Advanced Airway in Children

Aka: Advanced Airway in Children, Pediatric Intubation, Pediatric Advanced Airway

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II. Precautions

  1. Consider consulting Anesthesia for semi-elective intubations in children
  2. Consider Airway Foreign Body
  3. Infants are lowest among first pass success
  4. Children typically have better outcomes if intubation (or other Advanced Airway) is performed in a controlled setting
    1. Bag-Valve-Mask Positive Pressure Ventilation is preferred for children in the pre-hospital setting
    2. Laryngeal Mask Airway (LMA) may also be used effectively until definitive airway placement
  5. Prehospital Pediatric Intubation is uncommon and experience is difficult to maintain
    1. Bag Valve Mask is associated with better survival outcomes
    2. Esophageal intubation or tube displacement occurs in up to 8% of cases (nearly always fatal)
  6. Minimize intubated patient head movement in transport
    1. Endotracheal Tube may be easily displaced from trachea on repositioning
    2. Consider placing Cervical Collar (mark collar that is NOT being used for Cervical Spine precautions)
  7. Young children desaturate rapidly with intubation (despite preoxygenation, Apneic Oxygenation)
    1. Healthy, preoxygenated infants <6 months desaturate within 45 to 90 seconds
    2. Healthy, preoxygenated children at 10 years old, desaturate at 7 to 8 minutes
  8. References
    1. Gausche-Hill (2016) ACEP-PEM Conference, Difficult Airway Lecture, attended 3/8/2016
    2. Braude and Moore in Herbert (2015) EM:Rap 15(5):3-4
    3. Gausche (2000) JAMA 283(6): 783-90 +PMID:10683058 [PubMed]

III. Anatomy: Head and neck differences in children (make intubation more challenging)

  1. Prominent occiput (with resulting neck flexion while lying supine)
    1. Endotracheal Tube placement is optimized with the neck in neutral position
    2. Align the ear tragus or external auditory canal with the sternal notch
      1. Often requires a pillow under child's Shoulder (age <2 years)
  2. Large Tongue
  3. Small jaw
  4. Larynx is cephalad to adult position (at C2 in infants and C4 in adults)
  5. Vocal Cords are pink (not white) in infants
  6. Epiglottis is large and floppy
    1. Best managed with a Straight Laryngoscope Blade (Miller)
  7. Airway is most narrow at the cricoid ring (below the Vocal Cords)
    1. Has historically lead to the use of uncuffed tubes in young children (to prevent airway Trauma)
    2. However, the airway is also eliptical in children and subject to ET Tube leak (and need for replacement)
      1. Has lead to typical use of cuffed ET Tubes in children without increased airway Trauma findings
  8. LEMON Mnemonic is difficult to apply in children
    1. Reduced to Look externally, obstruction and reduced neck mobility
    2. The 3-3-2 rule is not validated in children (children's finger size should be used, if at all)
    3. Mallampati is difficult to assess in young children

IV. Risk Factors: Congenital syndromes (head and neck anatomic abnormalities complicating intubation)

  1. Down Syndrome
    1. Large Tongue and small mouth
    2. Larygospasm is common
    3. Atlantoaxial Instability
  2. Pierre Robin Syndrome
    1. Large Tongue and small mouth
    2. Mandibular anomaly
  3. Goldenhar Syndrome
    1. Mandibular Hypoplasia
  4. Turner Syndrome
    1. Short neck
  5. Cystic Hygroma
    1. Airway compression
  6. Hemangioma
    1. Hemorrhage with local Trauma

V. Risk Factors: Acute conditions that impair intubation

  1. Epiglottitis
  2. Croup
  3. Peritonsillar Abscess
  4. Angioedema

VI. Management

  1. Prepare as with adult intubation (e.g. SOAP-ME Mnemonic)
    1. Keep both large and smaller nasolaryngeal suction at hand
    2. Maximize Endotracheal Intubation Preoxygenation
    3. Consider Stomach decompression first if prolonged Positive Pressure Ventilation before intubation (aspiration risk)
    4. Optimize IV hydration (prevents Hypotension with RSI and intubation)
  2. Rapid Sequence Intubation (RSI)
    1. Pediatric sedation is most common with Etomidate 0.2 to 0.3 mg/kg or Ketamine 1.5 mg/kg
    2. Pediatric paralaysis is most common with Rocuronium 1 to 1.2 mg/kg
      1. However Succinylcholine 1.5 mg/kg may be used if no contraindication (e.g. neuromuscular disorder)
  3. Direct Laryngoscopy
    1. Philips 1 Blade is a cross between Miller Blade (straight for most of its length) and Mac blade (curved at the tip)
      1. Allows for switching between Epiglottis control (Miller Blade) and Vallecula control (Mac Blade)
      2. May be used from newborn to 5 years of age
  4. Video Laryngoscopy
    1. Video Laryngoscopy may improve first pass success
    2. Glidescope, Storz and Airtraq have all pediatric sizes
    3. However, hyperangulated blades (e.g. glidescope) may make intubating children more difficult
      1. ET Tube may not retain its hyperangulated position, when withdrawing stylet and advancing
      2. Direct Laryngoscopy blade does not introduce the hyperangulated blade position
    4. When inserting the Laryngoscope in children, advance progressively in the midline, over the Tongue
      1. Visualize the uvula, then the epiglottis, then the arytenoids
  5. Endotracheal Tubes
    1. Cuffed Endotracheal Tubes are now often used in infants and children
      1. Cuff is engineered to be a smaller width than prior cuffs (less than the prior 1/2 tube size adjustment)
      2. Uncuffed ET Tubes require replacement due to air leak in 30% of cases (compared with 2-3% for cuffed ET)
      3. Prior concerns for airway Trauma from cuff hyperinflation
        1. Start with a small amount of cuff air insertion (1-3 cc) and inflate more if air leak
    2. Pre-mark/tape the Endotracheal Tube at the calculated depth for age and ET size (e.g. 3x the ET diameter)
      1. Marking depth helps prevent inserting Endotracheal Tube too far
      2. Right mainstem intubation is very common in pediatrics (30% of intubations)
  6. Landmarks
    1. Vocal Cords may be more difficult to identify (pink instead of white)
      1. Attempt to visualize the glottic opening instead
    2. Epiglottis is very superficial (may even be seen by simply depressing Tongue)
      1. Using Direct Laryngoscopy, depress the Tongue down and to the side
      2. Slowly advance to the base of the Tongue and vallecula
  7. Useful associated devices and techniques
    1. Capnography
    2. Consider lifting the occiput to aid alignment
    3. Consider BURP Maneuver (adjusting the Larynx posteriorly)
    4. Consider twisting the Endotrachaeal tube between fingers to pass it through the cords
  8. Devices that may be less effective in children
    1. Elastic Bougie
      1. Tracheal rings are difficult to distinguish in children
      2. Adult Elastic Bougie is 5 mm diameter (15 Fr) and will only fit inside a 6 mm ET Tube or larger
      3. Pediatric Elastic Bougie is 3.3 mm diameter (10 Fr) and will fit inside a 4 to 5.5 mm ET
    2. Oral Airways in congenital craniofacial deformities
      1. Usefulness in children may be limited to Macroglossia, Down Syndome, and mucopolysaccharide diseases
  9. Devices that require precautions
    1. Bag-valve mask ventilation
      1. Avoid over-ventilation
      2. Gently squeeze bag to initiate chest rise and then release
      3. Nasogastric Tube or oral Gastric Tube may be required to decompress Stomach
  10. Consider alternatives to Endotracheal Intubation if difficult airway is anticipated
    1. Nasopharyngeal Airway
    2. Oropharyngeal Airway
      1. Insert without 180 degree rotation
    3. Laryngeal Mask Airway (LMA) as rescue airway in children
      1. Failure rate: 5-10% (due to large epiglottis)
      2. Pediatric LMAs are available
      3. Can temporize for an hour until a definitive airway can be placed
      4. Sizes per age are on Broselow Tape
    4. Needle Cricothyrotomy
      1. Can be used to temporize in children under age 10 years
      2. Surgical Cricothyrotomy is contraindicated in under age 10 years due to very small cricothyroid membrane
      3. Can temporize for up to 45 minutes until definitive airway can be placed

VII. References

  1. Sacchetti and Nagler in Herbert (2019) EM:Rap 19(8): 4-5,7
  2. Sacchetti and Nagler in Herbert (2019) EM:Rap 21(1): 6-7
  3. Swaminathan and Drapkin (2020) EM:Rap 20(2): 8

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