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Symposium: Critical Airway Management Website: www.ijciis.org
DOI: 10.4103/2229-5151.128015
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Pediatric airway management

Jeff Harless, Ramesh Ramaiah, Sanjay M Bhananker

ABSTRACT Department of Anesthesiology and Pain

Medicine, University of Washington
Securing an airway is a vital task for the anesthesiologist. The pediatric patients have School of Medicine, Seattle, Washington,
significant anatomical and physiological differences compared with adults, which impact USA
on the techniques and tools that the anesthesiologist might choose to provide safe Address for correspondence:
and effective control of the airway. Furthermore, there are a number of pathological Dr. Sanjay M Bhananker,
processes, typically seen in the pediatric population, which present unique anatomical Box 359724, Harborview Medical Center,
or functional difficulties in airway management. The presence of one of these syndromes 325 Ninth Avenue, Seattle, Washington,
98104, USA.
or conditions can predict a “difficult airway.” Many instruments and devices are currently E‑mail: sbhanank@uw.edu
available which have been designed to aid in airway management. Some of these have
been adapted from adult designs, but in many cases require alterations in technique to
account for the anatomical and physiological differences of the pediatric patient. This
review focuses on assessment and management of pediatric airway and highlights the
unique challenges encountered in children.
Key Words: Airway anatomy, congenital syndromes, difficult intubation, pediatric airway

INTRODUCTION most pronounced at birth and the most unfamiliar

One of the fundamental skills of an anesthesiologist is
management of the airway. To be successful at this task,
it is important for the provider to have knowledge of the
important anatomical, physiological, and pathological
features related to the airway as well as knowledge of
the various tools and methods that have been developed
for this purpose. In this vein most anesthetic providers
are very familiar and skilled at managing the adult
airway successfully. However, children are not merely
small adults. There are important differences that
occur during development that require a different
approach or technique. Forewarned is forearmed.
Therefore, this review article will highlight some of the
important anatomical and physiological differences
and their implication. It will then briefly describe some
of the pathological conditions which present particular
concern for airway management. Finally, an overview of
techniques and tools for managing the pediatric airway
will be discussed.
AIRWAY ANATOMY
The airway of the pediatric patient differs in many
ways which impact the anesthesiologist’s management
of the airway. Predictably, these differences are
(non‑adult like) airway is encountered in neonates and
infants under 1 year of age. Observational data bears
out this point as laryngoscopy is more likely to yield
suboptimal views in this age group.[1]
The first anatomical difference between the pediatric
and adult patient becomes important when positioning
the child prior to or immediately after the induction
of anesthesia. The head of a pediatric patient is larger
relative to body size, with a prominent occiput. This
predisposes to airway obstruction in asleep children,
because the neck is in flexed when they lie on a flat
surface. A folded towel is often required as a shoulder
roll to achieve a neutral position of the neck and open
up the airway. This is demonstrated visually in Figure 1.
The larger occiput combined with a shorter neck makes
laryngoscopy relatively more difficult by providing
obstacles to the alignment of the oral, laryngeal, and
tracheal axes.[2]
The tongue is larger and the mandible shorter in the
young child. In infancy, the child is an obligate nasal
breather until 5 months of age. Prominent adenoids and
tonsils are frequently found in preschool age children
and are a frequent reason to present for elective ENT
surgery.[3] These factors all contribute to loss of upper
airway space which can lead to difficulty with mask

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Harless, et al.: Pediatric airway management
ventilation, obstruction during spontaneous ventilation,
and can make laryngoscopy more difficult. In addition,
sedatives, hypnotic, and anesthetic drugs cause loss of
tone of upper airway muscles which can itself result in
potential upper airway obstruction.[4]
The hypopharynx of the pediatric patient is relatively
shorter in height and narrower in width. On cross section,
the airway of an adult is more elliptical than that of the
child. [5] This has implication for supraglottic airway
placement.
The larynx is relatively higher in the neck in children.
In some positions, the mandible may lie in line with
the upper glottic structures. The cricoid ring is located
approximately at the level of the C4 vertebrae at
birth, C5 at age 6, and C6 as adult. [6] Vocal cords
are not typically found at a right angle (90°) to the
trachea. They are angled in an anterior‑inferior to
posterior‑superior fashion.[2] While this typically does
not affect laryngoscopic view, it can make insertion of the
endotracheal tube more challenging or more traumatic.
Especially in suboptimal views or with indirect video
laryngoscopy, the endotracheal tube will have a higher
tendency to collide with or become obstructed on the
anterior commissure of the vocal folds.
The epiglottis in children is more “U” shaped (compared
to flat in adults) and it is less in line with the trachea and
may lie across the glottic opening.[6] This feature makes
many anesthesiologists prefer semi‑straight laryngoscope
blades such as a Miller which are designed to directly lift
the epiglottis out of view compared to a curved Macintosh
blade which relies on ligamentous connection from the
vallecula with the epiglottis to lift it out of view [Figure 2].
a during laryngoscopy or a rapid sequence induction,
b
Figure 1: Artistic rendering of infant airway. (a) In image a note the large occiput
which has caused flexion of the head and subsequently caused the base of the
tongue to obstruct the upper airway. This obstruction has been relieved (b) by
placing a towel under the shoulders and neck allowing more extension of the
head and an opening of the upper airway
66 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
The hyoid bone is the first airway structure to ossify.
The cartilaginous portions of the airway are soft and
compliant. Calcification of the larynx and trachea
typically does not occur until the teenage years. [7] The
flexible cartilaginous rings of the trachea can predispose to
dynamic obstruction with negative pressure ventilation,
especially when any partial airway obstruction exists.[6,8]
Based on cadaveric studies, it has been a commonly held
belief that the pediatric airway is funnel‑shaped with the
narrowest portion of the airway being found at the level
of the cricoid. This was contrasted to the adult airway,
where the narrowest portion is the glottis and the airway
is described as cylindrical. These refer to the more rigid
structures of the larynx as outlined by the laryngeal
and tracheal cartilages.[6] Recent in vivo measurements
taking into account the functional location of the softer
tissues, specifically the vocal folds present a somewhat
different picture. Measurements of the size of the airway
of children using bronchoscopic images as well as
magnetic resonance imaging images were consistently
found to have glottic openings smaller than at the cricoid.
[9‑11]
However, the distensibilty of the glottic tissues and
the relatively nondistensible cricoid cartilage may still
lead to the effect of the cricoid being functionally the
narrowest part of the airway. This cartilaginous ring is
the only circumferential complete structure in the airway
and an endotracheal tube that passes easily though the
vocal cords may not pass through the cricoid ring. The
cricoid ring in an infant is elliptical, not circular, being
oflarger diameter in the Antero-posterior dimension.[12]
This affects the seal of cuffed and uncuffed endotracheal
tubes and may guide selection of tracheal tubes.
PHYSIOLOGY
The pediatric patient has a number of physiological
challenges which can predispose him/her to hypoxemia.
Oxygen consumption of an infant is relatively greater
than an adult with some authors quoting differences at
rest of 6 mL/kg/min vs. 3 mL/kg/min.[8] This combined
with a somewhat lower functional residual capacity
can lead to rapid desaturation during apnea, such as
a b
Figure 2: Artistic rendering demonstrating proper technique of Macintosh (a) and
Miller (b) laryngoscope blades
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Harless, et al.: Pediatric airway management
despite best efforts at preoxygenation. CO2 production
is likewise increased, on the order of 100-150 mL/kg/min
compared to the 60 mL/kg/min of an adult. Since the
tidal volume (per kg body weight) is relatively consistent
with that of an adult, the respiratory rate in children is
higher to achieve this need for higher minute ventilation
to eliminate the CO2.[13]
The resistance to flow in the airway is governed by
Poiseulle’s law: R =8ƞL/πr 4. The resistance to flow is
inversely related to the radius of the airway raised to
the fourth power, a small amount of narrowing (due to
edema, inflammation, etc.,) in the already small pediatric
airway could have severe consequences on respiratory
function. A number of disease processes that could result
in such narrowing of the airway include growths within
the airway such as hemangiomas or papillomas, aberrant
embryological development such as tracheomalacia,
laryngomalacia, and laryngeal clefts, iatrogenic causes
like vocal cord paralysis and subglottic stenosis, or
compression of the airway structures by a mass located
outside the airway.[14] The management of these processes
is unique to the disease itself but common themes exist,
such as the desire to avoid further trauma to the tissues of
the airway in order to avoid edema and further narrowing
of the already compromised airway.
AIRWAY ASSESSMENT
The initial airway assessment starts with a good history.
Questions are directed toward eliciting indications of
a potentially difficult airway. This would include any
complications of birth or delivery, any history of prior
trauma or surgery to the airway or adjacent structures,
or of prior anesthetics. Additionally, one should inquire
about current or recent symptoms suggesting upper
respiratory infection (URI), difficulty in speaking,
difficulty breathing, difficulty feeding, hoarseness, and
noisy breathing. Questions such as a history of snoring,
day time drowsiness, or stopping breathing during sleep,
may help to identify children with obstructive sleep
apnea. Many syndromes are associated with potentially
difficult airway management. A nonexhaustive list
of syndromes with potential airway complications is
summarized in Table 1.[12,15]
Many physical exam findings which may be well‑known
in the adult difficult airway literature also apply to
children. Limited head extension, reduced mandibular
space, and increased tongue thickness have been
shown to be the most reliable predictors of difficult
intubation.[16] Some studies have attempted to use scores
calculated from various facial measurements to predict
difficult laryngoscopic views. However, these scoring
systems can be difficult to use in clinical practice. Some
series of cases have demonstrated a relationship between
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Table 1: List of possible factors complicating airway management
in a number of congenital syndromes
Syndrome Airway implication
Pierre robin sequence Micrognathia, glossoptosis, cleft palate
Goldenhar syndrome Micrognathia (unilateral), cervical
dysfunction
Treacher Collins syndrome Micrognathia, small oral opening,
zygomatic hypoplasia
Apert syndrome Limited cervical motion, macroglossia,
micrognathia, midface hypoplasia
Hunter and Hurler syndromes Cervical dysfunction, macroglossia
Beckwith‑Wiedemann Macroglossia
syndrome
Freeman‑Sheldon syndrome Circumoral fibrosis, microstomia, limit
cervical motion
Down syndrome Atlantooccipital abnormalities, small
oral cavity, macroglossia
Klippel‑Feil syndrome Cervical fusion
Hallermann‑Streiff syndrome Microstomia
Arthrogryposis Cervical dysfunction
Cri‑du‑chat syndrome Micrognathia, laryngomalacia
Edwards syndrome Micrognathia
Fibrodysplasia ossificans Limited cervical motion
progressiva
mandible length and lip to chin distance being associated
with Cormack and Lehane view classification.[17] In one
study, bilateral microtia was associated with a 42%
incidence of difficult laryngoscopy. [18] However, even
if no specific diagnosis is known severity of disease or
certain types of surgery are associated with increased
risk for airway management complications. In one large
case series the rate of difficult laryngoscopy, as defined
as Cormack and Lehane grade III or IV, was found to be
1.35%. Some factors that increased likelihood of difficult
visualization included age <1 year, cardiac surgery, ASA
status III and IV, Mallampati III or IV, and low body
mass index.[1]
MANAGEMENT TOOLS AND TECHNIQUES
The fundamental maneuver in airway management
is properly performed mask ventilation. As in adults,
there are one‑ and two‑hand techniques. Upper airway
obstruction which may be encountered during simple
mask ventilation is often relieved by head tilt, chin lift,
jaw thrust, and the application of continuous positive
airway pressure.[19] Additionally, the lateral position
may also improve airway patency, particularly when
combined with chin lift and jaw thrust. This has been
demonstrated in children undergoing surgery for
adenotonsillary hypertrophy, a group that is more prone
to upper airway obstruction.[20] It is important to note that
face mask ventilation increases dead space compared to
ventilation via an endotracheal tube. In smaller children,
this increase in volume becomes more significant due to
the low absolute volumes of ventilation.[13]
The use of an oral airway during spontaneous or positive
pressure ventilation with a face mask helps to relieve the
obstruction that may be caused by posterior displacement
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Harless, et al.: Pediatric airway management
of the tongue in the anesthetized child. The appropriate
size of airway can be approximated by the distance from
the anterior gum line to the angle of the mandible.[13]
Nasopharyngeal airways may also be used to relive
upper airway obstruction during mask ventilation. Their
use has also been described as a means of providing
anesthetic gas, oxygen, and End tidal CO2 monitoring
while performing fiber optic tracheal intubation in the
child with a difficult airway.[21]
A relatively recent advancement is the development of
the supraglottic airway. Many devices exist. The specifics
of each device provide a unique set of pros and cons for
each device. The variables to consider includematerial of
construction, ability to adjust seal pressure, reusability,
gastric port, ability to use as intubating conduit, and
ease of insertion among other factors. Two of the more
popular supraglottic devices, the classic laryngeal mask
airway (LMA) and proseal LMA have good data in
the pediatric population to support their safety and
efficacy.[22] The classic LMA has a 95%‑98% success rate
in achieving adequate ventilation in children.[23] When
studied in a series of 1400 patients, there is also reported
a low overall rate of problems (11.5%) with none of the
problems resulting in major morbidity.[24] Some authors
report successful use of proseal LMAs for laparoscopic
procedures in children age 6 months to 8 years.[25]
The supraglottic airway may hold some advantages over
endotracheal intubation for anesthesia in children with
recent URI. In one randomized trial comparing LMA
to endotracheal tube, the LMA group had significantly
fewer respiratory complications compared to the
endotracheal tube group.[26] However, the LMA is still
associated with an increased incidence of respiratory
complications when used in children with a recent URI
as compared to healthy children.[27]
It has been recommended that a manometer be used to
gauge the inflation pressure of the cuff of the LMA. In one
observational study following routine insertion of proseal
or classic LMAs using slight elevation of the device as
a clinical endpoint guiding inflation, inflation pressures
significantly exceeded the 60 cm H 2O recommended
by the manufacturer. Higher intracuff pressure may
expose the patient to increased risk for mucosal damage
by exceeding mucosal perfusion pressures.[28] Once a
supraglottic airway has been chosen and inserted, it
is recommended that the inflation pressure be kept
to less than 40 cm H2O. This appears to improve the
oropharyngeal leak pressure and reduce the incidence
of throat pain postoperatively.[12]
There are dozens of tools to facilitate tracheal intubation.
The gold standard is still direct laryngoscopy. Within this
practice, there are a multitude of different laryngoscope
68 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
blade styles and sizes from which to choose. Many
anesthesiologists prefer the Macintosh blade, adapted
from adult sizes, for older children. This blade is designed
to be utilized with an indirect elevation of the epiglottis by
placing the tip of the blade in the vallecula. Though this
blade was originally envisioned as a device to facilitate
laryngoscopy in the preneuromuscular blocking drug
era in more lightly anesthetized patients, its popularity
has continued to this day. [29] As mentioned before, in
younger children the orientation of the epiglottis in a
more anterior‑posterior plane this indirect method of
elevating the epiglottis may be less effective. Therefore,
many anesthesiologists prefer the use of a straight or
semi‑curved blade designed to directly elevate the
epiglottis in patients under the age of 4 or 5 years.[6,30]
It is increasingly common to use cuffed endotracheal
tubes in neonates, infants, and young children. Whereas
historically uncuffed endotracheal tubes were used in
this population in an effort to minimize resistance of
the endotracheal tube while also minimizing pressure
trauma to the subglottis, it is now believed that cuffed
tubes can provide better ventilating conditions while also
minimizing trauma to the delicate airway of pediatric
patients. The elliptical shape of the cricoid leads to the
possibility that an uncuffed tube with an acceptable leak
pressure may still be causing pressure trauma to the
subglottic mucosa.[12] Additionally, the use of uncuffed
endotracheal tubes may be associated with a higher
incidence of laryngospasm.[12,31]
The utility of using an audible air leak at an airway
pressure of less than 20 cm H 2O has been called into
question as being inadequate to prevent over inflation
of endotracheal tube cuffs. In one observational study
median cuff pressures were found to be 40‑60 cm H2O,
exceeding the commonly accepted limit of 20-30 cm
H2O.[28]
There are multiple options for induction of anesthesia in
the anticipated difficult intubation. The use of inhalational
induction tends to maintain spontaneous respirations
but also depresses upper airway musculature and may
worsen upper airway obstruction.[4,32] Remifentanil has
the advantage of being short‑acting opioid which can
produce reasonable intubating conditions, while muscle
relaxant rocuroniumhas the advantage of being reversible
by sugammadex. Experience with sugammadex is limited
however and has limitations of not reversing anesthetic
agents, and may not be sufficient for a patient to regain
upper airway muscular tone in a failed airway situation
due to potential trauma and edema of the attempted
airway as is suggested by a recent case report.[33] In adults,
awake fiberoptic intubation is often considered the gold
standard method for the known or predicted difficult
airway. It allows for the maintenance of spontaneous
respirations until the trachea is intubated. [12] In the
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Harless, et al.: Pediatric airway management
pediatric population, this option is usually not feasible
due to the need for significant cooperation on the part
of the patient. In one survey of pediatric anesthesiologist
in Canada, the use of inhalational induction was the
preferred method approaching a predicted difficult
airway.[34]
Many techniques for managing the challenging airway
take advantage of the relatively good positioning of a
supraglottic device above the glottic opening. One method
is to place a supraglotic airway and then use a fiberoptic
bronchoscope through an airway exchange catheter to
intubate the trachea. The fiberscope and the supraglottic
airway are then removed and an endotracheal tube can
be advanced over the exchange catheter. [35] Another
method involves placement of the supraglottic airway,
followed by introduction of the fiberscope into the trachea
through the supraglottic airway. Once the fiberscope is in
the trachea a J‑wire can be placed through the operating
port of the scope. The scope can then be removed and
an airway exchange catheter advanced over the wire.
Following the removal of the wire and supraglottic device
an endotracheal tube can be advanced over the exchange
catheter.[36] More recently, supraglottic devices have been
designed specifically for use as conduits for intubation.
These devices do not have fenestrations and allow for
direct placement of endotracheal tubes through the
supraglottic airway.[37] In cases series, excellent success
rates, 96% first attempt, have been reported.[38]
There are many newer devices designed to aid
laryngoscopy. These include pediatric sizes of Glidescope
video larygoscope, a Karl‑Storz video laryngoscope
on what is essentially a Miller 1 blade, Airtraq optical
laryngoscope, among others. [30] Though rigorous
prospective trials of many of these devices have yet to be
done, there is some early evidence and experience that
they may provide improved glottic views and therefore
provide viable alternatives to direct laryngoscopy when
direct laryngoscopy is predicted to be or found to be
challenging.[39]
The difficulty of airway management is usually due
to either difficulty in either performing adequate
mask ventilation or in successfully achieving tracheal
intubation. The intersection of these two scenarios is the
“cannot ventilate, cannot intubate” situation. An often
recommended strategy for anesthesiologists in the failed
airway to provide oxygenation is the needle cricoidotomy.
In the pediatric population, however, this may be more
challenging. Owing to the flexible and compressible
nature of the cricoid and trachea, it may be more likely to
pierce through‑and‑through the airway with the needle
and penetrate the esophagus. It has been suggested that
risk of complications to successful cannulation of the
airway with the needle cricothyroidotomy is too high
in children under age 5 or 6. [40] In light of this, there
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
is some suggestion that a direct surgical approach to
cricothyroidotomy is likely to be more successful.[40]
However, there are a number of anatomical differences
in the pediatric airway which complicate any potential
transcutaneous approach to the airway. First of all the
neonatal cricothyroid membrane is small, measuring
only 3 mm wide and 2.6 mm tall.[41] Second, in infants,
the hyoid bone by overlap the usually prominent thyroid
cartilage, thereby making identification of crucial
anatomy more difficult.[42] Some experts have, therefore,
suggested that in these youngest patients the preferred
approach may be direct puncture of the trachea below
the level of the cricoid.[42]
CONCLUSION
Airway management is a key skill for the anesthesiologist.
The airway of the pediatric patient has a number of
significant differences when compared to the adult
airway and presents some unique challenges. Awareness
of anatomical and physiological differences, important
pathological conditions affecting children, and a
knowledge of the available airway techniques and tools
will allow the anesthesiologist to formulate and execute
safe and effective management of the pediatric airway.
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Cite this article as: Harless J, Ramaiah R, Bhananker SM. Pediatric
airway management. Int J Crit Illn Inj Sci 2014;4:65-70.
Source of Support: Nil, Conflict of Interest: No.

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70 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014