Basics of Pediatric Airway Anatomy,

Physiology and Management

Christine Mai, MD
Claudine Mansour, MD
Faculty Advisor: Ruth Padilla, MD
Boston University Medical Center
Department of Anesthesiology
 The Pediatric Airway
Introduction
Normal Anatomy
Physiology
Airway evaluation
Management of
normal vs. abnormal
airway
Difficult airway
 Introduction
Almost all of pediatric codes are due to respiratory origin
80% of pediatric cardiopulmonary arrest are primarily due
to respiratory distress
Majority of cardiopulmonary arrest occur at <1 year old
1990 Closed Claim Project by ASA
Respiratory events are the largest class of injury (34%)
More common in children than adults
92% of claims occurred between 1975-1985 before continuous
pulsoximetry and capnography (Brain damage and death in
85% of cases)
With continuous O2 sat and ETCO2 monitoring after 1990s,
decrease in brain damage and death (56% 1970s to 31% 1990s)
Normal Pediatric Airway Anatomy

Larynx composed of hyoid

bone and a series of
cartilages
Single: thyroid, cricoid,
epiglottis
Paired: arytenoids,
corniculates, and cuneiform
 Pediatric Anatomy cont.
Laryngeal folds consist of:
Paired aryepiglottic folds extend from epiglottis posteriorly to
superior surface of arytenoids
Paired vestibular folds (false vocal cords) extend from thyroid
cartilage posteriorly to superior surface of arytenoids
Paired vocal folds (true vocal cords) extend from posterior surface
of thyroid plate to anterior part of arytenoids
Interarytenoid fold bridging the arytenoid cartilages
Thyrohyoid fold extend from hyoid bone to thyroid cartilage
Sensory Innervation:
Recurrent Laryngeal Nerve-supraglottic larynx
Internal Branch of Superior Laryngeal Nerve-infraglottic larynx
Motor Innervation:
External branch of Superior Laryngeal Nerve-cricothyroid muscle
Recurrent Laryngeal Nerve-all other laryngeal muscles
Blood Supply
Laryngeal branches of the superior and inferior thyroid arteries
5 Differences between Pediatric and Adult
Airway
More rostral larynx
Relatively larger tongue
Angled vocal cords
Differently shaped epiglottis
Funneled shaped larynx-narrowest part of
pediatric airway is cricoid cartilage
 More rostral pediatric larynx
Laryngeal apparatus develops from brachial clefts and descends caudally
Infants larynx is higher in neck (C2-3) compared to adults (C4-5)
Relatively larger tongue
Obstructs airway
Obligate nasal breathers
Difficult to visualize larynx
Straight laryngoscope blade
completely elevates the epiglottis,
preferred for pediatric
laryngoscopy

Angled vocal cords

Infants vocal cords have more
angled attachment to trachea,
whereas adult vocal cords are
more perpendicular
Difficulty in nasal intubations
where blindly placed ETT may
easily lodge in anterior
commissure rather than in trachea
Image from: http://www.utmb.edu/otoref/Grnds/Pedi-airway-2001-01/Pedi-
airway-2001-01-slides.pdf
Differently shaped epiglottis
Adult epiglottis broader, axis parallel to trachea
Infant epiglottis ohmega () shaped and angled away
from axis of trachea
More difficult to lift an infants epiglottis with
laryngoscope blade
 Funneled shape larynx
narrowest part of infants
larynx is the undeveloped
ADULT INFANT cricoid cartilage, whereas in
the adult it is the glottis
opening (vocal cord)

Tight fitting ETT may cause

edema and trouble upon
extubation

Uncuffed ETT preferred for

patients < 8 years old

Fully developed cricoid

cartilage occurs at 10-12
years of age

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-

EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagem
ent.ppt
 Pediatric Respiratory Physiology
Extrauterine life not possible until 24-25 weeks of gestation
Two types of pulmonary epithelial cells: Type I and Type II
pneumocytes
Type I pneumocytes are flat and form tight junctions that
interconnect the interstitium
Type II pneumocytes are more numerous, resistant to oxygen
toxicity, and are capable of cell division to produce Type I
pneumocytes
Pulmonary surfactant produced by Type II pneumocytes
at 24 wks GA
Sufficient pulmonary surfactant present after 35 wks GA
Premature infants prone to respiratory distress syndrome
(RDS) because of insufficient surfactant
Betamethasone can be given to pregnant mothers at 24-35wks GA to
accelerate fetal surfactant production
 Pediatric Respiratory Physiology cont.
Work of breathing for each kilogram of body weight is
similar in infants and adult
Oxygen consumption of infant (6 ml/kg/min) is twice that
of an adult (3 ml/kg/min)
Greater oxygen consumption = increased respiratory rate
Tidal volume is relatively fixed due to anatomic structure
Minute alveolar ventilation is more dependent on
increased respiratory rate than on tidal volume
Lack Type I muscle fibers, fatigue more easily
FRC of an awake infant is similar to an adult when
normalized to body weight
Ratio of alveolar minute ventilation to FRC is doubled,
under circumstances of hypoxia, apnea or under
anesthesia, the infants FRC is diminished and
desaturation occurs more precipitously
 Physiology: Effect Of Edema
Poiseuilles law
R = 8nl/ r4

If radius is halved, resistance increases 16 x

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
 Normal Inspiration and Expiration

turbulence

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 Obstructed Airways

turbulence &
wheezing

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 Airway Evaluation
Medical History
URI predisposes to coughing,
laryngospasm, bronchospasm,
desat during anesthesia
Snoring or noisy breathing
(adenoidal hypertrophy, upper
airway obstruction, OSA)
Chronic cough (subglottic
stenosis, previous
tracheoesohageal fistula
repair)
Productive cough (bronchitis,
pneumonia)
Sudden onset of new cough
(foreign body aspiration)
Inspiratory stridor
(macroglossia, laryngeal web,
laryngomalacia, extrathoracic
foreign body)
Hoarse voice (laryngitis, vocal
cord palsy, papillomatosis)
Asthma and bronchodilator
therapy (bronchospasm)
Repeated pneumonias (GERD,
CF, bronchiectasis,
tracheoesophageal fistula,
immune suppression, congenital
heart disease)
History of foreign body
aspiration
Previous anesthetic problems
(difficulty intubation/extubation
or difficulty with mask
ventilation)
Atopy, allergy (increased airway
reactivity)
History of congenital syndrome
(Pierre Robin Sequence, Treacher
Collins, Klippel-Feil, Downs
Syndrome, Choanal atresia)
Environmental: smokers
 Signs of Impending Respiratory Failure
Increase work of breathing
Tachypnea/tachycardia
Nasal flaring
Drooling
Grunting
Wheezing
Stridor
Head bobbing
Use of accessory muscles/retraction of muscles
Cyanosis despite O2
Irregular breathing/apnea
Altered consciousness/agitation
Inability to lie down
Diaphoresis
 Airway Evaluation
Physical Exam
Facial expression Mallampati
Nasal flaring Loose/missing teeth
Mouth breathing Size and configuration of palate
Drooling Size and configuration of
Color of mucous membranes mandible
Retraction of suprasternal, Location of larynx
intercostal or subcostal Presence of stridor
Respiratory rate (inspiratory/expiratory)
Voice change Baseline O2 saturation
Mouth opening Global appearance (congenital
Size of mouth anomalies)
Body habitus
 Diagnostic Testing
Laboratory and radiographic evaluation extremely helpful
with pathologic airway
AP and lateral films and fluoroscopy may show site and
cause of upper airway obstruction
MRI/CT more reliable for evaluating neck masses,
congenital anomalies of the lower airway and vascular
system
Perform radiograph exam only when there is no
immediate threat to the childs safety and in the presence
of skilled personnel with appropriate equipment to
manage the airway
Intubation must not be postponed to obtain radiographic
diagnosis when the patient is severely compromised.
Blood gases are helpful in assessing the degree of
physiologic compromise; however, performing an arterial
puncture on a stressed child may aggravate the underlying
airway obstruction
 Airway Management: Normal Airway

Challenging because of unique anatomy

and physiology
Goals: protect the airway, adequately
ventilate, and adequately oxygenate
Failure to perform any ONE of these tasks
will result in respiratory failure
Positioning is key!
 Bag-Mask Ventilation

Clear, plastic mask with inflatable rim Place fingers on mandible to avoid
provides atraumatic seal compressing pharyngeal space
Hand on ventilating bag at all times to
Proper area for mask application-bridge
monitor effectiveness of spontaneous breaths
of nose extend to chin
Continous postitive pressure when needed
Maintain airway pressures <20 cm H2O to maintain airway patency
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-
 Oropharyngeal Airway

PROPER
SIZE POSITION

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Oropharyngeal Airway Placement

Image from: http://depts.Washington.edu/pccm/Pediatric%20Airway%20management.ppt

 Nasopharyngeal Airway

Distance from nares to angle of mandible approximates the proper length

Nasopharyngeal airway available in 12F to 36F sizes
Shortened endotracheal tube may be used in infants or small children
Avoid placement in cases of hypertrophied adenoids - bleeding and
trauma Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
Sniffing Position
Patient flat on operating table, the oral (o),
pharyngeal (P), and tracheal (T) axis pass through
three divergent planes

A blanket placed under the occiput aligns the

pharyngeal (P) and tracheal (T) axes

Extension of the atlanto-occipital joint

aligns the oral (O), pharyngeal (P), and
tracheal (T) axes

Image from: http://depts.Washington.edu/pccm/Pediatric%20Airway

%20management.ppt
 Selection of laryngoscope blade:
Miller vs. Macintosh
Miller blade is preferred for infants and younger
children
Facilitates lifting of the epiglottis and exposing
the glottic opening
Care must be taken to avoid using the blade as a
fulcrum with pressure on the teeth and gums
Macintosh blades are generally used in older
children
Blade size dependent on body mass of the patient
and the preference of the anesthesiologist
 Endotracheal Tube

Age Wt ETT(mm ID)

Length(cm)
Preterm 1 kg 2.5 6

1-2.5 kg3.0 7-9

Neonate-6mo 3.0-3.5 10
6 mo-1 3.5-4.0 11
1-2 yrsNew AHA Formulas:
4.0-5.0 12
Uncuffed ETT: (age in years/4) + 4
Cuffed ETT: (age in years/4) +3

ETT depth (lip): ETT size x 3

 Complications of Endotracheal Intubation
Postintubation Croup
Incidence 0.1-1%
Risk factors: large ETT, change in patient position introp,
patient position other than supine, multiple attempts at
intubation, traumatic intubation, pts ages 1-4, surgery >1hr,
coughing on ETT, URI, h/o croup
Tx: humidified mist, nebulized racemic epinephrine, steroid
Laryngotracheal (Subglottic) Stenosis
Occurs in 90% of prolonged endotracheal intubation
Lower incidence in preterm infants and neonates due to relative
immaturity of cricoid cartilage
Pathogenesis: ischemic injury secondary to lateral wall pressure
from ETT edema, necrosis, and ulceration of mucosa, infx
Granulation tissues form within 48hrs leads to scarring and
stenosis
 Cuff vs Uncuffed Endotracheal Tube
Controversial issue
Traditionally, uncuffed ETT recommended in children < 8 yrs old to
avoid post-extubation stridor and subglottic stenosis
Arguments against cuffed ETT: smaller size increases airway
resistance, increase work of breathing, poorly designed for pediatric
pts, need to keep cuff pressure < 25 cm H2O
Arguments against uncuffed ETT: more tube changes for long-term
intubation, leak of anesthetic agent into environment, require more
fresh gas flow > 2L/min, higher risk for aspiration
-Concluding Recommendations-
For short cases when ETT size >4.0, choice of cuff vs uncuffed
probably does not matter
Cuffed ETT preferable in cases of: high risk of aspiration (ie. Bowel
obstruction), low lung compliance (ie. ARDS, pneumoperitoneum,
CO2 insufflation of the thorax, CABG), precise control of ventilation
and pCO2 (ie. increased intracranial pressure, single ventricle
physiology)
Golden, S. Cuffed vs. Uncuffed Endotracheal tubes in children: A review Society for Pediatric Anesthesia. Winter 2005 edition.
 Laryngeal Mask Airway
Supraglottic airway device developed by Dr. Archie Brain
Flexible bronchoscopy, radiotherapy, radiologic procedures,
urologic, orthopedic, ENT and ophthalmologic cases are most
common pediatric indications for LMA
Useful in difficult airway situations, and as a conduit of drug
administration (ie. Surfactant)
Different types of LMAs: Classic LMA, Flexible LMA, ProSeal
LMA, Intubating LMA
Disadvantages: Laryngospasm, aspiration
LMA size Weight Max cuff volume (mL) ETT (mID)
1 .0 Neonate/Infants 5kg 4 3.5
1.5 Infants 5-10kg 7 4.0
2.0 Infants/children 10-20kg 10 4.5
2.5 Children 20-30kg 14 5.0
3.0 Children/small adult > 30kg 20 6.0 cuff
4.0 Normal/large adolescent/adult 30 7.0 cuff
5.0 Large adolescent/adult 40 8.0 cuff
 Other Supraglottic Devices
Laryngeal tube
Latex-free, single-lumen silicone tube, which is closed at distal end
Two high volume-low pressure cuffs, a large proximal oropharyngeal cuff
and a smaller distal esophageal cuff
Both cuffs inflated simultaneously via a single port
Situated along length of oropharynx with distal tip in esophagus
Sizes 0-5, neonates to large adults (only sizes 3-5 available in US)
Limited data available for its use in children

Cobra Perilaryngeal Airway

Perilaryngeal airway device with distal end shaped like a cobra-head
Positioned into aryepiglottic folds and directly seats on entrance to glottis
Inflation of the cuff occludes the nasopharynx pushing the tongue and soft
tissues forward and preventing air leak
Available in sizes pediatric to adult to 6
No studies currently available evaluating this device in children
 Difficult Airway Management Techniques
Rigid bronchoscopy
Flexible bronchoscopy
Direct laryngoscopy
Intubating LMA
Lighted stylet
Bullardscope
Fiberoptic intubation
Surgical airway
 Airway Management
Classification of Abnormal Pediatric Airway
Congenital Neck Masses (Dermoid cysts, cystic teratomas, cystic
hygroma, lymphangiomas, neurofibroma, lymphoma, hemangioma)
Congenital Anomalies (Choanal atresia,tracheoesophageal fistula,
tracheomalacia, laryngomalacia, laryngeal stenosis, laryngeal web, vascular
ring, tracheal stenosis)
Congenital Syndromes (Pierre Robin Syndrome, Treacher Collin,
Turner, Downs, Goldenhar , Apert, Achondroplasia, Hallermann-Streiff,
Crouzan)
Inflammatory (Epiglottitis, acute tonsillitis, peritonsillar
abscess,retropharyngeal abscess, laryngotracheobronchitis,bacterial
tracheitis,adenoidal hypertrophy,nasal congestion, juvenile rheumatoid
arthritis)
Traumatic/Foreign Body (burn,laceration,lymphatic/venous
obstruction,fractures/dislocation, inhalational injury, postintubation
croup (edema),swelling of uvula
Metabolic (Congenital hypothyroidism, mucopolysaccharidosis,
Beckwith-Wiedemann Syndrome,glycogen storage disease, hypocalcemia
laryngospasm)
 Congenital Neck Masses

Image from:
http://bms.brown.edu/pedisurg/fetal/seminar/imagebank.html

http://bms.brown.edu/pedisurg/Brown/IBImages/Teratoma/BronchospyTeratoma.html
 Congenital Anomalies
Tracheoesphageal Fistula
Radiograph of a neonate with
suspected esophageal atresia.
Note the nasogastric tube coiled
in the proximal esophageal
pouch (solid arrow). The
prominent gastric bubble
indicates a concurrent
tracheoesphageal fistula (open
arrow)

Feeding difficulties (coughing, choking and

cyanosis) and breathing problems
Associated with congenital heart (VSA, PDA,
TOF), VATER, GI, musculoskeletal and urinary
tract defects
Occurs in 1/ 3000-5000 births
Most common type is the blind esophageal pouch
with a fistula between the trachea and the distal
esophagus (87%)
Clark, D. Esophageal atresia and tracheoesophageal fistula American Family Physician. Feb 15,
1999. Vol 59(4) http://www.aafp.org/afp/99021ap/910.htlm
 Congenital Anomalies
Choanal Atresia
Complete nasal obstruction of
the newborn
Occurs in 0.82/10 000 births
During inspiration, tongue
pulled to palate, obstructs oral
airway
Unilateral nare (right>left)
Bilateral choanal atresia is
airway emergency
Death by asphyxia
Associated with other
congenital defects
Tewfik, T. Choanal atresia emedicine.com
http://www.emedicine.com/ent/topic330.htm
 Congenital Syndromes
Pierre Robin Sequence
Occurs in 1/8500 births
Autosomal recessive
Mandibular hypoplasia,
micrognathia, cleft palate,
retraction of inferior dental arch,
glossptosis
Severe respiratory and feeding
difficulties
Associated with OSA, otitis
media, hearing loss, speech
defect, ocular anomalies, cardiac
defects, musculoskeletal
(syndactyly, club feet), CNS
delay, GU defects)
Tewfik, T. Pierre Robin Syndrome emedicine.com
http://www.emedicine.com/ent/topic150.htm
 Congenital Syndrome
Treacher Collins Syndrome
Mandibulofacial dysotosis
Occurs in 1/10 000 births
Cheek bone and jaw bone
underdeveloped
External ear anamolies, drooping
lower eyelid, unilateral absent
thumb
Respiratory difficulties
Underdeveloped jaw causes
tongue to be positioned further
back in throat (smaller airway)
Associated with OSA, hearing
loss, dry eyes

www.ccakids.com/syndrome/treacher.pdf
 Congenital Syndrome
Trisomy 21 Downs Syndrome
Occurs in 1/660 births
Short neck, microcephaly,
small mouth with large
protruding tongue, irregular
dentition, flattened nose, and
mental retardation
Associated with growth
retardation, congenital heart
disease, subglottic stenosis,
tracheoesophageal fistula,
duodenal atresia, chronic
pulmonary infection, seizures,
and acute lymphocytic
leukemia
Atlantooccipital dislocation
can occur during intubation
due to congenital laxity of
ligaments
http://www.nlm.nih.gov/medlineplus/ency/article/0000997.htm
Inflammatory
Etiology: Haemophilus influenzae
type B
Occurs in children ages 2-6 years
Disease of adults due to
widespread H. influenza vaccine
Progresses rapidly from a sore
throat to dysphagia and complete
airway obstruction (within hours)
Signs of obstruction: stridor,
drooling, hoarseness, tachypnea,
chest retraction, preference for
upright position
OR intubation/ENT present for
emergency surgical airway
Do NOT perform laryngoscopy
before induction of anesthesia to
avoid laryngospasm
Inhalational induction in sitting
position to maintain spontaneous
respiratory drive
(Sevo/Halothane)
Range of ETT one-half to one size
smaller
 Inflammatory
Etiology: Parainfluenza virus
Occurs in children ages 3 months
to 3 years
Barking cough
Progresses slowly, rarely requires
intubation
Medically managed with oxygen
and mist therapy, racemic
epinephrine neb and IV
dexamethasone (0.25-0.5mg/kg)
Indications for intubation:
progressive intercostal retraction,
obvious respiratory fatigue, and
central cyanosis
 Metabolic
Beckwith-Wiedemann Syndrome
Occurs in 1/13000-15000 births
Chr 11p.15.5
Autosomal dominant
Macroglossia, Exomphalos,
Gigantism
Associated with mental retardation,
organomegaly, abdominal wall defect,
pre- and postnatal overgrowth,
neonatal hypoglycemia, earlobe pits,
Wilms tumor

Ferry, R Beckwith-Wiedemann Syndrome emedicine.com

http://www.emedicine.com/ped/toic218.htm
Pediatric Difficult Airway Algorithm