2. ▪Significant anatomic, physiologic & equipment
differences between paediatrics & adults
▪80% of paediatrics cardiopulmonary arrest are
primarily due to respiratory distress
Introduction
4. Large head & occiput
Large tongue
Superior larynx & anterior cords
Cricoid narrowing
Large adenoids & tonsils
Small cricoid cartilage
Large stomach, low gastroesophageal sphincter
tone, relatively small lungs
Anatomical Differences of
Paediatric Airway
5. ANATOMY POTENTIAL
IMPLICATIONS
AIRWAY MANEUVERS
Large head &
occiput
May push head forward,
occluding airway;
propensity for the
posterior pharynx to
buckle anteriorly as a
result of passive flexion
Avoid passive flexion;
Shoulder roll may be
required to align airway
axes
Large tongue May occlude upper airway
in obtunded or paralyzed
patient; visualisation of
larynx difficult
Jaw thrust, oral or
nasopharyngeal airway,
Miller (straight)
laryngoscope blade
Larynx and
vocal cords
more
cephaled and
anterior,
floppy
May make visualization of
cords difficult
Shoulder roll may be
required to align airway
axes, straight
laryngoscope blade to lift
epiglottis
6.
7. ANATOMY POTENTIAL IMPLICATIONS AIRWAY MANEUVERS
Cricoid narrowing Subglottic space is the
narrowest portion of the
pediatric airway, prone to
inflammation & upper airway
obstruction
Monitor cuff insufflation
pressures in small children
Large adenoids &
tonsils
May cause upper airway
obstruction; may bleed with
nasal intubation
Avoid blind nasal intubation
in young children; practice
of inserting the
oropharyngeal airway
backwards and rotating 180
degree not recommended
Funnel shaped
larynx
Secretions accumulate in
retropharyngeal area;
ETT might be able to pass
through the glottic opening and
tight below it
Do not force ETT if
encounter tightness; suction
ready
9. ANATOMY POTENTIAL IMPLICATIONS AIRWAY MANEUVERS
Small cricoid
cartilage
Makes open cricothyrotomy
technically difficult
Needle cricothyrotomy
preferred in young children
Short trachea
(infant 5cm to 7cm
at 18 months)
Intubation into the right
mainstem bronchus,
inadequate ventilation,
accidental tube dislodgment,
mechanical or barotrauma
Check for depth of ETT;
(approximately 3 times
appropriate size tube); secure
airway well, check breath
sounds periodically
Large stomach,
low
gastroesophageal
sphincter tone,
relatively small
lungs
Insufflation of stomach with
bag-valve mask ventilation or
swallowed air can compromise
respiratory status; children are
prone to vomiting
Consider early placement of
oro-/nasogastric tube to deflate
stomach when using positive
pressure ventilation or in the
obtunded patient
10. ▪The narrow trachea combined with redundant,
mobile periglottic tissues, predisposes the young
child to airway obstruction
▪Use of straight blade is helpful in the presence of a
large tongue & redundant soft tissues
▪The narrowest point of the child’s trachea is the
cricoid ring
Anatomical Differences of
Paediatric Airway
11. ▪Equipment:
✓Principal challenge is selecting the appropriate
size equipment
▪All EDs should have airway equipment:
✓Stocked (restocking must also be reliable, all
sizes available when needed)
✓Organized by age or size
✓Easily accessible
Paediatric Airway Management
12. Broselow tape:
a system that uses length-based estimates of equipment & medications,
organized by colour
Paediatric Airway Management
14. Preparation for Intubation
▪Rapid sequence induction:
✓Preoxygenation
✓Prepare appropriately sized equipment & ensure they
are functioning
▪Assess airway difficulty – prepare rescue devices
▪Reliable IV / IO access – fluid bolus 20cc / kg NS
beneficial before RSI – patient dehydrated usually in
respiratory failure / insensible fluid loss / PPV affects
preload
Approach to Airway
Management
15. Oropharyngeal airway Nasopharyngeal airway
Unconscious patient with no
Gag reflex
Can be use in semiconscious
patient
Not in patient with suspected
basal skull fracture
Approach to Airway
Management
16. Oropharyngeal airway in
place in the mouth
Nasopharyngeal airway in
place in the nose
Oropharyngeal/ Nasopharyngeal Airway
in correct position
17. ▪ principal rescue technique before intubation / if
intubation fails
▪ good technique is important
▪ match the rate & volume appropriate for age
▪ obtain mask-seal with “E-C clamp” or “C-grip”
Bag Mask Ventilation
20. •
•
Choose the appropriate size
Recommended size guidelines:
< 5 kg
–
–
–
–
–
–
–
Size 1:
Size 1.5:
Size 2:
Size 2.5:
Size 3:
Size 4:
Size 5:
5 -
10
20
30
50
10 kg
-
-
-
20
30
50
kg
kg
kg
– 70 kg
>70 kg
Laryngeal Mask Airway
21. ▪Straight blades (Miller) are preferred in young
children because:
✓the large epiglottis can be lifted directly
✓the large tongue is more easily displaced to provide
direct visualization
▪Proper blade length: from the tip to the handle
joint – tip of incisors to within 1 cm proximal or
distal of the angle of mandible
Laryngoscope Blade
22. Size of ETT: Internal Diameter (ID)
▪ Newborns
▪< 1kg: 2.5 mm
▪1-2 kg: 3.0 mm
▪2-3 kg: 3.5 mm
▪> 3kg : 3.5 to 4.0 mm
▪ Infant under 6 months: 3.5 - 4.0 mm
▪ Infant under 1 year: 4.0 - 4.5 mm
▪ Child under 2 years: 4.5 - 5.0 mm
▪ Child over 2 years: (Age in years)/4 + 4mm
Endotracheal Tube
23. 2. Distance or Depth of Insertion (from distal tube tip to lip)
▪ Estimate: ETT size x 3
▪ Newborns ('Tip to Lip' distance = 6 + Weight in Kg)
▪ Infant under 6 months: 10 cm
▪ Infant under 1 year: 11 cm
▪ Child under 2 years: 12 cm
▪ Child over 2 years: (Age in years)/2 + 12 cm
3. Suction catheter to fit within ET Tube
▪ ET Tube 2.5 mm: Use 5 or 6 French Catheter
▪ ET Tube 3.0 mm: Use 6 or 8 French Catheter
▪ ET Tube 3.5 mm: Use 8 French Catheter
▪ ET Tube 4.0 mm: Use 8 or 10 French Catheter
Endotracheal Tube
24. Mnemonic for preparation
▪ ETT x 1 = (Age/4) + 4 cm (for > 2 years old)
▪ ETT x 2 = Nasogastric Tube, Orogastric Tube or Foley
Catheter tube size
▪ ETT x 3 = Endotracheal Tube depth of insertion
▪ ETT x 4 = Chest Tube size (maximum)
Endotracheal Tube
25. ▪ Colour of the patient – pink
▪ Visible equal chest rise
▪ Vapour in ETT
▪ 5 points auscultation
▪ Capnography/ ETCO2
Confirmation of Placement
26. ▪Paediatric patients are not a small adults
▪The differences in anatomy has to be considered
when managing the airway of paediatric patients
Conclusion
