Pediatric Airway Management and Respiratory Care
Anatomic differences that drive technique
The pediatric airway is not a small adult airway. The head is large, the neck short, the tongue large, the larynx cephalad (C1 in neonates to C3–C4 in older children), the epiglottis long and floppy, and the narrowest point is the cricoid ring in young children (versus the glottis in adults). The airway is prone to obstruction during induction and to edema because of small caliber.
Practical points
- Equipment sizing: age-based formulas for ETT internal diameter (e.g., uncuffed ≈ age/4 + 4; cuffed ≈ age/4 + 3.5); confirm with capnography and auscultation.
- Difficult airway: anticipate with craniofacial anomalies, syndromes, and prior airway surgery; have a plan for supraglottic rescue and surgical airway.
- Laryngospasm: recognize by stridor, paradoxical chest movement, and desaturation; treat with 100% oxygen, jaw thrust, deepening anesthesia, and low-dose propofol or succinylcholine if needed.
- Postextubation croup: stridor after extubation; treat with humidified oxygen, nebulized epinephrine, and dexamethasone.
- Respiratory physiology: infants have high oxygen consumption and low FRC, so desaturation is rapid; preoxygenation and apneic oxygenation matter.
Traps
A common trap is choosing an ETT size by adult intuition or ignoring the cricoid as the narrowest point. Another is treating laryngospasm with positive pressure alone without deepening anesthesia or removing the stimulus.
Rule of thumb
When desaturation occurs in a child, first ensure the airway is open, then confirm ventilation, then consider laryngospasm - and remember that the infant's oxygen reserve is small.
Worked example
A 4-year-old (16 kg) for tonsillectomy. Uncuffed ETT ≈ 4/4 + 4 = 5.0 mm; cuffed ≈ 4.5 mm. Preoxygenate, place a supraglottic airway or ETT, and plan dexamethasone and deep extubation to minimize laryngospasm and postextubation croup.