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There are significant physiologic, anatomic, and equipment differences between children and adults that must be considered when planning the approach to the emergent pediatric airway. The presentation of a critically ill child requiring intubation is relatively uncommon compared to adults.1,2,3 This chapter presents the physiologic and anatomic characteristics of the pediatric airway, strategies for effective airway management, and organization methods for equipment to minimize errors in equipment sizing and medication dose calculation.4


Due to a higher metabolic rate, oxygen consumption is increased in children, especially in infants. Infants and children have an increased relative cardiac output and minute ventilation to match the increased metabolic demand. However, children are vulnerable to rapid desaturation when oxygenation or ventilation is reduced. Children have relatively small-volume lungs with small functional residual capacities. This translates into a reduced oxygen reservoir, which decreases the effectiveness of preoxygenation and makes optimal preoxygenation more difficult. Therefore, be prepared to support oxygenation with bag-mask ventilation, often before an intubation attempt, while awaiting the onset of induction and paralysis. Attempts at intubation may need to stop once oxygen saturation drops below 90% to allow for bag-mask ventilation before the next attempt. Below an oxygen saturation of 90%, desaturation is particularly rapid.5 The vast majority of children are easily bag ventilated when the proper technique is used, even when partial obstruction is present. The key is anticipation and early use of good bag-mask ventilation.

Children can develop gastric distention from air swallowing during distress as well as insufflation during bag-mask ventilation. Gastric distention can further compromise functional residual capacity, tidal volume, and ventilation. Early placement of an orogastric or nasogastric tube may remedy this. Gastric tubes have also been recommended to minimize the risk of reflux from an incompetent gastroesophageal junction, but the incidence of aspiration in children appears to be quite low, even in emergent intubation.

Children have a proportionally larger extracellular fluid compartment than adults. This results in a quicker onset and shorter duration of action of drugs and may require higher doses per kilogram for many of the drugs used to facilitate rapid-sequence intubation.


There are a number of anatomic characteristics of children that must be appreciated to optimize the success of endotracheal intubation (Table 111–1). Most of the unique anatomic characteristics are present in the first few years of life. From 2 to 8 years of age, there is a transition to a smaller but similarly proportioned anatomy compared to adults. Most children do not have the many acquired anatomic challenges present in older adults, and the differences in children are predictable. With good technique and anticipation of these differences, the majority of pediatric airways are successfully managed.

Table 111–1

Anatomic Considerations in the Pediatric Airway

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