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Chapter 18: Airway Management

Loren G. Yamamoto

HIGH-YIELD FACTS

  • 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 (BMV) 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.”

  • Confirmation of tracheal intubation should always include use of an end-tidal CO2 (ETCO2) device.

AIRWAY ANATOMY

Appreciation of pediatric airway conditions is based on the anatomy of the airway. Figure 18-1 (A and B) shows lateral neck radiographs 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 18-1.

(A) Lateral neck radiograph of a child with croup. (B) Labeled version of Figure 18-1A. Identify the following structures. To: Tongue (posterior portion). The laryngoscope blade slides over this portion to visualize the airway. V: Vallecula, 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 structure is a curved paddle (an elongated spoon). Understanding this structure in three dimensions helps to recognize its radiographic appearance depending on the angle of the radiograph 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 radiograph, 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. (Reproduced 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). www.hawaii.edu/medicine/pediatrics/pemxray/v1c10.html. Accessed January 2, 2008.)

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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. 18-2). Some textbooks have quoted Poiseuille’s equation describing airflow resistance as proportional to the fourth power of the radius. This is not ...

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