List the ways in which the paediatric airway differs from the adult airway. Outline how these influence your management.
Anatomic paediatric airways offer significant potential challenges to the critical care practitioner. Factors to consider include:
• Absolute size of airway (including trachea), small mandible, large tongue (use of chart, formula [age/4 + 4 mm if > 1 yr] or Braselow measurement tape to allow sizing of ETT, and depth estimates essential [age/2 + 12 cm from lower lip]; often need smaller blade [narrower, shorter]; concern about tracheostomy)
• Large head (neck already flexed, not need pillow or as much head extension for intubation and airway management)
• Epiglottis long and stiff and may obscure view (may need to include epiglottis under laryngoscope blade, or consider using straight blade)
• Larynx high, anterior and the narrowest point is usually the laryngeal outlet/cricoid cartilage (often use uncuffed tubes, increased concern about laryngeal stenosis)
Other specific management concerns related to the small size of the artifical airways include: importance of fixation (ease of dislodgement), increased likelihood of blockage, circuit/mechanics to minimise work of breathing.
This is another question which would benefit from a tabulated answer.
| And strategies that may be used to overcome these. | ||
| Anatomical problem | How this is a problem | Strategy to overcome this problem |
| Prominent occiput | Neck is flexed in the supine poistion. Laryngoscopy will be difficult in this position. |
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| Small mandible | Less anterior excursion; smaller mouth opening |
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| Large tongue | Large tongue relative to the size of the oral cavity. Causes airway obstruction and interferes with laryngoscopy. |
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| Larger tonsils and adenoids | Can cause airway obstruction. Nasopharyngeal airways may cause bleeding and aspiration. |
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| Superior laryngeal position | Located opposite the C3 to C4 vertebrae, compared with the C4 to C5 in adults. Laryngoscpy is made more difficult. |
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| Large, floppy epiglottis | The epiglottis projects further into the airway and covers more of the glottis (until the age of 4) |
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| Short trachea | Easy to intubate the right main bronchus. Easy to inadvertently extubate the child. |
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| Narrow trachea | More predisposed to obstruction: small decreases in the airway size will cause obstruction. The needle or surgical cricothyroidotomy is more difficult, as the target is smaller. One should also be concerned about the risk of tracheal stenosis following prolonged intubation or tracheostomy. |
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| Soft trachea and cricoid | Cricoid pressure may collapse the airway |
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| Anatomic subglottic narrowing | An effective anatomic seal can be expected without the need for a cuffed ETT. Foreign bodies can become lodged below the cords. This resolves by age 10-12. |
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Esther Weathers has made available an excellent document in which the pediatric airway caveats are explained, as well as the ways around them.
Heard, A. M. B., R. J. Green, and P. Eakins. "The formulation and introduction of a ‘can't intubate, can't ventilate’algorithm into clinical practice." Anaesthesia64.6 (2009): 601-608.
Stacey, Jonathan, et al. "The ‘Can't Intubate Can't Oxygenate’scenario in Pediatric Anesthesia: a comparison of different devices for needle cricothyroidotomy." Pediatric Anesthesia 22.12 (2012): 1155-1158.
Weathers E., "The Anatomy of the Pediatric Airway" 2010 -RC EDUCATIONAL CONSULTING SERVICES, INC.
Santillanes, Genevieve, and Marianne Gausche-Hill. "Pediatric airway management." Emergency medicine clinics of North America 26.4 (2008): 961-975.
HOLM‐KNUDSEN, R. J., and L. S. Rasmussen. "Paediatric airway management: basic aspects." Acta Anaesthesiologica Scandinavica 53.1 (2009): 1-9.
Cardwell, Mary, and Robert WM Walker. "Management of the difficult paediatric airway." BJA CEPD Reviews 3.6 (2003): 167-170.