Differences in the pediatric airway compared to adults:
Smaller airway (smaller diameter and shorter airway)
Tongue = large and occupies more of the mouth
Occiput often large and needs additional positioning
Larynx = anterior
Epiglottis = long and floppy
Narrowest at the level of the cricoid cartilage (in kids <10 years old)
Preparation for the Pediatric Airway
Apneic oxygenation. Oxygen provided by nasal cannula to diffuse to the alveoli during laryngoscopy is associated with a significant reduction in moderate and severe oxygen desaturation during intubation (1). If not possible, preoxygenation can also be helpful.
Blade selection. Personal preference, but…
- Miller blades (straight blade): infants and young children. Designed to go underneath that floppy epiglottis and lift it out of the way.
- Macintosh blades (curved blade): older children and positioned in the vallecula to lift the epiglottis.
- Video Laryngoscopy. Registry data suggest that video laryngoscopy may improve first pass success and decrease tracheal intubation associated adverse events.
Tube selection. Quick calculation for tube size: age/4 + 4 and go a half size down for a cuffed tube.
- You can also estimate tube size as the same diameter as the patient’s pinky finger.
Tube depth. Approximately 3x the inner diameter of the tube (4.0 tube – 12cm at the teeth).
Post-intubation sedation and analgesia
This is most commonly achieved with an opioid +/- an alpha-2 agonist or benzodiazepine. Fentanyl is used by most intensivists as a first line opioid. Versed, although historically was frequently used as a second line agent, has largely been phased out with increasing concern for its contribution to ICU delirium. Dexmedetomidine is now often used as an adjunct to fentanyl. Sedation may vary by institution as consensus guidelines do not exist.
- Remember the STOLEN mnemonic for the pediatric airway
- Use Apneic oxygenation
- Consider why certain laryngoscope blades are easier than others
- Remember the equation for tube selection and tube depth
- Use an opioid +/- an alpha-2 agonist or benzodiazepine for sedation and analgesia
- Napolitano, Natalie, MPH, RRT, RRT-NPS, FAARC, et al. Apneic Oxygenation As a Quality Improvement Intervention in an Academic PICU*. Pediatr Crit Care Med. 2019;20(12):e531-e537. doi:10.1097/PCC.0000000000002123.
- Grunwell JR, Kamat PP, Miksa M, et al. Trend and Outcomes of Video Laryngoscope Use Across PICUs. Pediatr Crit Care Med. 2017;18(8):741-749. doi:10.1097/PCC.0000000000001175
- Kaji AH, Shover C, Lee J, et al. Video Versus Direct and Augmented Direct Laryngoscopy in Pediatric Tracheal Intubations. Acad Emerg Med. 2020;27(5):394-402. doi:10.1111/acem.13869