This document discusses best practices for pediatric airway management. It begins by outlining differences between pediatric and adult airways that make intubation more challenging in children, such as a prominent occiput, cephalad larynx, large tongue, and elliptical larynx. Predictors of difficult pediatric intubation are identified as age under 1, congenital anomalies, low BMI, and history of difficult intubation. The document then reviews optimal pre-oxygenation, induction agents like ketamine and etomidate, paralytics like rocuronium, and equipment like microcuffed tubes and video laryngoscopy that can facilitate intubation. Common pitfalls like inadequate sedation and aggressive bag-mask ventilation are

1. Pediatric Airway
Management:
Leave the
Cowboy Hat
Behind
Maria J. Mandt, MD
Associate Professor of Pediatrics
Medical Director of EMS
Medical Director Flight For Life, Children’s
Hospital Colorado Team

2. I have no relevant financial
disclosures
Quality is not an act. It is a habit.
- Aristotle

3. • Discuss the clinically relevant differences
between the pediatric and adult airways
• Identify predictors of a difficult pediatric
airway
• Formulate a plan in the event of an
unanticipated difficult pediatric
intubation
Time to Talk Objectives, Cowboy
Photo credit: www.theredlist.com

4. Low incidence, high risk. . .
CCT intubation statistics:
• 1.3% of trips involve peds/neo intubation
• Difficult airway predictors present in 77%
• Neonatal 1st-pass success rate: 59.3%
• Neonatal 1st-pass success without hypoxia or hypotension:
30.8%
• Pediatric 1st-pass success rate: 81.7%
• Pediatric 1st-pass success rate without hypoxia or
hypotension: 60.7%
What should we take away from these numbers?
Burns BJ et al. Ann Emerg Med 2017; Reichert, RJ
et al. Prehosp Emerg Care 2018

5. Scared now? You Need a Plan
Photo credit:
https://www.youtube.com/watch?v=DwzCrhth090

6. If you climb in the saddle, be ready
for a ride. . . .
Learn the 7 Ps of
Preparation:
Prior Proper Planning
Prevents Piss Poor
Performance
Photo credit: www.coburgbanks.co.uk

7. Oh, baby. . . Let
me count the
ways
Critical differences
between the big and
the small

8. Prominent occiput
Management:
• Shoulder roll for all < 8
years of age
Implication:
• Neck flexion causes UAO
• O/P/L axes not aligned,
making laryngoscopy
difficult
Photo credit: JEMS.com,

9. Cephalad Larynx
Implication:
• Shorter distance between
tongue and epiglottis
creates acute angle
• Larynx seems more
anterior
Management:
• Optimal positioning
• Gentle cricoid
Photo credit: www.youtube.com/watch?v=EIty86wXmB8

10. Epiglottis angled over vocal cords
Implication:
More difficult to lift epiglottis and
visualize VC
ETT can get caught on anterior
commissure of VC
Management:
• Gentle cricoid
• Straight blade in
children under 3
Pediatric
Adult

11. Significant soft tissue and large
tongue
Management:
• OPA
• Lateral approach
to laryngoscopy
Implication:
• Increased risk of
obstruction
• Difficult direct
visualization

12. Shape of larynx
Management:
• Critical to have
multiple sizes of
ETT
Implication:
• Elliptical shape of
cricoid ring
• ETT may seem
“stuck” just
beyond cords
Harless, J et al. Int J Crit Illn Inj Sci 2014Photo credit: In Coté CJ, Ryan JF, Todres ID, et al [eds]: A
Practice of Anesthesia for Infants and Children.

13. Physiologic Immaturity
Management:
• Expect rapid desaturation during
apnea
• Early O2, preoxygenation
• Light sedation just prior to
induction can be beneficial
Implication:
• Higher O2 consumption
• Smaller tidal volumes
• Lower FRC
• Higher RR

14. Predicting difficulty in the
pediatric airway
Incidence of laryngoscopy difficulty in children:
0.1% to 3.5%
• Age < 1 year
• Cardiac anomaly
• Congenital ear malformations
• Cleft palate
• Low BMI
• + usuals
Harless, J et al. Int J Crit Illn Inj Sci 2014

15. Looks Like
Your Throat
Could Use
Some Plastic:
Preparing for intubation

16. Considerations Before the
Drugs
• Pre-oxygenation
• Consider nasal cannula for apneic
oxygenation: Low-flow O2 (2-5LPM)
• Consider delayed sequence intubation (DSI)
• Highly anxious children
• Craniofacial abnormalities
• How’s your BMV?

17. Don’t Be This Guy . . . Creating an Upper
Airway Obstruction

18. First Learn Stand. Then Learn Fly
• Mental Miyagi Mantra:
“Lift the mask to the
face, Daniel-San”
• 2-person whenever
possible
• Modify the C-E to a “V
clamp”

19. Considerations Before the Drugs
• Fill the tank
• Head up 20 degrees
• Have the (ever growing)
equipment smorgesboard
available
Weingart SD et al. Ann Emerg Med 2012

20. Choose Your Weapons!
Growing number of advanced airway options:
• Microcuffed endotracheal tubes
• Supraglottic devices
• Bougie
• Videolaryngoscopy

21. Cuffed Endotracheal Tubes
Use a cuffed tube whenever possible:
• Uncuffed tube usage leads to excessive tube
exchange rates approaching 30%
• Difficult to predict the correct size with uncuffed
tubes
• No increased adverse event rate with cuffed tubes
• New micro-cuffed tubes have changed the landscape
Crankshaw D, et al. Pediatr Anesth Crit Care J 2014

22. Microcuff Endotracheal Tubes
• High volume, low pressure: average
11cm H2O
• Short cuff length when inflated and
expands below the sub-glottis
• No change in capnogram
Rameshwar M, et al. Indian J Anaesth 2015
Tube size: Age in years + 3
4
Photo credit:www.richardsmedical.com

23. Beyond the DL
Have a supraglottic available for
the difficult airway
• 1st choice in 23% of children
with known difficult airway
• High first-pass success and skill
retention rates
• Short insertion times
Jagannathan N, et al. Br J Anaesth 2014;
Hughes C, et al. Pediatr Anaesth 2012
Photo credit:www.remotemedical.com

24. Beyond the DL
Bougie is an option, but:
• Tracheal rings can be harder to feel
• Smallest Bougie is 10F, fits over
3.5mm tube
• Need 2 people
Photo credit:www.bay-medical.com

25. VL in Pediatrics
• Improves laryngoscopic
view in the anticipated
difficult airway
• Faster time to successful
ETI in difficult or after
failed ETI
• Higher first-pass success in
those with little intubating
experience
Pros: Not So Pros:
De. Jong A, et al. Int Care Med 2014; Abdelgadir IS, et al.
Cochrane Data Syst Rev 2017; Sun Y et al. Paediatr Anaesth
2014
• Same hypoxia, hypotension and
airway trauma rates as with DL
• In the typical airway, no
difference in 1st-pass success
between VL and DL
• Time to intubation prolonged
with VL
• Increased rate of intubation
failure

26. Cocktails Preferred by Children
• Atropine
• Ketamine
• Etomidate
• Rocuronium vs succinylcholine

27. Atropine
Consider for :
• < 1year of age
• Septic shock or hypovolemic shock
• Patients < 5 years of age receiving succinylcholine or
any child receiving a second dose of succinylcholine
Who will grumble:
• Neurosurgeons - pupils will be dilated
• Respiratory therapists - prevents bradycardic
response to hypoxemia
Jones P, et al. Ped Crit Care Med 2013; Jones P,
et al. Arch Dis Child 2012

28. Ketamine
Arguably, the ultimate RSI sedative:
• Rapid onset: 30 seconds IV
• Brief duration: 10-15 minutes IV
• Fantastic safety profile
• Neuroprotective role now shown in children
• Respiratory depression and laryngospasm are
rare and manageable
Bar-Joseph G, et al. J Neurosurg Pediatr 2009; Green
SM et al. Ann Emerg Med 2011

29. Ketamine
The old contraindications have been
proven false:
• Neuroprotective role now shown in
children
• No clinically significant rise in IOP
• Respiratory depression and
laryngospasm are rare and
manageable
Bar-Joseph G, et al. J Neurosurg Pediatr 2009; Green
SM et al. Ann Emerg Med 2011
No longer brings the
“you horrible person”
face

30. Etomidate
• Reliably maintains hemodynamics and decreases ICP while
maintaining CPP
• Dose 0.3-0.5mg/kg IV for induction
• Not recommended for sepsis, but significant debate remains:
• Single dose doesn’t change 24-hour cortisol levels (or it
does)
• Decrease in vasopressor therapy requirement when
etomidate used (or increased mortality)
• Risk of adrenal suppression +/- negated with steroid
administration

31. Paralytics
• Onset 30-60 seconds IV
• Duration 30 minutes
• Serious adverse effects:
few
• Reversal agent available
Rocuronium Succinylcholine
• Onset 30-60 seconds IV
• Duration 4-6 minutes IV
• Serious adverse effects:
multiple
• May be preferred in the
difficult airway

32. What About the Narcs?
• RSI with opioids in children is generally not
recommended
• Increased risk of hypotension, early
respiratory depression that interferes with
preoxygenation
• Provide analgesia as part of post-intubation
care

33. What to do about those neos?
• Median success rate is doubled
with premedication, regardless
of experience
• Successfully intubated in half
the time
• Fewer changes in baseline
heart rate
Give ‘em drugs!
Le CN, et al. J Perinatol 2014; Bottor LT Adv
Neonatal Care 2009

34. Cocktails Preferred by Children
For most RSI circumstances:
• Atropine (if < 1 year), Ketamine, Rocuronium
For neonates > 36 weeks:
• Atropine, Fentanyl, Rocuronium

35. Common Pediatric Airway
Management Pitfalls
Watch that last
step, it’s a
doozy. . .

36. Common Airway Management
Pitfalls
1. Late recognition of upper airway obstruction
• Tracheal tug, stridor, snoring
• Paradoxical chest wall movement
• Capnography changes
The solution:
• Visualization
• Improve technique
Karsli C. Can J Anesth 2015

37. Common Airway Management
Pitfalls
Understand the critical importance of jaw thrust
(start video on next slide at 5:45)
Video credit: Kalra A, Tufts Medical Ctr Anesthesia Dept

38. Common Airway Management
Pitfalls
2. Inadequate sedation/paralytic depth
• Incorrect dosing or failure to redose
• Results in thrashing, breath-holding and partial
obstruction, leading to rapid oxygen desaturation
The solution:
• Ensure correct dosing
• Ensure multiple doses available
• Ensure effect prior to manipulation
Karsli C. Can J Anesth 2015

39. Common Airway Management
Pitfalls
3. Overly aggressive BMV during and before induction
• Leads to gastric insufflation, reducing lung volumes and
increasing the risk of regurgitation
• Worsens TV
The solution:
• 2-person BMV
• Ventilation timer
• Capnograph
Karsli C. Can J Anesth 2015

40. Common Airway Management
Pitfalls
4. Suboptimal glottis visualization
Children have anteriorly placed larynx and angled
The solution:
• External laryngeal manipulation
• Optimize head position
• Insert laryngoscope deeply and withdraw slowly
• Change blade type or size
• High reps
Burns BJ. Ann Emerg Med 2017

41. The Unanticipated Difficult Airway
This is why you:
• Practice BMV
• Have a supraglottic available
• Have a video laryngoscope
• Carry a bougie
• Have reversal agents
• Secure prior to departure when possible

42. Can’t Ventilate, Can’t Intubate
Needle cricothyrotomy
preferred in children < 12
years of age
Assemble:
• a syringe half-filled with
saline
• A 14- or 16-guage syringe
• 15-mm adapter from a
tracheal tube

43. Can’t Ventilate, Can’t Intubate
Step 1: Palpate the cricothyroid
membrane: laryngeal prominence
not fully developed in child < 8yoa
Warning: Unless you’re a sharp-
shooter, this is why it is critical to
make needle cric a last resort:
2.6mm x 3mm
Photo Credit: David Low, CHOP,
www.entokey.com

44. Can’t Ventilate, Can’t Intubate
• Insert the catheter (14-16g)
• Aspirate air to confirm
placement
• Attach tracheal tube adapter
• RR 5-6bpm
• Allows further intubation
attempts if appropriate
Karsli C. Can J Anesth 2015

45. Can’t Ventilate, Can’t Intubate
If spontaneous respirations:
3) IV
extension set
2) 3-way stopcock
4) 14-16g angio
1) O2 extension
tubing

46. Summary
• Understand the unique anatomical and physiologic
differences in children and you will increase your
chances of success in pediatric airway management
• A thorough mental check for the risk factors of pediatric
airway difficulty should be part of your 7 Ps
• Know your airway toolbox: optimal drugs, techniques
and equipment
• Be an expert at BMV

47. Maria.Mandt@childrenscolorado.org
So Long, Cowboy