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  • The relatively large tongue in an unconscious infant is the most common cause of airway obstruction. An oral or nasopharyngeal airway can resolve the problem.
  • Overinflation with bag-mask ventilation can result in gastric distention and restrict lung expansion. This can be resolved by placing a nasogastric tube.
  • A self-inflating bag does not deliver blow-by oxygen when it is not being compressed.
  • Before using sedatives and paralytics for tracheal intubation, be sure to assess for conditions that may be associated with a “difficult airway.”
  • Selection of a sedating agent for tracheal intubation is based on recognition of three specific clinical conditions: head trauma (increased intracranial pressure), asthma, and hypotension.
  • Confirmation of tracheal intubation should always include use of an ETCO2 device.


Appreciation of pediatric airway conditions is based on the anatomy of the airway. Figures 23–1A and B are lateral neck x-rays of a child with croup. The patient's nose (anterior) is on the right and the occiput (posterior) is on the left. Note the lordotic (extended) cervical spine vertebral bodies.

Figure 23-1.
Graphic Jump LocationGraphic Jump Location

(A) Lateral neck of a child with croup. (B) Labeled version of Figure 23-1–1A. Identify the following structures. To: Tongue (posterior portion). The laryngoscope blade slides over this portion to visualize the airway. V: Valeculla, also called the preepiglottic space. The tip of the laryngoscope blade can be directed into this space to lift the epiglottis anteriorly. E: Epiglottis. This stucture is a curved paddle (an elongated spoon). Understanding this structure in 3 dimensions helps to understand its radiographic appearance depending on the angle of the x-ray beam. Note that the hinge of the epiglottis is anterior. Gravity causes the epiglottis to fall posteriorly and inferiorly (downward) to cover the opening to the airway. Tr: Trachea. The Tr label is in the superior aspect of the trachea. The portion of the airway between the upper trachea and the epiglottis is the larynx which contains the vocal chords. In this particular x-ray, the trachea narrows inferiorly due to subglottic edema (croup). PV: Prevertebral soft tissue, also called the retropharyngeal soft tissue because it is behind the pharynx. This tissue should be approximately the width of half a vertebral body. C2 and C3: Cervical spine vertebral bodies C2 and C3. (With permission from Boychuk RB. Drooling, stridor, and a barking cough: croup?? In: Yamamoto LG, Inaba AS, DiMauro R, eds. Radiology Cases in Pediatric Emergency Medicine. 1994:1(10). Accessed January 2, 2008.)


Pediatric Airway Differences


Physical factors that differ between adults and children account for the airway differences that are clinically important. The most important of these is a smaller airway diameter. Smaller airways with the same degree of airway edema result in proportionately greater obstruction (Fig. 23–2). ...

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