Securing an airway is a critical task for anesthesiologists.1 In order to provide safe and effective control of the airway, anesthesiologists must have knowledge of important anatomical, physiological, and pathological features related to the airway.1 Difficulties with pediatric airway management are not infrequent and present a major cause for cardiac arrest, death, and brain injury in children undergoing general anesthesia.2,4 Therefore, it is critical for anesthesiologists to recognize the key differences between the adult and pediatric airway so they can formulate the best strategy to overcome the challenges presented by the pediatric airway.
Compared with adults, pediatric patients have significant anatomical and physiological differences that impact the techniques and tools that anesthesiologists need to provide safe and effective control of the airway.1,3 These differences are most pronounced in children under 2 years of age.1,3 One example is that the head of the pediatric patient is larger relative to body size.1 Anesthesiologists should especially be aware of this fact when positioning the child prior to the induction of anesthesia to prevent airway obstruction.1 Additionally, pediatric patients have larger tongues and shorter mandibles than adults.1,3 These factors contribute to loss of upper airway space, which can lead to difficulty with mask ventilation and sometimes respiratory failure.1,3 A final example is that the larynx is higher in the neck in pediatric patients, which can make insertion of the endotracheal tube more challenging.1,3 Typically, by the age of 8, the airway is very similar to the adult airway.3
When attempting to manage the pediatric airway, anesthesiologists should proceed in a stepwise fashion. Prior to starting any procedure, anesthesiologists should perform a short evaluation and assess for clinical signs of acute airway obstruction.4 Next, a clear plan should be created that acknowledges all possible complications that may arise.5 This is important because a child with a compromised airway will immediately become hypoxemic if issues occur.4,5 Once in the operating room, anesthesiologists should first ensure that the child is properly positioned and suctioned.3 The child’s head should be placed in a midline sniffing position with the neck extended and the chin lifted.3 This can be accomplished by placing a folded towel underneath the neck to achieve a neutral position of the neck and open up the airway.1,3 If the pediatric patient is an infant, the nose should be suctioned to prevent severe respiratory distress.3
Next, anesthesiologists should properly perform mask ventilation, a critical step in pediatric airway management.1 Face mask ventilation helps to relieve obstructions that may be caused by posterior displacement of the tongue in the anesthetized child.1 When ready to facilitate tracheal intubation, anesthesiologists typically perform direct laryngoscopy.1 Forced tracheal intubation must be avoided in order to avoid trauma to the airway.3 For this reason, it is becoming increasingly common to use cuffed endotracheal tubes in infants and young children to minimize resistance of the endotracheal tube and protect the sensitive airway.1 The difficulty of pediatric airway management is usually the result of inadequate mask ventilation or unsuccessful tracheal intubation.1 If an anesthesiologist is unable to secure an airway, it is recommended that they perform a needle cricothyrotomy.1 However, anesthesiologists should exercise caution when performing this procedure because the pediatric cricoid and trachea are soft, making it more likely to completely pierce through the airway and penetrate the esophagus.1
The airway of the pediatric patient differs significantly from that of adult patients, which presents unique challenges for anesthesiologists.1,3 Thorough preoperative assessment, awareness of key differences between the pediatric and adult patient, and regular practice in basic pediatric airway management are necessary to reduce the incidence of pediatric airway mismanagement.2
References
- Bhananker, S., Harless, J., and Ramaiah, R. 2014. “Pediatric Airway Management”. International Journal of Critical Illness and Injury Science 4 (1): 65. doi:10.4103/2229-5151.128015.
- Weiss, M., and Engelhardt, T. 2010. “Proposal for The Management of The Unexpected Difficult Pediatric Airway”. Pediatric Anesthesia 20 (5): 454-464. doi:10.1111/j.1460-9592.2010.03284.x.
- Santillanes, G., and Gausche-Hill, M. 2008. “Pediatric Airway Management”. Emergency Medicine Clinics of North America 26 (4): 961-975. doi:10.1016/j.emc.2008.08.004.
- Hsu, G., and Fiadjoe, J. E. 2020. “The Pediatric Difficult Airway”. Anesthesiology Clinics. doi:10.1016/j.anclin.2020.05.001.
- Engelhardt, T., Machotta, A., and Weiss, M. 2013. “Management Strategies for The Difficult Paediatric Airway”. Trends in Anaesthesia And Critical Care 3 (4): 183-187. doi:10.1016/j.tacc.2013.05.007.
