8.1 Pediatric Airway Evaluation and Management
Key Features
The airway is relatively narrower and more tenuous in children.
The potential for airway emergency is high.
Many conditions causing respiratory distress in infants resolve spontaneously with growth.
The pediatric airway is proportionally smaller than that of the adult: the tongue is relatively larger and more anterior, the soft palate descends lower, the adenoid is larger, the epiglottis is omega-shaped, larger, and more acutely angled toward the glottis; the cricoid ring is narrower, the trachea is shorter and narrower, the surrounding soft tissue is looser, and cartilaginous structures are less rigid. Thus the pediatric airway is more prone to compromise by infection, inflammation, neoplasia, and normal breathing. Foreign body aspiration may be a life-threatening emergency. An aspirated solid or semisolid object may lodge in the airway. If the object is large enough to cause nearly complete obstruction of the airway, then asphyxia may rapidly cause death. Infants are at risk for foreign body aspiration because of their tendency to put everything in their mouths and because of immature chewing. Children may be asymptomatic. If present, physical findings may include stridor, fixed wheeze, or diminished breath sounds. If obstruction is severe, cyanosis may occur.
Clinical
Signs and Symptoms
Stridor: Harsh, high-pitched sound of turbulent airflow past partial obstruction in upper airway
Inspiratory stridor signifies supraglottic obstruction.
Biphasic stridor signifies glottic or subglottic obstruction.
Expiratory stridor signifies tracheal or large bronchial compression.
Stertor: Low-pitched, snorting sound resulting from partial nasal/nasopharyngeal/hypopharyngeal obstruction
Wheezing: A continuous whistling or musical sound on expiration from a small bronchiole constriction
For subjective assessment of respiratory distress, see Table 8.1 . Indications for intubation for airway compromise include P 2 < 60 mm Hg with F 2 > 0.6 (without cyanotic heart disease), P 2 > 50% (acute, unresponsive to other intervention), actual or impending obstruction, neuromuscular weakness (maximum negative inspiratory pressure over −20 cm H2O, vital capacity < 12–15 mL/kg), and an absent cough/gag reflex.
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