PICU Q+A: Paediatric Airway

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Cite this article as:
Short, K. PICU Q+A: Paediatric Airway, Don't Forget the Bubbles, 2013. Available at:
https://dontforgetthebubbles.com/picu-qa-paediatric-airway/

PICU Q+A: List the ways in which the paediatric airway differs from the adult airway.  Outline how these influence your management.

Anatomical and physiological differences between the paediatric and adult airway can lead to problems with intubation.

The more severe airway difficulties are usually associated with specific conditions:

  • Craniofacial: Pierre Robin; Treacher Collins; Goldenhar; Crouzon syndrome
  • Lysosomal enzyme defects: mucopolysaccharidoses
  • Congential swellings: cystic hygroma; haemangioma
  • Temperomandibular joint problems: Still’s disease; Cockayne-Touraine syndrome
  • Acquired pathology: thermal injury; abscesses; tumour; post-radiation injury

 

What is the difference between adult and paediatric airways?

The paediatric airway is smaller...

Greater risk of airway obstruction from small foreign bodies.

Loose deciduous teeth can dislodge into the airway.

Small amounts of swelling will result in a relatively greater reduction in airway diameter than would occur in the larger airway of the adult.

Infants are nose breathers...

In the first 4-6 months of age infants breathe exclusively through the nose and therefore have a lower threshold.

Can experience respiratory distress if the nose is blocked.

Consider flexible suction to the nares. 

They have a relatively larger tongue and smaller oral cavity...

The tongue is more likely to obstruct the airway than in the adult.

This makes it essential that there is correct positioning of the head/jaw to open the airway. 

They have a relatively larger occiput...

The large occiput of the infant flexes the head forward when child placed prone on flat surface.

Important in airway-opening manoeuvres.

May require pad under the torso of the infant to achieve neutral position:

  • But avoid hyperextension of the neck as this can result in airway obstruction, tracheal extubation.

Their trachea is more cartilaginous and soft...

More subject to collapse and obstruction than the adult airway if the child is not positioned appropriately.

The tonsils in toddlers and young children may be enlarged, contributing to airway obstruction and making nasal passage of an endotracheal tube difficult. 

Their larynx is higher and more anterior...

At level of C2/3 compared with C6/7 in the adult.

Visualisation more difficult than in the adult.

Horseshoe-shaped in a young child and projects posteriorly at 45 degrees.

Use a straight blade if <1 year old. 

The cricoid ring is the narrowest point in the airway...

Unable to view the tube pass through the narrowest section of the airway as in adults.

This influences ETT choice:

  • Cuffed ETT sits at the level of the cricoid ring taking up valuable airway diameter
  • Local pressure from cuff can cause oedema of susceptible epithelium
  • Traditionally use uncuffed ETTs in <8 years old but dependant on clinical situation

The trachea is short...

There is increased risk of dislodgement of the ETT and mainstem intubation especially in neck flexion.

Nasal tubes can provide more security, especially during interhospital transfers. 

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Kirsty is an advanced trainee in emergency medicine, another UK ex-pat on the team and unsuspecting local celebrity through her appearances on 'Kings Cross ER'. Currently studying for her ACEM fellowship exam, she appreciates the importance of online resources such as DFTB.

Author: Kirsty Short Kirsty is an advanced trainee in emergency medicine, another UK ex-pat on the team and unsuspecting local celebrity through her appearances on 'Kings Cross ER'. Currently studying for her ACEM fellowship exam, she appreciates the importance of online resources such as DFTB.