Because pediatric patients come in a variety of sizes (from a 500-gm neonate to a 100-kg teenager), the pediatric anesthesia provider is confronted with a variety of airway issues and must work with a variety of sizes of airway equipment. Preparedness is very important when securing a child’s airway; because babies and children desaturate so quickly, there is not much time to look through the anesthesia cart for airway equipment. Having a little foresight and preparing your anesthesia cart with the equipment you plan to use and equipment you think you might use will increase patient safety and save a lot of stress.

Understanding the anatomic differences between the pediatric and adult airway is the first step in pediatric airway management. Children have a proportionally larger head and tongue, narrow nasal passages, an anterior and cephalad larynx (at a vertebral level of C4, compared with C6 in adults), a long epiglottis, slanted vocal cords, and a cone-shaped larynx, with the narrowest point being at the cricoid cartilage. Remember also that infants are obligate nose breathers and the upper airway is relatively more prone to collapse. The relatively larger head and prominent occiput of children places the head in a naturally flexed position when the patient is placed supine. It is helpful to elevate the shoulders with a roll-this lets the head extend back slightly on the shoulders and optimizes the airway for mask ventilation and laryngoscopy. It also allows easier access to the neck if external laryngeal or cricoid pressure is required.

Remember always that children as well as adults can have difficult airways and that problems can occur both with establishing a mask airway and intubating. Oral and nasal airways are quite useful in children and should always be readily available in a variety of sizes. The appropriately sized oral airway should reach from the angle of the mandible to the corner of the mouth. Nasal airways should not be so long that they enter the esophagus. Laryngeal mask airways (LMAs) have become a mainstay in managing difficult airways in children, much as in adults.

Both curved and straight laryngoscope blades should be available prior to induction—each has its advantages. A curved blade can sweep the tongue
out of the way to improve the view when there is an obscured view of the larynx due to prominent adenoidal and tonsillar tissue. Straight blades are useful when the larynx is particularly anterior and cephalad; for example, a small Miller blade can be helpful in infants in picking up the epiglottis if it obscures the view of the larynx.

There are several issues to consider when selecting endotracheal tubes (ETT) for pediatric patients. The ETT must be large enough to permit spontaneous or controlled ventilation but not so large as to damage the trachea. Selecting the largest tube that will enter the patient’s trachea will decrease resistance, lessen the likelihood of plugging, allow the passage of suction catheters, and lessen the chance of airway aspiration. However, an ETT that is too large can cause tracheal damage when the pressure of the ETT against the wall of the trachea exceeds the capillary pressure of the mucosa. This pressure is believed to be 25 to 35 mmHg in adults; however, no values are available for children. Since the cricoid cartilage is the narrowest point of the airway in children and the only complete tracheal ring, mucosal trauma from placing too large an ETT usually occurs here. This can result in postoperative mucosal edema and swelling, which presents clinically as stridor, croup, airway obstruction, and increased work of breathing. According to Poiseuillle’s law: