Emergency airway management in children: Unique pediatric considerations

Author:
Joshua Nagler, MD
Section Editor:
Anne M Stack, MD
Deputy Editor:
James F Wiley, II, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Oct 2016. | This topic last updated: Jun 06, 2016.

INTRODUCTION — 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 "Emergency 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 [1-3].
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 [4,5].

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 [6]. 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) [7,8]. 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). Infants and young children with laryngomalacia may have an omega-shaped epiglottis
that can lead to positional, inspiratory stridor and can give the appearance of a thickened
epiglottis on lateral airway radiographs [9].  

Shorter trachea — The trachea increases in length with age, from approximately 5 cm in

neonates to 12 cm in adults [10,11]. 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 [12]. 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 [13].

Narrow trachea — In addition to being shorter, the trachea in younger children is also narrow
[10,11]. 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 [14]. (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 [15]. 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 [16,17].

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 [18]. 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 "Emergency 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 [19]. 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 [20]. 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 [21]; however, others have shown infants can breathe
through their mouths spontaneously or following nasal airflow obstruction [22,23]. For the
majority of infants who are nasal breathers, the nares account for nearly half the total airway
resistance [24]. 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 [25,26]. Therefore, young children have little intrapulmonary oxygen stores to
utilize during hypoventilatory or apneic periods. Apneic infants and toddlers, in particular, have a
more precipitous decline in oxygen saturation, for example, when they undergo rapid sequence
intubation [27,28]. 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) [29,30]. 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 [27].

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 [29]. 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 [30-33]. 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) [33]. 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 [34]. For non-anesthesia trainees, success also increased with
experience, with a predicted 90 percent rate of "good" intubations achieved after 47 prior
attempts [35].

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 [36], while studies based in adult facilities
demonstrate 6 to 10 intubations per 1000 patients per year [37,38]. 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 [39].

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 [40-47]. 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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REFERENCES
1. Todres ID. Pediatric airway control and ventilation. Ann Emerg Med 1993; 22:440.
2. Goetting MG. Mastering pediatric cardiopulmonary resuscitation. Pediatr Clin North Am
1994; 41:1147.
3. RUBEN HM, ELAM JO, RUBEN AM, GREENE DG. Investigation of upper airway
problems in resuscitation. 1. Studies of pharyngeal x-rays and performance by laymen.
Anesthesiology 1961; 22:271.
4. Don GW, Kirjavainen T, Broome C, et al. Site and mechanics of spontaneous, sleep-
associated obstructive apnea in infants. J Appl Physiol (1985) 2000; 89:2453.
5. Eastwood PR, Szollosi I, Platt PR, Hillman DR. Collapsibility of the upper airway during
anesthesia with isoflurane. Anesthesiology 2002; 97:786.
6. Arens R, McDonough JM, Costarino AT, et al. Magnetic resonance imaging of the upper
airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med
2001; 164:698.
7. Westhorpe RN. The position of the larynx in children and its relationship to the ease of
intubation. Anaesth Intensive Care 1987; 15:384.
8. Schwartz DS, Keller MS. Maturational descent of the epiglottis. Arch Otolaryngol Head
Neck Surg 1997; 123:627.
9. John SD, Swischuk LE. Stridor and upper airway obstruction in infants and children.
Radiographics 1992; 12:625.
10. Fearon B, Whalen JS. Tracheal dimensions in the living infant (preliminary report). Ann
Otol Rhinol Laryngol 1967; 76:965.
11. Griscom NT, Wohl ME. Dimensions of the growing trachea related to age and gender.
AJR Am J Roentgenol 1986; 146:233.
12. Miller KA, Kimia A, Monuteaux MC, Nagler J. Factors Associated with Misplaced
Endotracheal Tubes During Intubation in Pediatric Patients. J Emerg Med 2016; 51:9.
13. Weiss M, Knirsch W, Kretschmar O, et al. Tracheal tube-tip displacement in children
during head-neck movement--a radiological assessment. Br J Anaesth 2006; 96:486.
14. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support
(ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
15. ECKENHOFF JE. Some anatomic considerations of the infant larynx influencing
endotracheal anesthesia. Anesthesiology 1951; 12:401.
16. Litman RS, Weissend EE, Shibata D, Westesson PL. Developmental changes of
laryngeal dimensions in unparalyzed, sedated children. Anesthesiology 2003; 98:41.
17. Dalal PG, Murray D, Messner AH, et al. Pediatric laryngeal dimensions: an age-based
analysis. Anesth Analg 2009; 108:1475.
18. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life
support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation 2010; 122:S876.
19. Papastamelos C, Panitch HB, England SE, Allen JL. Developmental changes in chest
wall compliance in infancy and early childhood. J Appl Physiol (1985) 1995; 78:179.
20. Kelly DH, Stellwagen LM, Kaitz E, Shannon DC. Apnea and periodic breathing in normal
full-term infants during the first twelve months. Pediatr Pulmonol 1985; 1:215.
21. Swift PG, Emery JL. Clinical observations on response to nasal occlusion in infancy.
Arch Dis Child 1973; 48:947.
22. Miller MJ, Martin RJ, Carlo WA, et al. Oral breathing in newborn infants. J Pediatr 1985;
107:465.
23. Rodenstein DO, Perlmutter N, Stănescu DC. Infants are not obligatory nasal breathers.
Am Rev Respir Dis 1985; 131:343.
24. Stocks J, Godfrey S. Nasal resistance during infancy. Respir Physiol 1978; 34:233.
25. Gerhardt T, Reifenberg L, Hehre D, et al. Functional residual capacity in normal
neonates and children up to 5 years of age determined by a N2 washout method. Pediatr Res
1986; 20:668.
26. Stocks J, Quanjer PH. Reference values for residual volume, functional residual capacity
and total lung capacity. ATS Workshop on Lung Volume Measurements. Official Statement of
The European Respiratory Society. Eur Respir J 1995; 8:492.
27. Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and the onset of desaturation in
apnoeic children. Can J Anaesth 1994; 41:771.
28. Rinderknecht AS, Mittiga MR, Meinzen-Derr J, et al. Factors associated with
oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency
department: findings from multivariable analyses of video review data. Acad Emerg Med 2015;
22:431.
29. Keens TG, Bryan AC, Levison H, Ianuzzo CD. Developmental pattern of muscle fiber
types in human ventilatory muscles. J Appl Physiol Respir Environ Exerc Physiol 1978; 44:909.
30. Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian
emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal
intubation attempts. Ann Emerg Med 2005; 46:328.
31. Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric
emergency airway management. Pediatr Emerg Care 2002; 18:417.
32. Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J
Pediatr 2005; 146:638.
33. Kerrey BT, Rinderknecht AS, Geis GL, et al. Rapid sequence intubation for pediatric
emergency patients: higher frequency of failed attempts and adverse effects found by video
review. Ann Emerg Med 2012; 60:251.
34. Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in
anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth
Analg 1998; 86:635.
35. Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic intubation: learning and
performance. Anesthesiology 2003; 98:23.
36. Losek JD, Olson LR, Dobson JV, Glaeser PW. Tracheal intubation practice and
maintaining skill competency: survey of pediatric emergency department medical directors.
Pediatr Emerg Care 2008; 24:294.
37. Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in
patients intubated in the emergency department. Ann Emerg Med 2004; 44:307.
38. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the
emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998;
31:325.
39. Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management
simulation training in medical education: a systematic review and meta-analysis. Crit Care Med
2014; 42:169.
40. Chen L, Hsiao AL. Randomized trial of endotracheal tube versus laryngeal mask airway
in simulated prehospital pediatric arrest. Pediatrics 2008; 122:e294.
41. Davis DP, Valentine C, Ochs M, et al. The Combitube as a salvage airway device for
paramedic rapid sequence intubation. Ann Emerg Med 2003; 42:697.
42. Guyette FX, Roth KR, LaCovey DC, Rittenberger JC. Feasibility of laryngeal mask
airway use by prehospital personnel in simulated pediatric respiratory arrest. Prehosp Emerg
Care 2007; 11:245.
43. Kette F, Reffo I, Giordani G, et al. The use of laryngeal tube by nurses in out-of-hospital
emergencies: preliminary experience. Resuscitation 2005; 66:21.
44. Kurola J, Pere P, Niemi-Murola L, et al. Comparison of airway management with the
intubating laryngeal mask, laryngeal tube and CobraPLA by paramedical students in
anaesthetized patients. Acta Anaesthesiol Scand 2006; 50:40.
45. Kurola JO, Turunen MJ, Laakso JP, et al. A comparison of the laryngeal tube and bag-
valve mask ventilation by emergency medical technicians: a feasibility study in anesthetized
patients. Anesth Analg 2005; 101:1477.
46. Russi CS, Miller L, Hartley MJ. A comparison of the King-LT to endotracheal intubation
and Combitube in a simulated difficult airway. Prehosp Emerg Care 2008; 12:35.
47. Russi CS, Wilcox CL, House HR. The laryngeal tube device: a simple and timely adjunct
to airway management. Am J Emerg Med 2007; 25:263.