How to Manage the Difficult Pediatric Airway

Written by Aaron Lacy

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Anatomic and physiologic features specific to children can lead to difficulty during airway management. A good working knowledge of specific considerations and airway adjuncts can ensure proper airway management when a critical situation presents itself.

Why is this important?
Children ≠ little adults, particularly when it comes to the airway. Children are more likely to have difficulty with bag mask ventilation and more likely to have an unanticipated difficult airway compared to adults. Understanding what leads to this difficulty and how to handle it is imperative for physicians who manage pediatric airways.

Difficult airways, not just for grownups
This article has detailed suggestions for each of these considerations, and if any of the following make you nervous be sure to read the full paper.

Anatomic Considerations

• The pediatric larynx is more cephalad, requiring a more acute angle to visualize the cords.

• A more prominent occiput that varies in size by age requires different positioning.

• Macroglossia, cervical spine abnormalities, micrognathia, midface hypoplasia, cleft palate, and congenital obstruction are all pediatric-specific changes that can predispose to a difficult airway and mandate specific considerations.

Physiologic Considerations

• Children more rapidly desaturate; preoxygenate well and utilize apneic oxygenation.

• Asthma requiring intubation has increased intrathoracic pressures and decreased cardiac preload, which can lead to hemodynamic collapse during laryngoscopy.

• Congenital cardiac disease patients are at risk for acute decompensation and may have features of pulmonary hypertensive crisis during airway management.

Adjuncts and Modifications for Airway Management

• Effective BVM ventilation is critical as both a preoxygenation and rescue mechanism in pediatric airway management – a focus on BVM over repeated ETT attempts is associated with improved mortality in cardiac arrest.

• Videolaryngoscopy (both standard geometry and hyperangulated) can lead to easier visualization of the glottic opening, and there is some evidence it leads to increased first pass success.

• Bougie use in adults can lead to first-pass success; it is not as well studied in children, but providers should still be familiar with its use.

• Supraglottic airways are particularly useful in children with anatomic abnormalities and are very successful as rescue devices; before intubation make sure an appropriately sized SGA is available.

• In a “can’t oxygenate, can’t ventilate” situation, a surgical approach might be needed; age should determine whether a surgical or percutaneous approach should be done.

Source
Management of the Difficult Airway. Pediatric Emergency Care. 2023 March;39(3):192-200. Doi: 10.1097/PEC.0000000000002916