The Pediatric Patient

Joshua Nagler

Nathan W. Mick

CASE 1

A 6-month-old is admitted to the intensive care unit (ICU) after being rescued from a house fire. He was awake, alert, and crying without stridor or wheezing at the time of arrival at the hospital. Initial vitals were stable without tachypnea or hypoxemia. On initial physical examination, no facial or other burns were identified. His diagnostic evaluation did not reveal any significant injuries; however, his carbon monoxide level was 8%. He is rapidly transported to the ICU on a nonrebreather mask at 10 L/min to address his elevated carboxyhemoglobin. Soon after arrival in the ICU he develops progressive stridor and increased work of breathing.

How would you proceed with his airway management?

INTRODUCTION

Airway management is fundamental to the management of critically ill and injured pediatric patients. Unique anatomic and physiologic differences compared to adults, age-related drug dosing, equipment sizing, and for many, a relative infrequency in performing pediatric resuscitation or procedures may all contribute to the challenge with pediatric airway management.

Despite age and size-related differences between adults and children, the general principles of airway management are largely aligned. The approach to basic and advanced airway procedures is similar whether the patient is 8 days, 8 years, or 80 years of age. Central tenants of clinical care such as choosing appropriate equipment, identifying potentially difficult airways, considering alternative strategies, optimizing techniques, and recognizing and managing a failed airway are all universally applicable. Differences in children, where they occur, are most notable in the first 2 years of life. These predictable age-related anatomic and physiologic differences can be anticipated and addressed in most pediatric patients. Cases of truly anatomically difficult airways in children usually occur secondary to known congenital abnormalities or result from identifiable acute insults that modify normal airway structures. Difficulty related to unpredictable anatomic abnormalities revealed only after unsuccessful attempts at airway management, resulting in a failed pediatric airway, is rare in children.

PREDICTABLE CHALLENGES IN PEDIATRIC AIRWAY MANAGEMENT

Anatomic Differences

There are several predictable anatomic features in infants and children that may make airway management more challenging.¹ Table 36.1 summarizes some of these differences as well as the clinical implications and strategies to address them. Congenital and acquired abnormalities that result in truly anatomic difficulty are reviewed in the section that follows. (See also

Videos 36.1 and 36.2.)

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Video 36.1. Lifting the Epiglottis

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Video 36.2. Engaging the Hyoepiglottic Ligament

TABLE 36.1 Predictable Anatomic Features of Pediatric Airways and Implications for Management

Anatomic Difference	Clinical Significance	Optimizing Strategy
Large occiput	Neck is naturally flexed in young children when supine, potentially obstructing airway and limiting laryngoscopic view	Appropriately position the patient (e.g., towel roll) Align tragus or external auditory canal with sternal notch
Relatively large tongue	Large tongue relative to the size of the oral cavity, may directly cause airway obstruction or affect laryngoscopic visualization	Place patient in sniffing position Utilize oral and nasal airways during bag-mask ventilation Appropriate displacement into submandibular vault during laryngoscopy
Larger tonsils and adenoids	Contributes to airway obstruction and increases risk of bleeding with placement of nasal airway or ETT through nasopharynx	Use of airway adjuncts to ensure airway patency Ensure appropriate size equipment Lubricate equipment prior to nasal placement Blind nasal intubation is unlikely to be successful
Superior airway	Larynx is located more cephalad in younger children (C1 vertebra in infants, C2-3 in children, and C4-5 in adolescents and adults), creating a more acute angle during laryngoscopic visualization	Look for glottic anatomy at the top of the visual field during laryngoscopy Perform ELM Consider use of video laryngoscopy
Larger floppy epiglottis	Relatively large, floppy epiglottitis may project over the airway	Utilize a straight blade to lift the epiglottis directly (see Video 36.1) Engage the hyoepiglottic ligament to raise the epiglottis off the glottic opening (see Video 36.2)
Elliptical-shaped subglottis	Although historically described as funnel-shaped, the subglottic airway in children has similar cross-sectional area, but may be elliptical rather than round, creating functional narrowing in a single axis	Historical references recommended use of uncuffed ETTs, however, now, cuffed tubes are favored provided consideration of cuff location and pressure is addressed
Narrow, short trachea	Narrow trachea makes children more susceptible to airway obstruction and shorter trachea increases risk of misplaced ETTs	Select appropriately sized ETT Utilize system to predict anticipated insertion depth Secure tube carefully to avoid displacement
Small cricothyroid membrane	Identifying anatomic landmark for surgical airway may be challenging and success rates are low	Utilize percutaneous needle approaches into the airway Surgical airway approaches are generally limited to children >8-10 y of age
ELM, external laryngeal manipulation; ETT, endotracheal tube.

Physiologic Differences

There are also a number of physiologic differences that impact airway management in children compared to adults. The most significant is the rapid oxyhemoglobin desaturation. Basal oxygen consumption in children is approximately twice that of adults. In addition, children have a proportionally smaller functional residual capacity (FRC) when normalized to body weight. As a result, children often desaturate more rapidly than adults. See Table 36.2. This is most pronounced

in neonates and infants. Therefore, efforts to optimize preoxygenation and use of apneic oxygenation are recommended. In addition, the clinician must anticipate and communicate the possibility of desaturation during airway management to the clinical staff and be prepared to address oxygenation using BMV if the patient’s oxygen saturation drops below a predetermined cut-off value. Pediatric patients requiring advanced airway management in the ICU frequently have underlying pathophysiology that poses further challenges during advanced airway management. When coupled with the effects of medications used for sedation and paralysis and subsequent positive pressure ventilation, there may be significant risk of hemodynamic compromise. Adequate hemodynamic resuscitation prior to advanced airway management should be performed whenever the clinical imperative does not mandate more immediate intervention.

TABLE 36.2 Physiologic Differences

Physiologic Difference	Significance
Basal O₂ consumption is twice adult values (>6 mL/kg/min); proportionally smaller FRC as compared with adults.	Shortened period of protection from hypoxia for equivalent preoxygenation time as compared with adults. Infants and small children often require bag-mask ventilation while maintaining cricoid pressure to avoid hypoxia.
FRC, functional residual capacity.
From Luten RC, Mick NW. Differentiating aspects of the pediatric airway. In: Brown CA III, ed. The Walls Manual of Emergency Airway Management. 6th ed. Wolters Kluwer; 2023:281-296. Box 25.1.

Cognitive Load in Pediatric Care

In children, equipment sizing, drug dosing, and procedural approaches vary by age, weight, and length of the patient. Using resuscitation aids when caring for critically ill pediatric patients significantly reduces the cognitive load (and error) related to drug dosing calculations and equipment selection.² Table 36.3 is a length-based, color-coded equipment reference chart, based on the “resuscitation guide” of the Broselow-Luten system, with other similar systems also available. Using such approaches during pediatric airway management can help eliminate error-prone strategies including mnemonics, or calculations based on age and weight. Both equipment and drug dosing information are included in the system and can be accessed by a single length measurement or patient weight. Length-based physical cognitive aids (e.g., Broselow Tape), institutional reference sheets or binders for use at the bedside, reference cards, phone/tablet-based apps, and online references are all systematic approaches that can be helpful in reducing cognitive burden and optimizing patient safety.

TABLE 36.3 A Cognitive Aid to Help With Pediatric Airway Equipment Selection

	Pink^a	Red	Purple	Yellow	White	Blue	Orange	Green
*Length (cm)-Based Pediatric Equipment Chart*
Weight (kg)	6-7	8-9	10-11	12-14	15-18	19-23	23-31	31-41
Length (cm)	60.75-67.75	67.75-75.25	75.25-85	85-98.25	98.25-110.75	110.75-122.5	122.5-137.5	137.5-155
ETT size (mm)	3.5 cuff 3.0 uncuff	3.5 cuff 3.0 uncuff	4.0 cuff 3.0 uncuff	4.5 cuff 4.0 uncuff	5.0 cuff 4.5 uncuff	5.5 cuff 5.0 uncuff	6.0 cuff	6.5 cuff
Lip-to-tip length (mm)	10-10.5	10.5-11	11-12	12.5-13.5	14-15	15.5-16.5	17-18	18.5-19.5
Laryngoscope size+blade	1 straight	1 straight	1 straight	2 straight	2 straight	2 straight or curved	2 straight or curved	3 straight or curved
Suction catheter	8 French	8 French	8 French	8-10 French	10 French	10 French	10 French	12 French
Stylet	6 French	6 French	10 French	10 French	10 French	10 French	14 French	14 French
Oral airway (mm)	50	50	60	60	60	70	80	80
Nasopharyngeal airway	14 French	14 French	18 French	20 French	22 French	24 French	26 French	30 French
Bag/valve device	Infant	Infant	Child	Child	Child	Child	Child/adult	Adult
Oxygen mask	Newborn	Newborn	Pediatric	Pediatric	Pediatric	Pediatric	Adult	Adult
Vascular access	22-24/23-25	22-24/23-25	20-22/23-25	18-22/21-23	18-22/21-23	18-20/21-23	18-20/21-22	16-20/18-21
Catheter/butterfly	Intraosseous	Intraosseous	Intraosseous	Intraosseous	Intraosseous	Intraosseous
Nasogastric tube	5-8 French	5-8 French	8-10 French	10 French	10-12 French	12-14 French	14-18 French	18 French
Urinary catheter	5-8 French	5-8 French	8-10 French	10 French	10-12 French	10-12 French	12 French	12 French
Chest tube	10-12 French	10-12 French	16-20 French	20-24 French	20-24 French	24-32 French	24-32 French	32-40 French
Blood pressure cuff	Newborn/infant	Newborn/infant	Infant/child	Child	Child	Child	Child/adult	Adult
LMA^b	1.5	1.5	2	2	2	2-2.5	2.5	3
Mask Size		Patient Size (kg)
1		≤5
1.5		5-10
2		10-20
2.5		20-30
3		>30
Directions for use: (1) Measure patient length with centimeter tape or with a Broselow tape; (2) Using measured length in centimeters or Broselow tape measurement, access appropriate equipment column; (3) Column for ETTs, oral and nasopharyngeal airways, and LMAs; always select one size smaller and one size larger than recommended size.
^aFor infants smaller than the pink zone, but not preterm, use the same equipment as the pink zone.
^bBased on manufacturer’s weight-based guidelines.
ETT, endotracheal tube; LMA, laryngeal mask airway.
Modified from Luten RC, Wears RL, Broselow J, et al. Managing the unique size related issues of pediatric resuscitation: reducing cognitive load with resuscitation aids. Acad Emerg Med. 1992;21:900-904.

EQUIPMENT AND MEDICATION SELECTION

Equipment Selection

Appropriately sized equipment for pediatric patients can be chosen using a systematic approach such as a length-based aid. See Table 36.3. Specifics regarding appropriate selection and use of airway equipment in children are further described below.

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