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Airway management for pediatric anesthesia

Airway management for pediatric anesthesia
Literature review current through: Aug 2023.
This topic last updated: Jun 09, 2023.

INTRODUCTION — Airway management for infants and children is not the same as airway management in adults. This topic will discuss airway management for pediatric anesthesia, focusing on these differences. Management of the difficult airway in pediatric anesthesia and complications of airway management are discussed separately. (See "Management of the difficult airway for pediatric anesthesia" and "Complications of pediatric airway management for anesthesia".)

Airway management for anesthesia in adults is discussed separately in a number of other topics.

(See "Airway management for induction of general anesthesia".)

(See "Management of the difficult airway for general anesthesia in adults".)

(See "Direct laryngoscopy and endotracheal intubation in adults".)

(See "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults".)

(See "Flexible scope intubation for anesthesia".)

DIFFERENCES BETWEEN PEDIATRIC AND ADULT AIRWAY MANAGEMENT — Anatomic and physiologic differences between the pediatric and adult airway, as well as practical considerations, determine differences in airway management, as follows (see "Emergency airway management in children: Unique pediatric considerations"):

Anatomic features of the airway in infants and young children, including a relatively large tongue, prominent occiput, superior laryngeal position, and large epiglottis require adjustments in mask ventilation and intubation techniques (table 1).

A higher rate of oxygen consumption and relatively decreased functional residual capacity while anesthetized lead to a shorter time to oxygen desaturation.

Infants and young children may have a pronounced vagal response to laryngoscopy, airway suctioning, and hypoxemia.

Laryngospasm and postintubation stridor occur much more frequently in children than adults. (See "Complications of pediatric airway management for anesthesia", section on 'Laryngospasm'.)

Airway equipment in sizes appropriate for young children may be ergonomically more difficult to use than devices designed for adult use.

Patients are often unwilling or unable to cooperate, making awake intubation extremely challenging, and complicating even seemingly simple tasks like preoxygenation and awake intravenous (IV) catheter placement.

Inhalation induction without an IV catheter in place is routinely performed for pediatric patients. A plan for alternative routes of drug administration must be in place for treatment of airway emergencies such as laryngospasm. (See "Complications of pediatric airway management for anesthesia", section on 'Laryngospasm'.)

The response to rapid decompensation related to airway complications in small children requires weight-based dosing and reliable administration of small drug volumes.

AIRWAY ASSESSMENT — All patients undergoing anesthesia should have a complete history and anesthesia-directed physical examination, including assessment of features that may impact airway management. One goal of this evaluation is to predict the degree of difficulty with mask ventilation and endotracheal intubation. Factors that predispose the patient to aspiration during anesthesia should be identified (eg, pyloric stenosis, bowel obstruction). Finally, physiologic factors that may predispose the patient to rapid desaturation or cardiovascular decompensation during airway management should be identified. The plan for airway management follows from this assessment.

Airway history Prior anesthesia records should be reviewed, especially in children with a history of difficulty with airway management, and for children with syndromes associated with craniofacial abnormalities.

Craniofacial syndromes – The abnormalities associated with some syndromes worsen with age (eg, Treacher-Collins syndrome, Apert syndrome, and mucopolysaccharidoses), such that previously successful airway management techniques may become more difficult or impossible as the child grows [1]. Children with bilateral microtia have a high risk of difficult intubation, especially when associated with other facial abnormalities [2]. (See "Syndromes with craniofacial abnormalities".)

Airway examination Some of the bedside tests and measurements used to evaluate the adult airway have not been well studied in children, or are of limited use without patient cooperation (table 2). (See "Airway management for induction of general anesthesia", section on 'Airway examination'.)

The Mallampati score, as assessed in cooperative children over the age of four years, has been shown to correlate with Cormack-Lehane index on direct laryngoscopy [3].

Other anatomic features that may predict difficult airway management in children include micrognathia, mandibular hypoplasia, midface hypoplasia, macroglossia, cleft lip or palate, cervical spine immobility or instability, facial asymmetry, microstomia, limited mouth opening, masses involving the airway, and in older children, short thyromental distance. Micrognathia can be subtle and easy to miss in infants (picture 1).

Acquired conditions can impact the airway and may be rapidly progressive. These include infection, trauma, burns, tumors, surgical changes, radiation to the airway, and anaphylaxis. (See "The difficult pediatric airway for emergency medicine", section on 'Causes of the difficult pediatric airway'.)

DEVELOPING A PLAN FOR AIRWAY MANAGEMENT — The airway management strategy in children depends on the medical history, the planned surgical or diagnostic procedure, and the expected degree of difficulty with airway management. A framework for considering these issues is discussed separately. (See "Airway management for induction of general anesthesia", section on 'General approach' and "Management of the difficult airway for pediatric anesthesia", section on 'Prediction of the pediatric difficult airway'.)

Choice of induction technique (ie, inhalation induction versus intravenous [IV] induction) is discussed separately. (See "General anesthesia in neonates and children: Agents and techniques", section on 'Choice of induction technique'.)

Maintenance of oxygenation — The primary goal for airway management is maintenance of oxygenation. Infants and young children are particularly prone to rapid oxygen desaturation, hypoxemia, and cardiovascular decompensation when rendered apneic during anesthesia. (See "Complications of pediatric airway management for anesthesia", section on 'Hypoxemia'.)

Strategies for avoiding hypoxemia during airway management include the following:

Minimize apneic time and intubate quickly once spontaneous or mask ventilation ceases

Consider maintaining spontaneous ventilation if difficulty with airway management is anticipated. However, an adequate depth of anesthesia prior to airway instrumentation is vital to avoid laryngospasm, coughing, and patient movement, all of which can be particularly dangerous in a patient with a difficult airway. Use of neuromuscular blockers or deepening the anesthetic plane and taking control of ventilation may be necessary for successful intubation [4-6] (see "Management of the difficult airway for pediatric anesthesia", section on 'Anticipated difficult airway management').

Preoxygenate all patients as possible (see 'Preoxygenation' below)

Provide apneic oxygenation throughout airway management if difficult intubation is anticipated (see "Management of the difficult airway for pediatric anesthesia", section on 'Apneic oxygenation')

Choice of airway device — Most airway devices are available in a range of sizes, including those that are appropriate for neonates as well as older children. Choice of the airway device for general anesthesia in adults is discussed separately. Considerations specific to pediatric patients are discussed here. (See "Airway management for induction of general anesthesia" and "Airway management for induction of general anesthesia", section on 'Choice of airway device'.)

Airway device options

Facemask — Ventilation by facemask is usually performed in the operating room between induction of anesthesia and placement of an airway device (ie, supraglottic airway [SGA] or endotracheal tube [ETT]) unless a rapid sequence induction and intubation is performed.

Spontaneous ventilation and supplemental oxygen provided by mask or nasal cannula, using IV anesthesia, may be appropriate for some procedures. Examples include laryngoscopy or bronchoscopy requiring visualization of vocal cord movement, gastrointestinal endoscopy, radiologic procedures (eg, computed tomography or magnetic resonance imaging), and minor diagnostic procedures. Dual channel nasal cannulae that allow simultaneous oxygen delivery and capnography during spontaneous ventilation are available. For very short procedures, such as myringotomy and tympanostomy tube placement, deep inhalation anesthesia by facemask may be used.

Supraglottic airway — SGAs (eg, laryngeal mask airway [LMA], i-gel, air-Q) are available in sizes that may be used for neonates as small as 2 kg (table 3). An SGA can be used as the elective airway device throughout the anesthetic, as a conduit for endotracheal intubation, or as a rescue device when mask ventilation or endotracheal intubation is difficult. An SGA can also be used temporarily after inhalation induction and before endotracheal intubation, to free the clinician's hands for IV catheter placement [7]. SGAs may be used with spontaneous or controlled ventilation [8], and with or without neuromuscular blocking agents. The choice between use of an SGA and an ETT for airway management is discussed below. (See 'Supraglottic airway versus endotracheal tube' below and "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults", section on 'Routine laryngeal mask airway'.)

SGAs do not definitively secure the airway, and may fail at initial placement or later during maintenance of anesthesia, due to leak, obstruction, laryngospasm, or excessive coughing or bucking [9]. However, SGA failure is rare in both children and adults, and slightly less likely in children, with reported failure rates of 0.85 percent in children aged six months to eight years [9], and 1.1 percent in adults [10]. In a retrospective, single-institution database study of 11,910 children who underwent anesthesia with an LMA, risk factors for LMA failure included prolonged surgical duration (with increasing risk for each 30 minutes of duration); ear, nose, and throat procedures; inpatient admission status; airway abnormalities; and room-to-room transport with the LMA in place (eg, from anesthesia induction room to procedure room) [9]. LMA failure was defined as abandonment of the LMA and subsequent endotracheal intubation.

SGAs have been used in select brief (<1 hour) laparoscopic surgeries (such as inguinal herniorrhaphy) and procedures in the prone position (such as perirectal abscess drainage) [11-13]. We use SGAs electively for both short laparoscopic and prone surgeries if no risk factors for difficult airway management are anticipated and if we will have access to the airway throughout the procedure. For laparoscopic surgery, in practice this means that we usually use SGAs only for lower abdominal or pelvic procedures.

For prone surgeries, we prove the ability to mask ventilate prior to SGA placement, whether the SGA is initially placed in the prone or supine position. The technique for prone SGA placement for an older child with IV access is similar to the technique used in adults; the patient is assisted in lying prone on the operating table in a comfortable position with the head turned to the side, after which the patient is preoxygenated and anesthesia is induced. The technique for induction of anesthesia in this setting is described separately. (See "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults", section on 'Prone position'.)

Younger, lighter children may undergo induction of anesthesia and SGA placement in the supine position, then turned prone with the head turned to the side.

SGAs appear as rescue devices in multiple guidelines and algorithms for management of the difficult airway (see "Management of the difficult airway for pediatric anesthesia"). They may also be used for temporary airway rescue following inadvertent extubation during more complicated prone procedures, such as spine surgery. In these instances, the SGA provides an avenue for oxygenation and ventilation while airway equipment is prepared and the patient repositioned for reintubation.

Endotracheal tube — An ETT provides a secure, sealed airway.

Cuffed versus uncuffed endotracheal tubes — ETTs for small children are available both with and without an inflatable tracheal cuff. We suggest the use of cuffed ETTs for routine intubation for children of all ages during anesthesia. The literature comparing the use of cuffed and uncuffed ETTs for anesthesia is limited [14].

Advantages to the use of cuffed ETTs in children may include the following:

A smaller sized cuffed tube may be used for a given child, compared with the size uncuffed tube that would be used. The cuff is inflated as needed, limited to 20 cm H2O cuff pressure, to form a seal with the tracheal wall and improve efficiency of mechanical ventilation. Conversely, uncuffed ETTs do not have a mechanism for adjusting airway seal, which may result in poor fit and unacceptable airway leak, and more frequent need for replacement with a different size immediately after intubation. Therefore, use of cuffed ETTs may prevent some complications resulting from multiple intubation attempts [15,16]. In one multicenter study including 2246 children <5 years of age who underwent endotracheal intubation for anesthesia, reintubation was required for incorrect sizing (too large or too small) in 30.8 percent of children who were randomly assigned to uncuffed ETTs, compared with 2.1 percent of those who were randomly assigned to cuffed ETTs [17]. Conclusions from this study are limited by a high risk of bias, as the study was sponsored by the manufacturer of the cuffed tube, and also the fact that blinding of outcome assessment was unclear.

Cuffed ETTs are associated with a similar [16-18] or lower [19] risk of perioperative laryngospasm and stridor than uncuffed ETTs. This may be due to a decreased need for repeat intubations or because cuffed ETTs place less pressure on the narrowest glottic and subglottic structures than uncuffed ETT. An uncuffed ETT contacts the trachea at the glottic opening (the smallest transverse diameter of the airway), and the cricoid ring (the narrowest non-distensible portion) [20]. An appropriately sized and positioned cuffed ETT seals the airway in the wider, distensible distal trachea, placing less pressure on the glottis and cricoid.

Cuffed ETTs more effectively seal the trachea than uncuffed tubes, and therefore allow more accurate capnography and measurement of end tidal anesthetic gases, reduce consumption of and operating room pollution by anesthetic gases [21,22], and may decrease the risk of airway fire by reducing leakage of high concentration oxygen.

Choosing endotracheal tube size — Importantly, an appropriately sized ETT should be used. A calculator for estimating the appropriate sized ETT for children age one to eight years is provided (calculator 1). The formula for choosing an uncuffed ETT is 4 + (age in years/4), and for cuffed tubes is 3.5 + (age in years/4). When the age is an odd number, the tube size should be rounded down from the calculated number. As an example, for a five year old, the calculated size for a cuffed ETT would be 4.75, so a 4.5 ETT should be used. Children younger than six to eight months often require a 3.0, rather than 3.5, cuffed ETT (table 4).

The smallest cuffed ETTs available have an inner diameter of 3.0 mm (table 4). Therefore, in very small premature infants for whom a 3.0 is expected or found to be too large, an uncuffed ETT (available as small as 2.0) must be used. (See "Technique of emergency endotracheal intubation in children", section on 'Endotracheal tube size'.)

After intubation, inflation of the ETT cuff, and confirmation of placement by auscultation of bilateral breath sounds and capnography, the ETT size should be evaluated.

A tube that is too small will fail to make a seal with the tracheal wall, compromising positive pressure ventilation.

A tube that is too large may restrict blood flow to the tracheal mucosa, leading to postoperative edema and croup.

To confirm appropriate size, the cuff (if present) should be completely deflated, and a positive pressure breath administered while monitoring the airway pressure. A correctly sized ETT will have an audible air leak at, or close to, 20 cm H2O airway pressure. Absence of a leak indicates that the ETT is too large, and replacement with a smaller size should be considered. With an uncuffed ETT, a large leak at low airway pressures is an indication that the ETT is too small, and it should be replaced with the next larger size. With a cuffed ETT, for most surgical procedures the cuff should be inflated until a leak first becomes audible at 20 cm H2O airway pressure. If excessive intra-cuff pressure is required to achieve this seal (>20 cm H2O intra-cuff pressure, as measured by manometer), the ETT should be replaced with a larger size.

The decision to replace an ETT for a different size should be individualized, depending on patient factors (eg, high risk of aspiration, difficult ETT placement) and the clinical setting (eg, length of procedure, need for positive pressure ventilation). In certain circumstances, the risk of removing and replacing the ETT may be greater than the risk of leaving the poorly-sized ETT in place. Additionally, when mechanical ventilation will likely require higher airway pressures, such as with laparoscopic or intrathoracic surgery, or in patients with poor lung compliance, additional air may have to be added to the cuff to maintain a seal at airway pressures greater than 20 cm H2O. For these patients, the risks of postoperative tracheal edema must be weighed against adequate intraoperative ventilation, and an appropriate airway leak determined on a case-by-case basis.

Microcuff pediatric endotracheal tube — The Microcuff pediatric ETT is specifically designed for use in children. It has a high-volume, low-pressure, short, thin-walled cuff located more distally on the tube than conventional cuffed ETTs. By creating a lower-pressure seal further from the cricoid, this device may be less likely than other cuffed ETTs to cause pressure-related damage to fragile airway structures. There have been no studies comparing the Microcuff with standard cuffed ETTs, but both have performed favorably compared with uncuffed ETTs [17,19,23].

Microcuff ETTs are more expensive than standard cuffed ETTs. Despite the added cost, the Microcuff ETT may be preferable for patients who are at increased risk for pressure-related airway complications (eg, for long surgical procedures, or expected postoperative ventilation).

The manufacturer of the Microcuff ETT does not recommend their use in children weighing less than 3 kg. Conventional cuffed ETTs may be too large for these very small infants, who are intubated with uncuffed tubes in most centers. However, some experts recommend the use of Microcuff ETTs in small infants who exhibit a problematic air leak during mechanical ventilation with a size 3.0 uncuffed ETT in place [24]. The use of Microcuff ETTs in infants <3kg has been reported in small, single center retrospective studies. Examples include the following:

One study included 46 infants who weighed approximately 2600 grams, intubated in the operating room and subsequently ventilated in the intensive care unit with a Microcuff tube or an uncuffed tube [25]. There were no significant differences in postextubation stridor, atelectasis, ETT blockage, median ventilator leak, or the need to reintubate for poor ETT fit, but sample sizes were too small to draw definitive conclusions.

In another study including 208 infants who were intubated with Microcuff ETTs for cardiac surgery, weight <3 kg (one-third of patients) was not an independent risk factor for postextubation stridor [26]

Supraglottic airway versus endotracheal tube — The clinically important considerations when choosing between an SGA and an ETT for airway management in adults are discussed separately. Considerations specific to pediatric patients are discussed here. (See "Airway management for induction of general anesthesia", section on 'Supraglottic airway versus endotracheal tube'.)

Indications for endotracheal intubation in most children are similar to the indications in adults. In general, we perform endotracheal intubation, rather than using an SGA, for longer procedures (>2 to 3 hours), for patients at high risk of aspiration, and for procedures that require prolonged periods of muscle relaxation or abdominal or intrathoracic gas insufflation. (See "Airway management for induction of general anesthesia", section on 'Supraglottic airway versus endotracheal tube'.)

SGAs are usually easily placed, and placement is less stimulating that endotracheal intubation. However, they do not provide protection from laryngospasm, do not protect against aspiration as well as ETTs, and do not allow controlled ventilation with airway pressures as high as those possible with an ETT. Since they sit above the glottis, SGAs should not be used for children with subglottic airway obstruction or tracheomalacia. We usually avoid SGAs for procedures expected to last more than three hours, and in procedures in which access to the airway for troubleshooting or endotracheal intubation is limited.

The following issues are of particular concern in children:

Patient age The use of SGAs in very young children is debated among anesthesiologists. Some UpToDate contributors avoid SGAs in children younger than one year of age, while others (including the authors of this topic) use SGAs in these children when access to the airway will be possible throughout the anesthetic. SGAs may not seat well in infants and tend to become dislodged. Infants desaturate quickly, and there is less time to react to problems with the airway device. Therefore, with younger patients, one must be able to rapidly troubleshoot the SGA with repositioning or removal for mask ventilation and endotracheal intubation. If patient positioning or surgical site limits airway access, an ETT may be more appropriate.

There is little literature comparing the success of airway management with SGAs in infants versus older children. In a retrospective single institution study of 11,910 children who underwent general anesthesia with an LMA, age was not identified as an independent risk factor for failure [9]. In another study, fiberoptic evaluation after LMA placement in 350 children revealed an increasingly higher incidence of an obstructed view of the glottis with decreasing LMA sizes, but no clinical evidence of airway obstruction in any patients [27].

Perioperative respiratory adverse events – For children over the age of one year who are at high risk of perioperative respiratory adverse events (PRAEs; eg, laryngospasm, bronchospasm, postoperative stridor) (table 5) in whom either an ETT or SGA would be appropriate, we suggest the use of an SGA; the choice of airway device for younger infants is less clear. In general, increasing airway stimulation is associated with higher risk of at least some PRAEs (ie, mask ventilation < supraglottic airway < endotracheal intubation).

PRAEs in older children Multiple studies have reported a reduction in PRAEs with the use of an SGA compared with ETT in older children. A meta-analysis of 19 randomized controlled studies including 1498 children age 6 months to 12 years found that emergence laryngospasm, desaturation, cough and breath holding were lower with LMAs than ETTs [28]. This advantage is particularly important in patients with reactive airways, either due to upper respiratory tract infections or asthma, for whom an ETT is more likely to cause complications [29,30]. (See "Anesthesia for the child with a recent upper respiratory infection", section on 'Choice of airway device'.)

PRAEs in infants The effect of the choice of airway device on the risk of PRAEs in small infants is unclear; many studies comparing SGA with ETT have either excluded infants or did not specify patient ages. In one single center study, 180 infants <1 year of age were randomly assigned to LMA or ETT for airway management for general anesthesia during minor elective surgery [31]. LMAs were associated with a lower risk of all PRAEs than ETTs (18 versus 53 percent) and a lower risk of major PRAEs, defined as laryngospasm or bronchospasm (4 versus 19 percent). However, it may not be possible to generalize the results of this study, as the incidence of PRAE was unusually high, criteria for extubation were not specified, the anesthetic techniques were not standardized, and all patients were cared for by attending pediatric anesthesia specialists. In addition, most of the patients in the study were over seven months old. Therefore, further study is required before basing the choice of airway device for infants on the risk of PRAEs, especially for patients less than six months old.

Choice of intubation technique — The majority of children have anatomy which is favorable for airway management [32]. Endotracheal intubation in children is therefore usually performed with direct laryngoscopy (DL), by which the laryngoscope is used to create a view of the glottis with direct line of sight. DL is the fastest and simplest intubation technique to prepare for and to perform. Advanced indirect intubation techniques that make use of distal cameras are useful when patient anatomy or clinical conditions make DL difficult or impossible. Such devices should be prepared in advance if difficulty with DL is expected and should be immediately available for all airway management episodes in case of unanticipated difficulty. However, with indirect techniques, an excellent view of the glottic opening does not always translate to easy delivery of the ETT into the trachea. These techniques are discussed in detail separately. (See "Management of the difficult airway for pediatric anesthesia", section on 'Alternative intubation techniques'.)

The most commonly used indirect intubation technique is videolaryngoscopy (VL). A number of randomized controlled trials have compared DL and VL in the general pediatric population with mixed results in terms of initial success, eventual success, time to intubation, and complication rates. Interpretation of these studies is complicated by low quality evidence and the variety of videolaryngoscope devices studied, all of which have different features that may make them better or worse in certain circumstances [33-35].

In infants and neonates, VL may be beneficial as a first line choice. This was demonstrated by a multicenter randomized trial in which 564 infants (less than one year of age) with normal airway anatomy who were intubated for surgery were randomly assigned to intubation with a Macintosh style VL versus DL with either a Miller or Macintosh blade [36]. The first attempt success rate was higher with VL overall (93 versus 88 percent); in infants ≤6.5 kg, first attempt success was 92 percent with VL compared with 81 percent with DL. Overall severe complications occurred in 2 percent of patients intubated with VL, versus 5 percent of patients intubated with DL, though the number of events was small (4 versus 15, respectively).

For neonates with difficult anatomy, some clinicians find that the large profile of a VL blade in the mouth can obstruct ETT advancement and make intubation more difficult than other advanced airway techniques. While randomized trials comparing VL with other advanced airway techniques are lacking, retrospective multicenter data suggest that the use of a flexible scope through a supraglottic airway may have higher success rates than VL in patients less than one year of age with difficult airways [37].

The authors use DL as a first line technique in most pediatric patients without risk factors for difficult airway management, as overall rates of difficulty and complications are rare. This practice reflects the lower cost and greater convenience of DL in most cases, and the practical consideration that most hospitals do not have enough VL devices for use in all low-risk pediatric patients intubated for elective surgery. However, VL is also acceptable as a first line technique, especially in the educational setting where trainees can gain experience with advanced techniques in low-risk patients and receive real time coaching by a more experienced provider watching the video screen. If difficulty with laryngoscopy is anticipated based on the patient's medical history, physical examination, or anesthetic history, we start with an advanced airway technique. If unanticipated difficulty occurs, we limit DL to ≤2 attempts in all pediatric patients and use an alternative intubation strategy thereafter. (See "Management of the difficult airway for pediatric anesthesia", section on 'General concerns'.)

TECHNIQUES FOR AIRWAY MANAGEMENT

Preparation

Equipment preparation — A wide range of sizes of equipment must be available for pediatric airway management and other aspects of anesthesia (table 6 and table 7 and table 8).

Suction devices must be available for any anesthetic, in patient appropriate sizes. A standard Yankauer suction tip may be too large for use with a neonate, and a soft suction catheter should be used instead. Suction catheters in a range of sizes must also be available for clearing secretions from the endotracheal tube (ETT). The suction catheter should block no more than 50 percent of the internal cross sectional area of the ETT. The optimal size suction catheter (measure in French) can be approximated by doubling the internal diameter of the ETT (in mm) [38]. Thus, a size 8 French suction catheter should be used through a size 4 ETT (table 8) [38].

Airway equipment for mask ventilation should be available in the next size larger and smaller than anticipated.

Facemasks are available in sizes ranging from neonate to adult. A mask that will adequately seal around the nose and mouth should be attached to the anesthesia circuit (picture 2).

The size of an oral airway can be estimated by measuring from the corner of the mouth to the angle of the mandible (picture 3).

An appropriately sized nasopharyngeal airway should extend from the nose to earlobe, and should be slightly smaller in diameter than the nares (picture 4).

Two functional laryngoscopes should be available with different blades, either one curved and one straight (ie, Miller 2 and Mac 2), or two of the same shape in consecutive sizes (ie, Miller 1 and Miller 1.5).

An appropriately sized ETT, as well as one 0.5 mm smaller, should be available, along with a pediatric ETT stylet. (See 'Endotracheal tube' above.)

A supraglottic airway (SGA) sized according to the manufacturer's recommendations should always be available for potential rescue ventilation for difficult airway management (table 3).

Emergency drugs for treatment of laryngospasm and bradycardia should be immediately available prior to any attempt at pediatric airway management. If an inhalational induction is performed prior to establishing intravenous (IV) access, drug-filled syringes should be attached to needles appropriate for intramuscular injection. The author's practice is to have succinylcholine 4 mg/kg and atropine 0.02 mg/kg in syringes with 25 g needles attached within arm's reach any time induction or airway management is attempted without IV access.

Preoxygenation — Adults and older children are routinely preoxygenated before induction of anesthesia to increase oxygen reserve. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Preoxygenation'.)

Preoxygenation may not be possible in young children, who may not accept placement of a face mask. High flow oxygen can be administered by mask placed as close to the child's face as is tolerated, to enrich the inhaled air with oxygen.

We suggest the use of apneic oxygenation for all children thought to be at risk for prolonged or difficult intubation [39]. Apneic oxygenation techniques are shown in a graphic (picture 5). (See "Management of the difficult airway for pediatric anesthesia", section on 'Apneic oxygenation'.)

Patient positioning for airway management — Patient positioning for optimal airway management in older children is similar to positioning for adults. In infants, because of the prominent occiput, the support that is usually placed under the occiput in older children is unnecessary, and a towel is often placed under the shoulders to extend the neck and align the pharyngeal and tracheal axes (picture 6 and picture 7). Positioning for intubation is discussed separately. (See "Technique of emergency endotracheal intubation in children", section on 'Positioning'.)

Induction of anesthesia — Induction of anesthesia, including the choice of anesthetic agents, adjunctive medications, and rapid sequence induction and intubation, are discussed separately. (See "General anesthesia in neonates and children: Agents and techniques", section on 'Induction of general anesthesia'.)

Mask ventilation — A relatively large tongue and reduction in airway tone associated with anesthesia predisposes children to airway obstruction during induction. Signs of obstruction during an inhaled induction include tracheal tugging, paradoxical chest wall movement, and absence of capnograph tracing or movement of the anesthesia circuit reservoir. Chin lift, jaw thrust, oral or nasopharyngeal airways, two-person mask ventilation, and continuous positive airway pressure (CPAP) with a tight mask seal are all strategies for alleviating anatomical obstruction during mask ventilation, similar to adults. When applying a chin lift or jaw thrust, care should be taken not to apply pressure to the soft tissue within the mandible, as this will compress the tongue against the palate and worsen obstruction. Obstruction due to partial laryngospasm can be overcome by applying CPAP or deepening the plane of anesthesia, while complete laryngospasm requires the rapid administration of neuromuscular blocking agents. (See "Complications of pediatric airway management for anesthesia", section on 'Laryngospasm'.)

Airway obstruction should be corrected immediately during induction to avoid hypoxemia.

The technique for mask ventilation in children and the use of airway adjuncts are discussed separately. (See "Basic airway management in children".)

Supraglottic airway insertion — Techniques for insertion of SGAs in children and adults are discussed separately. (See "Supraglottic airway devices in children with difficult airways" and "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults", section on 'Placement technique'.)

Once the SGA is inserted, the anesthesia circuit should be attached and positive-pressure ventilation attempted, even if the plan is to use spontaneous ventilation throughout the procedure. An appropriate seal is demonstrated by the ability to achieve adequate (7 to 10 cc/kg) tidal volumes and a leak pressure of at least 15 to 20 cm H2O. If adequate volumes or pressures are not achieved, options include adding or removing air from the cuff, removing the device and reinserting with a different placement technique (eg, rotational), or replacing with a different size or type of SGA. If all such attempts fail to produce adequate ventilation, an ETT should be placed.

Intubation techniques — The technique for direct laryngoscopy in children, including proper positioning, is discussed separately. (See "Technique of emergency endotracheal intubation in children", section on 'Procedure'.)

Alternative intubation techniques, including videolaryngoscopy and flexible scope intubation are also discussed separately. (See "Video laryngoscopy and other devices for difficult endotracheal intubation in children" and "Flexible scope intubation for anesthesia" and "Management of the difficult airway for pediatric anesthesia", section on 'Awake intubation'.)

Endotracheal tube depth — The optimal position for the tip of the ETT is midway between the vocal cords and carina, to avoid dislodgement proximally into the pharynx or distally into the bronchus. An estimate for the appropriate depth (in centimeters from the tip of the tube to the lip) for an uncuffed ETT can be calculated by multiplying the internal diameter of the ETT (in mm) by three. For cuffed ETTs, the optimal depth can be calculated using the formula (3 X internal diameter in mm + 1.5 cm) to reflect the fact that a cuffed tube 0.5 mm smaller is typically placed, compared with the uncuffed tube that would be used. For example, in a two year old, a 4.0 mm cuffed ETT should be taped at 13.5 cm at the lip. In neonates and small children in particular, the distance between the vocal cords and carina is very short, and it may be difficult to accurately estimate correct tube placement based on patient size. Therefore, in these patients the ETT should be advanced so that the entire cuff is just past the vocal cords during direct laryngoscopy.

Bilateral breath sounds and a normal end-tidal carbon dioxide trace should be confirmed, and the ETT securely taped. Bilateral breath sounds should also be confirmed after any change in patient position, especially in infants and young children, who are at greater risk of the ETT tip migrating into the pharynx or main stem bronchus.

EMERGENCE AND EXTUBATION — Airway devices (ie, endotracheal tubes [ETTs] and supraglottic airways [SGAs]) should only be removed when the patient is either deeply anesthetized or fully awake, to avoid emergence laryngospasm, which may occur from airway stimulation during light planes of anesthesia. Other considerations, such as risk for aspiration, risk for airway obstruction, reactive airway disease, length of procedure, and desire to avoid coughing on emergence, may influence the decision on timing of airway device removal. (See "General anesthesia in neonates and children: Agents and techniques", section on 'Emergence and extubation'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Airway management in children" and "Society guideline links: COVID-19 – Index of guideline topics".)

SUMMARY AND RECOMMENDATIONS

Differences between children and adults

Airway anatomy, respiratory physiology, level of patient cooperation, and airway-related complications are different in children than adults. (See 'Differences between pediatric and adult airway management' above.)

Techniques for mask ventilation, supraglottic airway insertion, and endotracheal intubation are different in young children than adults. (See 'Mask ventilation' above and 'Supraglottic airway insertion' above and 'Intubation techniques' above.)

Airway evaluation Preanesthesia evaluation should identify risk factors for difficulty with airway management and risk factors for aspiration during anesthesia. (See 'Airway assessment' above.)

Choice of airway device

Endotracheal tube – We usually place a tracheal tube (ETT) rather than a supraglottic airway (SGA) for longer procedures (>2 to 3 hours), for patients at high risk of aspiration, and for procedures that require prolonged periods of muscle relaxation or abdominal or intrathoracic gas insufflation. (See 'Supraglottic airway versus endotracheal tube' above.)

We suggest the use of cuffed rather than uncuffed endotracheal tubes for routine intubation for children of all ages during anesthesia. (Grade 2C) Cuffed tubes are more likely to result in placement of a correctly sized tube on the first attempt and provide better tidal volumes and less leakage during ventilation without causing an increase in acute postextubation respiratory complications (ie, postextubation stridor and/or sore throat). (See 'Cuffed versus uncuffed endotracheal tubes' above.)

SGA – The use of SGAs in children under one year of age is debated among anesthesiologists. We use SGAs in infants selectively. (See 'Supraglottic airway versus endotracheal tube' above.)

For children over the age of one year who are at high risk of perioperative respiratory adverse events (PRAEs; eg, children with asthma, recurrent wheezing, or recent upper respiratory infection) (table 5) in whom either an ETT or SGA would be appropriate, we suggest the use of an SGA (Grade 2B). SGAs may reduce the incidence of PRAEs (eg, laryngospasm, bronchospasm, postoperative stridor) in children, compared with ETTs, but the effect of the choice of airway device on the risk of PRAEs in small infants is unclear. (See 'Supraglottic airway versus endotracheal tube' above.)

Maintain oxygenation

The primary goal for airway management is maintenance of oxygenation to avoid airway-related morbidity. Infants and young children are particularly prone to rapid oxygen desaturation, bradycardia, and cardiovascular decompensation during airway management. (See 'Maintenance of oxygenation' above.)

Patients should be preoxygenated when possible prior to induction of anesthesia. In addition, apneic oxygenation should be performed for patients at risk for prolonged or difficult intubation. (See 'Preoxygenation' above.)

Choice of intubation technique For endotracheal intubation in children without predicted difficulty with airway management, we use direct laryngoscopy (DL) as the first technique. If difficulty is predicted, we start with an advanced airway technique (eg, flexible scope intubation with or without a supraglottic airway [SGA], videolaryngoscopy [VL]). (See 'Choice of intubation technique' above and "Management of the difficult airway for pediatric anesthesia", section on 'Alternative intubation techniques'.)

Extubation Airway devices should only be removed when the patient is either deeply anesthetized or fully awake to avoid laryngospasm. (See 'Emergence and extubation' above.)

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Topic 113570 Version 20.0

References

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