PEDIATRIC AIRWAY MANAGEMENT
Management of the pediatric airway is covered in more detail in
textbooks on pediatric anesthesia and is discussed only in general terms here. After
about 8 years of age, airway differences between adults and children mainly reflect
size differences. The newborn has the most dramatically different anatomy from the
adult, and it persists during the first year of life and then slowly evolves to the
adult form. Differences include a large head that tends to flex the short neck and
obstruct the airway and a disproportionately large tongue that may cause airway obstruction
and more difficult laryngoscopy. The larynx is more cephalad in infants because
the cricoid cartilage is opposite the fourth cervical vertebra (rather than the sixth
in adults). The epiglottis is longer and stiffer, and it lies
more horizontally than in adults. The cricoid cartilage is the narrowest point of
the airway until about age 8. The shorter trachea also leaves less margin for error
in placement of the endotracheal tube. The angles of the main bronchi take-off points
make left-sided endobronchial intubation as likely as right-sided procedures.
The sizes and insertion lengths of uncuffed endotracheal tubes
for children are shown in Table 42-5
.
Tubes should pass easily and allow for leak at inflation pressures of 15 to 20 cm
H2
O. The use of cuffed tubes for children of all ages has become common
practice, as has the use of appropriately sized LMAs (see Fig.
42-9
).[18]
Awake intubation may be performed
in newborns up to about 4 weeks of age. Oxygen, atropine, and topicalization of
the tongue with lidocaine jelly on a finger are followed by laryngoscopy with a straight
blade and thin-handled laryngoscope. Hyoid pressure with the little finger may aid
visualization. Older or more vigorous children require anesthesia for intubation
in most circumstances. Sevoflurane has rapidly become the mask induction agent of
choice for most circumstances.
