate twice that of adults (6 versus 3 mL/kg/min) [ 23,24 ]. This higher oxygen consumption,
coupled with the lower FRC in children, results in a shorter safe apnea time. In a study of
preoxygenated ASA I children (ie, healthy, no medical problems), the mean time to oxygen
desaturation to 90 percent ranged from 1.5 minutes in children less than six months to more than
six minutes in children greater than 11 years of age [ 22 ].
Prone to respiratory fatigue — Infants and younger children have a lower percentage of
efficient, slow-twitch (type 1) skeletal muscle fibers in their intercostal muscles than older
patients [ 23 ]. Therefore, when children utilize retractions to facilitate airflow during respiratory
distress, they are more prone to fatigue, and ultimately, respiratory failure.

Higher vagal tone — Infants and young children may have a pronounced vagal response to
laryngoscopy or airway suctioning. Because hypoxia potentiates the risk for bradycardia, efforts
to maintain oxygenation before and during endotracheal intubation should be maximized.

The role for atropine in preventing bradycardia during airway management is discussed
elsewhere. (See "Rapid sequence intubation (RSI) in children", section on 'Atropine' .)

LIMITED OPPORTUNITY TO GAIN PROFICIENCY — Laryngoscopy and endotracheal

intubation are complex psychomotor skills that require sufficient training and practice to achieve
and maintain proficiency. Studies including neonatal, pediatric, and adult populations have
shown that intubation success increases by level of training [ 24-27 ]. As an example, in an
observational study that evaluated first-time success rates for 114 pediatric rapid sequence
intubations in children’s hospital emergency departments, pediatric emergency medicine
attendings had a higher first-time success rate (89 percent) than pediatric emergency medicine
fellows (43 percent) or pediatric residents (35 percent) [ 27 ]. More specifically, learning curves
for anesthesia resident clinicians in a controlled setting showed that after 10 intubations the
success rate was less than 50 percent, and only after 57 intubations did these trainees achieve a
90 percent success rate [ 28 ]. For non-anesthesia trainees, success also increased with
experience, with a predicted 90 percent rate of "good" intubations achieved after 47 prior
attempts [ 29 ].

In pediatrics, advanced airway management experience for many providers outside of anesthesia
may be limited. Comparing data from pediatric and adult tertiary care emergency departments,
health care providers have less frequent opportunities to perform intubation in children than in
adults. A survey of pediatric emergency departments suggests a range of 1.1 to 3.3 intubations
per 1000 patients per year [ 30 ], while studies based in adult facilities demonstrate 6 to 10
intubations per 1000 patients per year [ 31,32 ]. This demonstrated need for extensive
experience, in contrast to the infrequent opportunities to perform advanced airway techniques in
children, also needs to be considered in pediatric airway management. Simulation training can
provide an alternative means for pediatric airway management training.

Rescue ventilation devices such as the laryngeal mask airway, esophageal-tracheal combination
tube (Combitube®), or laryngeal tube provide alternatives to endotracheal intubation, and are
more likely to be placed correctly than endotracheal tubes by providers with limited prior
experience [ 33-40 ]. Thus, health care providers who will be involved in airway management
should develop comfort and familiarity with at least one rescue ventilation device. (See
"Emergency rescue devices for difficult pediatric airway management" .)

SUMMARY — Although the indications for airway management in children are similar to those
in adults, unique pediatric anatomy and physiology create specific challenges in assessment and
management:
  Anatomic structures in children predispose them to airway obstruction and significantly
impact pediatric airway management. For example, the larger oropharyngeal structures
(tongue, tonsils, and adenoids) and the large floppy epiglottis lead to greater difficulty in
visualizing the vocal cords during laryngoscopy. Also, the shorter and narrower trachea
predisposes to endotracheal tube malposition after intubation. (See 'Anatomic
considerations' above.)
 Infants and children become hypoxemic more quickly than adults because of decreased
functional residual capacity and increased oxygen consumption. These physiologic
differences result in a shorter and less safe apnea time during rapid sequence intubation
(RSI), emphasizing the need for adequate preoxygenation and occasionally, bag-mask
ventilation during RSI. (See 'Physiologic considerations' above and "Rapid sequence
intubation (RSI) in children" .)
 Developing competence and maintaining proficiency with advanced airway management
is particularly challenging in children because of the relative infrequency with which
most practitioners utilize these skills. Simulation training can provide an alternative
means for airway management training. (See 'Limited opportunity to gain proficiency'
above.)

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