Signs that an infant has respiratory distress can be subtle but demand the administration of supplemental oxygen and transfer to a higher level of care. Infants exhibit tachypnea, pallor, nasal flaring, and air hunger. Hypoxemia may become manifest as irritability and restlessness, so caution demands an evaluation with a pulse oximetry before sedatives or analgesics are considered. Retractions of the chest wall and soft tissues of the lower neck and upper chest reflect increased work of breathing. As the infant tires or begins to decompensate periods of apnea occur. Bradycardia, a late sign, indicates hypoxemia and impending cardiac arrest. Cyanosis is also a late sign and may not be seen because the patient may decompensate before desaturated hemoglobin levels reach 5 g/dL, the concentration associated with the color.

Infant airways tend to obstruct. Their large head and prominent occiput flex the neck and collapse the upper airway, easily opened by head tilt and jaw lift maneuvers (Fig. 34.1). Any parent knows that young children always have food and a variety of other foreign material near or in their mouths, always are eating, and frequently have a respiratory infection. Suction equipment must be close at hand. Early placement of a nasogastric tube is a necessary step in airway control to decompress the stomach and prevent aspiration. A common error is using a feeding tube that is too small for adequate decompression. Infants require at least a 10 French tube.

Supplies necessary for airway control must be at hand when seeing children with emergency conditions, including laryngoscopes and tubes of sizes appropriate for infants and small children. A useful memory aid is that the patient’s little finger approximates the appropriate size of the endotracheal tube. Supplies must be inventoried and checked regularly to assure they remain in working order, especially items like laryngoscopes that have batteries and require illumination. Practice dummies of the infant head and neck allow practice intubation and fairly accurately reproduce the anatomic features that make the procedure a challenge. The orifice itself is small. The larynx lies high in the neck, obscured by the epiglottis, which is rigid and shaped like an “omega” rather than a broad based “U.” The maneuver to visualize the larynx is to lift the tip of the epiglottis with the tip of a straight laryngoscope blade (Fig. 34.2). If the larynx cannot be seen the usual error is that the laryngoscope is too distally placed.

A surgical airway may be mandatory in massive upper airway injuries where there is bleeding or soft tissue trauma. If the patient is exchanging air the best initial maneuver is to provide supplemental oxygen and move to the operating room where light, equipment, and trained assistance are at hand. The most experienced anesthesiologist or anesthetist then attempts orotracheal intubation without paralytics or anesthesia. If standard airway control is unsuccessful after multiple attempts then the most experienced surgeon performs a tracheotomy using an incision with which he or she is most comfortable. In such a situation the incision must be of adequate size to provide immediate access to the trachea and control bleeding. Use a standard pediatric endotracheal tube—in such a situation a standard tracheotomy appliance is too short and the stay collars are cumbersome.