Airway management for

pediatric anesthesia
DIFFERENCES BETWEEN PEDIATRIC
AND ADULT AIRWAY MANAGEMENT
• Anatomic features of the airway in infants and young children,
including a relatively large tongue, prominent occiput, superior
laryngeal position, and large epiglottis
• A higher rate of oxygen consumption and relatively decreased
functional residual capacity while anesthetized lead to a shorter time
to oxygen desaturation
• Infants and young children may have a pronounced vagal response to
laryngoscopy, airwaysuctioning, and hypoxemia
• Infants and young children may have a pronounced vagal response to
laryngoscopy, airway suctioning, and hypoxemia
• Airway equipment in sizes appropriate for young children may be
ergonomically more difficult to use than devices designed for adult use
• Inhalation induction without an intravenous (IV) catheter in place is
routinely performed for pediatric patients. A plan for alternative
routes of drug administration must be in place for treatment of airway
emergencies such as laryngospasm
• The response to rapid decompensation related to airway
complications in small children
•  requires weight-based dosing and reliable administration of small
drug volumes
AIRWAY ASSESSMENT
 
• Airway history
• Craniofacial syndromes
• Airway examination

Other anatomic features that may predict difficult airway management in children :
micrognathia, mandibular hypoplasia, midface hypoplasia, macroglossia, cleft lip or palate,
cervical spine immobility or instability, facial asymmetry, microstomia, limited mouth
opening, masses involving the airway, and in older children, short thyromental distance
Acquired conditions can impact the airway and may be rapidly progressive.
infection, trauma, burns, tumors, surgical changes, radiation to the airway, and
anaphylaxis
DEVELOPING A PLAN FOR AIRWAY
MANAGEMENT
• Maintenance of oxygenation
• Minimize apneic time and intubate quickly
• Preoxygenate all patients as possible
• Maintain spontaneous ventilation if difficulty with airway management is anticipated
• Provide apneic oxygenation throughout airway management if difficult intubation is
anticipated

• Choice of airway device

• Face mask
• Supraglotis airway (SGA)
• Endotracheal Tube (ETT)
Supraglottic airway
SGAs do not definitively secure the airway
SGAs appear as rescue devices in multiple guidelines and algorithms for
management of the difficult airway

Endotracheal tube
ETT provides a secure, sealed airway.
ETTs for small children are available both with and without an inflatable
tracheal cuff
Cuffed versus uncuffed endotracheal tubes
• Uncuffed ETTs may need to be replaced for a different size
immediately after intubation more often than cuffed ETTs
• Cuffed ETTs are associated with a similar or lower risk of perioperative
laryngospasm and stridor than uncuffed ETTs
• Cuffed ETTs more effectively seal the trachea than uncuffed tubes
Choosing endotracheal tube size
The formula for choosing an uncuffed ETT is 4 + (age in years/4)
cuffed tubes is 3.5 + (age in years/4)
Children younger than six to eight months often require a 3.0, rather than 3.5,
cuffed ETT

• A tube that is too small will fail to make a seal with the tracheal wall,
compromising positive pressure ventilation
• A tube that is too large may restrict blood flow to the tracheal mucosa,
leading topostoperative edema and croup.
TECHNIQUES FOR AIRWAY
MANAGEMENT
Equipment preparation
• Suction devices must be available for any anesthetic, in patient appropriate sizes
• Airway equipment for mask ventilation should be available in the next size larger
and smaller than anticipated.
• Two functional laryngoscopes should be available with different blades
• An appropriately sized ETT, as well as one 0.5 mm smaller, should be available,
along with a pediatric ETT stylet
• A supraglottic airway (SGA) sized according to the manufacturer's
recommendations should always be available
• Emergency drugs for treatment of laryngospasm and bradycardia should be
immediately available
Preoxygenation
Adults and older children are routinely preoxygenated before induction
of anesthesia to increase oxygen reserve

Patient positioning for airway management

In infants, because of the prominent occiput, the support that is usually
placed under the occiput in older children is unnecessary, and a towel is
often placed under the shoulders to extend the neck and align the
pharyngeal and tracheal axes
Induction of anesthesia
Induction of anesthesia, including the choice of anesthetic agents, adjunctive medications, and
rapid sequence induction and intubation

Intubation techniques

Endotracheal tube depth

The optimal position for the tip of the ETT is midway between the vocal cords and carina
uncuffed ETT can be calculated by multiplying the internal diameter of the ETT (in mm) by
three
cuffed ETTs, the optimal depth can be calculated using the formula (3 X internal diameter in
mm + 1.5 cm)
EMERGENCE AND EXTUBATION
 
• Airway devices ( endotracheal tubes (ETTs) and supraglottic airways
(SGAs)) should only be removed when the patient is either deeply
anesthetized or fully awake
• risk for aspiration, risk for airway obstruction, reactive airway disease,
length of procedure, and desire to avoid coughing on emergence, may
influence the decision on timing of airway device removal.
SUMMARY AND RECOMMENDATIONS
 
• Airway anatomy, respiratory physiology, level of patient cooperation, and airway-related
complications are different in children than adults
• Preanesthesia evaluation should identify risk factors for difficulty with airway
management and risk factors for aspiration during anesthesia
• The primary goal for airway management is maintenance of oxygenation to avoid
airway- related morbidity.
• We usually place an endotracheal tube (ETT) rather than a supraglottic airway (SGA) for
longer procedures (>2 to 3 hours), for patients at high risk of aspiration, and for
procedures that require prolonged periods of muscle relaxation or abdominal or
intrathoracic gas insufflation
• SGAs may reduce the incidence of laryngospasm, bronchospasm, postoperative stridor
• in children, compared with ETTs
• Patients should be preoxygenated when possible prior to induction of
anesthesia
• Airway devices should only be removed when the patient is either
deeply anesthetized or fully awake in order to avoid laryngospasm
TERIMA KASIH