There are significant physiologic, anatomic, and equipment differences between
children and adults that must be considered when planning the approach
to the emergent pediatric airway. The presentation of a critically
ill child requiring intubation is relatively uncommon compared to adults.
This chapter presents the physiologic and anatomic characteristics
of the pediatric airway, strategies for effective airway management, and
organization methods for equipment to minimize errors in equipment
sizing and medication dose calculation.1
Due to a higher metabolic rate, oxygen consumption is increased
in children, especially in infants. Infants and children have an
increased relative cardiac output and minute ventilation to match
the increased metabolic demand. However, children are vulnerable
to rapid desaturation when oxygenation or ventilation is reduced.
Children have relatively small volume lungs with small functional
residual capacities. This translates into a reduced oxygen reservoir,
which decreases the effectiveness of preoxygenation and makes optimal
preoxygenation more difficult. Therefore, be prepared to support
oxygenation with bag-mask ventilation, often before an intubation
attempt, while awaiting the onset of induction and paralysis. Attempts
at intubation may need to stop once oxygen saturation drops below
90% to allow for bag-mask ventilation before the next attempt.
Below an oxygen saturation of 90%, desaturation is particularly rapid.2 The
vast majority of children are easily bag ventilated when the proper
technique is used, even when partial obstruction is present. The key
is anticipation and early use of good bag-mask ventilation.
Children have a proportionally larger extracellular fluid compartment than
adults. This results in a quicker onset and shorter duration of
action of drugs, and may require higher doses per kilogram for many
of the drugs used to facilitate rapid-sequence intubation (RSI).
Children can develop gastric distention from air swallowing during
distress as well as insufflation during bag-mask ventilation. Gastric
distention can further compromise functional residual capacity,
tidal volume, and ventilation. Early placement of an orogastric
or nasogastric tube may remedy this. Gastric tubes have also been
recommended to minimize the risk of reflux from an incompetent gastroesophageal
junction, but the incidence of aspiration in children appears to
be quite low, even in emergent intubation.
There are a number of anatomic characteristics of children that
must be appreciated to optimize the success of endotracheal intubation
(Table 29-1). Most of the unique anatomic
characteristics are present in the first few years of life. From
2 to 8 years of age there is a transition to a smaller but similarly
proportioned anatomy compared to adults. Most children do not have
the many acquired anatomic challenges present in older adults, and
the differences in children are predictable. With good technique
and anticipation of these differences, the majority of pediatric
airways are successfully managed.
29-1 Anatomic Considerations in the Pediatric Airway |Favorite Table|Download (.pdf)
29-1 Anatomic Considerations in the Pediatric Airway
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