Pediatr Clin N Am 55 (2008) 873–886

Airway Management
Robert M. Bingham, MB, BS, FRCAa,*,
Lester T. Proctor, MD, FAAPb
a
Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street,
London, WC1N 3JH, UK
b
University of Wisconsin School of Medicine and Public Health, Department of
Anesthesiology, Room B6/319 Clinical Sciences Center, 600 Highland Avenue, Madison,
WI 53792, USA

The pediatric airway and respiratory function differ from those in adults.
Optimum management requires consideration of these differences, but the
application of adult principles is usually sufficient to buy time in an emer-
gency until specialist pediatric help is available. Simple airway opening tech-
niques such as head tilt and jaw thrust are usually sufficient to open the
child’s airway, but there is now a range of equipment available to bypass
supraglottic airway obstructiondthe strengths and weaknesses of such
devices are explored in this article. The role of tracheal intubation is also dis-
cussed, along with the pros and cons of the use of cuffed tracheal tubes in
children, and methods of confirming tracheal placement of the tube.

Scientific background
The etiology of cardiorespiratory arrest differs in children from that in
adults. Most frequently, there is an asphyxial rather than cardiogenic cause;
consequently airway management and pulmonary ventilation are central to
effective pediatric resuscitation. Nowhere is this truer than in the delivery
room, where establishing an airway and providing sufficient ventilation
can reverse neonatal distress in 90% of cases. Children of all ages are
more likely to suffer respiratory compromise and respond to airway and
ventilation maneuvers than are adults.
Emergency airway management of infants and children is evolving. Some
of the basic tenets and dogmas are being challenged, and new equipment
and capabilities are affecting our approach. It is often stated that children,

* Corresponding author.
E-mail address: binghr@gosh.nhs.uk (R.M. Bingham).

0031-3955/08/$ - see front matter Crown Copyright Ó 2008 Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.pcl.2008.04.004 pediatric.theclinics.com
874 BINGHAM & PROCTOR

especially infants and newborns, are not just small adults. There are mor-
phologic differences in airway anatomy, which require changes to manage-
ment and redesign, rather than miniaturization, of equipment. Nevertheless,
children are not a different species, and many adult-based techniques are
applicable; adult-oriented health care providers should not be inhibited
from the emergency care of a child’s airway from fear of doing harm if there
is no pediatric specialist immediately available.
The differences in airway anatomy from adults are particularly marked in
infants. The head shape is completely different in infants compared with
older children and adults. The occiput is protuberant, and the head flexes
on the cervical spine in repose. The tongue is relatively large, and the epi-
glottis relatively longer and thinner. The larynx has a more anterior and
cephalad position, which results in a shortening of the thyromental distance
and consequent ‘‘bunching’’ of the tongue in the oropharynx. The infant
larynx is traditionally described as being cone-shaped, with the narrowest
segment at the level of the cricoid cartilage. This assumption has been chal-
lenged recently, and it is possible that the observations are an artifactual
result of descriptions drawn from cadaveric studies [1]. In any event, the cri-
coid is a complete ring of cartilage, and any mucosal edema here encroaches
on the lumen of the larynx, resulting in large increases in resistance to gas
flow, because flow is proportional to the fourth power of the radius
(Poiseuille’s law).
Developmental changes in the soft tissue structures of the upper airway
occur with age. Radiographic studies [2,3] show that whereas the bony struc-
tures remained proportionately the same size, there is a disproportionate
increase in the size of the adenoidal tissue between 3 and 5 years of age,
resulting in a narrowing of the nasopharyngeal airway at this time. Subse-
quently, bony growth outstrips soft tissue growth, and the airway dimen-
sions increase. An MRI study [4] also demonstrated an increase in
adenoidal size in early childhood, with later regression, but put the age of
maximal adenoid dimension slightly later at 7 to 10 years of age. In contrast,
a further MRI study found that body and soft tissues grow proportionately
through childhood, with airway dimensions increasing steadily with age [5].
The main consequences of all this for emergency airway management are
that, if muscle tone is reduced (as accompanies a reduced level of conscious-
ness), the head will flex and pharyngeal tone is reduced, resulting in reduced
oropharyngeal volume and occlusion of the oropharynx by the tongue.
In this setting, an airway-opening maneuver is required to maintain airway pa-
tency. Modifications to adult-based airway equipment will also be necessary
for neonates and infants, because simply scaled-down equipment may not
be able to provide optimum conditions for airway opening and laryngoscopy.
Differences in pulmonary physiology also affect airway management.
Higher oxygen consumption (6–8 mL/kg/min in infants versus 4–6 mL/
kg/min in adults) and higher ratio of minute ventilation to functional resid-
ual capacity result in far faster falls in arterial oxygen partial pressures if the
 AIRWAY MANAGEMENT 875

airway becomes occluded, which in turn requires more rapid resolution of

airway compromise if hypoxic injury is to be avoided.
Clearly, assisted breathing is indicated for an unconscious child who has
impaired ventilation, but what is the optimum method to provide respira-
tory support? Measurements of pulmonary function in children reveal
that although functional residual capacity is nearly the same as in adults,
the infant’s higher oxygen consumption, subsequent higher risk of absorp-
tion atelectasis, and associated intrapulmonary shunt augment the rapid
arterial oxygen desaturation described above [6]. Alveolar recruitment
maneuvers may bring about a faster recovery than an equal minute ventila-
tion of subvital capacity breaths [7]. The use of continuous positive airway
pressure (CPAP) improves the amount and distribution of ventilation, but
excessive CPAP in the unconscious, spontaneously breathing infant may de-
crease tidal volume, because the infant’s ability to adjust to a higher work of
breathing is impaired [8]. In addition, high ventilation pressures or volumes
may damage the newborn or infant lung.
In newborns, the volume of ventilation or duration of inflation [9] may be
more critical to successful resuscitation than the oxygen concentration of the
resuscitating gas [10].
During cardiopulmonary resuscitation (CPR) there is a great tendency to
overventilate, and this may be harmful [11,12]. Positive pressure ventilation
increases intrathoracic pressure, which inhibits systemic venous return to the
right atrium and thus diminishes already compromised cardiac output.
Furthermore, raised right atrial, and therefore coronary sinus, pressures
reduce coronary perfusion at a time when it is already critically low [13].
Because cardiac output, and thus pulmonary blood flow, is low during
CPR, there is no possibility of reducing carbon dioxide levels by increasing
minute ventilation. The only feasible goal is to oxygenate the blood passing
through the alveolar bed, and this can be achieved by a small number of in-
flations (preferably with oxygen) per minute. Once the trachea is intubated,
chest compression should continue uninterrupted and ventilation should be
at a frequency of about 8 to 10 breaths/minute; although care must be taken
to ensure that adequate lung inflation occurs, particularly if an uncuffed
tube is used.
Educational priorities also favor reducing the frequency of ventilations
during resuscitation. Fewer breaths are not only easier to teach and admin-
ister, but may well result in better outcomes.

Airway management techniques

Simple airway opening techniques
Although there are many aspects of the pediatric airway that are dis-
tinctly different from that of adults, some of the persistent dogma concern-
ing infant airways can inhibit development of effective airway management
876 BINGHAM & PROCTOR

techniques. One example is the tenet that infants are ‘‘obligate nasal
breathers.’’ Although the anatomy of the infant airway allows better breath-
ing while suckling than does adult anatomy, infants can also maintain an
effective oral airway [14], and open-mouth, jaw-thrust airway maneuvers
are very effective. In addition, the nasopharynx (unlike the oropharnx) is
nondistensible and can easily be occluded. This may explain why mouth-
to-nose ventilation was not superior to mouth-to mouth or mouth-to-nose
and mouth ventilation in infants [15].
In unconscious children, a variety of techniques can be used to open the
airway. In those who have spontaneous respiratory effort, lateral position-
ing may be all that is required [16]. Lateral positioning also improves airway
patency in unconscious children having their airway maintained with simple
airway maneuvers [17]. It is not clear which is the optimum simple airway
maneuver in children [18], although jaw thrust appears superior to simple
positioning in the ‘‘sniffing’’ position [19]. Studies in anesthetized children
have mixed results, with one showing chin lift is equally effective as open-
mouth jaw thrust in improving airway patency [20], and others showing
jaw thrust to be superior [21,22]. Both maneuvers apply anterior tension
to the hyoid bone, which in turn draws the epiglottis away from the poste-
rior pharyngeal wall, opening the pharynx [23]. In addition, the jaw thrust
pulls the tongue away from the palate, also opening the oropharynx.
Thus only the jaw thrust opens both the pharynx and oropharynx. In addi-
tion, the jaw-thrust maneuver can be a potent arousal stimulus, also improv-
ing respiratory effort [24]. Although adult studies suggest that the most
commonly taught jaw-thrust maneuver causes cervical spine motion, the
chin lift does as well [25], because both maneuvers recommend a head tilt.
In patients such as trauma victims, in whom cervical instability may be of
concern, cervical spine immobilization and the use of the minimum head
tilt necessary to open the airway should occur with either maneuver.
CPAP improves airway patency by widening the lateral dimensions of the
airway above the glottis, and preventing collapse of the airway below the
glottis by stenting it open pneumatically [8,20,22,26]. CPAP may also
improve tidal and minute ventilation in spontaneously breathing uncon-
scious children, although by not as much as the jaw thrust [19]. Although
optimal airway management in the relaxed, obstructed airway includes an
open-mouth jaw thrust plus CPAP, the effective application of CPAP usu-
ally requires the use of a flow-inflating (anesthesia) type of bag; personnel
who do not use these regularly are more confident and proficient using
self-inflating bags [27].
In apnoeic children, a two-person bag-mask technique may be more effec-
tive in generating adequate tidal volumes [28], and also creates the opportu-
nity to apply cricoid pressure to prevent regurgitation and limit gastric
distension [29]. In this technique, one rescuer uses both hands to open the air-
way with a jaw thrust and ensure that the mask makes a seal with the face, and
the second rescuer squeezes the bag (and applies cricoid pressure, if required).
 AIRWAY MANAGEMENT 877

Airway adjuncts
A number of adjuncts can be use to facilitate an open airway in children.
The simplest of these is the oropharyngeal airway, which is a curved and
flanged tube placed in the oropharynx to bypass the tongue. It is important
to insert the correct size, which can be estimated by lining it up against the
side of the face and ensuring that it extends from the incisors to the angle of
the jaw. Such airways are not tolerated unless there is a low level of con-
sciousness, and attempts to insert one in a child who is resisting can result
in vomiting and laryngospasm. Oropharyngeal airways should always be
inserted with care, because palatal trauma has been reported.
Oropharyngeal airways (OPAs) are occasionally used in conscious new-
borns who have complete nasal airway obstruction (eg, choanal atresia) as
a temporary airway before definitive surgical treatment.
Nasopharyngeal airways are better tolerated at higher levels of conscious-
ness, and have been used for long-term relief of obstructive sleep apnea in
children who have midfacial abnormalities such as in Pierre Robin sequence.
Purpose-made nasopharyngeal airways with a trumpet-shaped flange in-
tended to prevent them migrating into the nose are available (depending on
the manufacturer) down to size 6 mm internal diameter (ID). Below this
size, one can be constructed from a suitable sized tracheal tubedusually
1mm less ID than would be used for tracheal intubation. The length is judged
by measuring from the nose to the external auditory meatus. Once the tube is
cut to length, the connector should be reinserted to prevent loss of the tube
into the nostril. The airway should be inserted in a directly posterior direction
(rather than upwards), and the tube should be well-lubricated and preferably
softened in warm water to minimize nasal trauma. Nasopharyngeal airways
should never be used if there is any suspicion of skull base trauma because
they could introduce infection or even penetrate the anterior cranial fossa
[30].

‘‘The gold standard’’

Airway control is a crucial initial step in pediatric resuscitation, irrespec-
tive of the etiology. The simple airway maneuvers described above may be
sufficient to clear the airway in most circumstances, but in health care envi-
ronments, adjuncts are usually employed to facilitate the establishment and
maintenance of a clear airway and provide positive pressure ventilation. In
adult practice, it is usually assumed that the ‘‘gold standard’’ for airway
maintenance is the tracheal tube, but in children it is accepted that inserting
a tracheal tube is technically more demanding, and there are considerable
practical difficulties for acquiring and retaining this skill for health profes-
sionals dealing with acutely ill children.
The goal of opening the airway and providing pulmonary ventilation can
also be provided by bag-mask ventilation, and a well-designed, prospective
controlled trial comparing bag-mask ventilation with tracheal intubation in
878 BINGHAM & PROCTOR

the out-of-hospital setting found no difference in outcome in 830 children

randomized between these two techniques [31]. Of particular concern, how-
ever, subgroup analysis found that survival was worse for intubated children
in the respiratory failure/arrest group. Furthermore, 15 children in the tra-
cheal intubation group had unrecognized esophageal intubation or tracheal
tube dislodgement, and all but one of these died. Furthermore, a study of
outcomes and complications in a series of 31,464 children who had severe
head injury showed no advantage of tracheal intubation [32]. Finally, an
examination of survival predictors in pediatric trauma patients showed
that prehospital tracheal intubation was an independent predictor of poor
outcome [33].
The authors therefore suggest that the gold standard for initial airway
management in children should be bag-mask ventilation (with or without
airway adjuncts); the outcome following the use of other airway manage-
ment techniques should be compared with this intervention.

Tracheal intubation
Despite the earlier comment about the efficacy of bag-mask ventilation
during the initial phase of resuscitation, tracheal intubation offers the
advantages of long-term airway maintenance and protection from aspira-
tion of gastric contents, and the technique is an important part of the further
management of the child’s airway. It is also indicated if airway patency can-
not be achieved by the use of airway maneuvers and adjuncts. A number of
different types of tracheal tube are available (eg, preformed, armored), but
for resuscitation purposes a plain tube made of implant-tested polyvinyl
chloride (PVC) is adequate. Sizes range from 2 to 10 mm ID, and the appro-
priate ID is usually estimated from the formula: age/4 þ 4 (mm ID). This
tends to result in a tube that is slightly too small, so some use age/4 þ
4.5. Tubes one half size larger and smaller should be available in case the
formula does not predict the correct size.
For many years, tracheal tubes without a cuff were routinely recommen-
ded for children. This was based on the anatomy of the infant and small
child’s airwaydthe narrowest part (the cricoid ring) is circular in cross sec-
tion, so a plain tube will create a seal at this level to allow positive pressure
ventilation and prevent ingress of gastric contents. In the older child and
adult airway, where the narrowest part is the hexagonal-shaped glottis, no
seal is possible without a cuff positioned in the trachea. Another concern
in children was that the cuff might cause damage at the cricoid ring and, be-
cause this is a complete ring of cartilage, even a small amount of edema will
result in significant narrowing and very large increases in resistance to flow.
This latter concern was largely based on experience with older type tubes
that used high-pressure cuffs made from irritant materials. Modern
implant-tested tubes with high-volume, low-pressure cuffs have much less
propensity to cause harm.
 AIRWAY MANAGEMENT 879

During resuscitation, high inflation pressures may be required if lung com-

pliance is reduced. Furthermore, there may be airway narrowing, and select-
ing the correct size for an uncuffed tube is complex and may require one or
more tube changes, which is clearly undesirable [34]. Consequently there
has been an increase in the use of cuffed tracheal tubes in children recently
[35,36], with no evidence of any increase in complication rates [34,37]. Cuffed
tubes do, however, require more care during use. Not only does cuff pressure
need close attention to allow positive pressure ventilation without pressure
damage to the tracheal wall, but also the correct length is more difficult to
judge, because the cuff has to be below the cricoid as well as the tip being
above the carina. Achieving this may be facilitated by the use of newer cuff
designs incorporating smaller cuffs positioned further down the tube [38].
Tracheal tubes are passed with the use of a laryngoscope, and either
a straight Miller or curved Macintosh blade, which are available in a range
of sizes. A curved blade is placed in the vallecula, at the base of the tongue,
and used to lift the epiglottis from above. Because small infants have a long,
floppy epiglottis with a more cephalad position, it is usually easier to use
a straight-bladed laryngoscope with the blade positioned below the epiglot-
tis, which is lifted directly. Although this provides an improved view of the
larynx, it may stimulate the vagus nerve, which innervates the underside of
the epiglottis, resulting in bradycardia.
During resuscitation, tracheal tubes are normally passed orally. For pro-
longed intensive care, however, nasal tubes may be more comfortable, but
changing to a nasal tube is best performed electively when the child is stable.
In cardiac arrest, tracheal tubes may be passed without the use of sedative or
muscle relaxant drugs, but such agents may be required for resuscitation of
a child in respiratory failure, for example. In this circumstance a rapid
sequence intubation is usually performed [39].
Once inserted, tube position should be confirmed by careful auscultation
of both lung fields and over the stomach, because listening to the lungs alone
can be unreliable [40]. Once position is confirmed, the tube should be
secured according to local practice. A chest radiograph should be performed
if the tube is to remain in situ.

Confirmation of tracheal intubation

Misplacement of a tracheal tube has serious consequences, and confirma-
tion of the correct position within the trachea is vital. Devices used to con-
firm correct tracheal tube position include the esophageal detector device,
fiberscope, colorimetric expired CO2 detection, and capnography.
The esophageal detector device consists of a self-inflating bulb and a con-
nector compatible with the tracheal tube connector. The bulb is compressed
and the air within it expelled, and then it is attached to the tracheal tube. In
theory, on release the bulb will quickly refill from the gas in the lung if the
tracheal tube is correctly sited, but will not fill if the tube is sited in the
880 BINGHAM & PROCTOR

esophagus. Of concern is that this is more likely to be true of a cuffed than

an uncuffed tube, because air may be drawn around the sides in the latter.
There are few studies of this device in children and none in the context of
cardiac arrest. One study showed poor accuracy of the esophageal detector
in infants [41], whereas another group demonstrated good sensitivity and
specificity in children both under and over 20 kg [42,43].
Tracheobronchoscopy, using a fiberoptic scope, provides absolute assur-
ance of the position of the tracheal tube, but requires equipment, expertise,
and time, which is seldom available in emergency situations.
Measurement of expired carbon dioxide using either a colorimetric detec-
tor or a capnograph is often cited as the gold standard for confirming
correct placement of a tracheal tube. Colorimetric devices have the advan-
tages of being portable, simple to use, and requiring no power supply.
They are, however, qualitative rather than quantitative devices, and this
potentially limits their use. Pediatric studies are rare, but demonstrate
that, in children over 2 Kg with a perfusing rhythm, detection of expired
CO2 is an effective method of confirming tracheal tube placement [44,45].
A relatively small prospective trial of the use of a disposable CO2 detector
during pediatric CPR [46] showed 100% specificity (ie, all esophageal intu-
bations were detected) but only 84.6% sensitivity (ie, no CO2 detection in
approximately 15% of children who had correct tube placement). In the
context of cardiac arrest, absence of expired CO2 does not confirm misplace-
ment of the tracheal tube, and an alternative confirmation of position (such
as direct laryngoscopy) should be used.
Because dislodgement of tracheal tubes is a constant risk during trans-
port, the use of expired CO2 to confirm tube position and adequacy of ven-
tilation during transport is highly recommended [47].

Laryngeal mask airways

The laryngeal mask airway (LMA) is a supraglottic airway device that
sits over the laryngeal introitus and can facilitate positive pressure ventila-
tion, provided the vocal cords are relaxed and open. It was developed
from studies of adult cadavers, and is available in pediatric sizes that are
suitable for use in neonates, infants, and children (Table 1). The pediatric

Table 1
Size of laryngeal mask airway related to weight of child and recommended maximum cuff
inflation volume
Size of LMA Weight of patient (kg) Maximum cuff inflation volume (mL)
1 !5 4
1.5 5–10 7
2 10–20 10
2.5 20–30 14
3 30–50 20
 AIRWAY MANAGEMENT 881

versions are, however, simply scaled-down versions of the adult devices, and
there is no allowance for the differences in pediatric laryngeal and pharyn-
geal anatomy.
LMAs are useful in adult resuscitation, where they may be a preferable
alternative to bag-mask or mouth-to-mouth ventilation [48]. Although
there are a number of case reports describing the successful management
of supraglottic airway obstruction by experienced operators using LMAs
[49,50], there are currently no published trials of their general use in
pediatric resuscitation. There are good data supporting the safe use of
LMAs in pediatric anesthesia [51,52], but also some evidence that compli-
cation rates are higher, particularly with the smaller sizes [53–56]. There
appears to be a high incidence of impingement of the epiglottis on the
LMA bars following insertion, particularly the size 1 [57]. Complication
rates are also higher for inexperienced users [58], but a recent study
showed that critical care nurses can be successfully trained to use the
LMA in anesthetized children, although time to first breath was slightly
longer than with bag-mask ventilation [59]. A manikin study comparing
LMA ventilation with bag-mask ventilation in prehospital providers found
that time to first breath was greater and that tidal volumes were lower in
the LMA group [60].
There are now a number of other types of LMA such as the intubating
LMA. The intubating LMA is designed to provide a conduit for the blind
passage of a tracheal tube. It is only available for children weighing more
than 25 kg, and although one study reported reasonable success with tra-
cheal tube placement [61], there remains the concern that blind passage of
the tube in the presence of a downfolded epiglottis would result in damage.
Perhaps surprisingly, there is more supporting evidence for the use of the
LMA during resuscitation at birth. Observational studies showed that the
LMA can be used successfully for this purpose and are as effective as
mask ventilation in normal [62,63] and low birth weight [64] babies. A
Cochrane review [65] comparing the use of LMAs with tracheal intubation
in this setting found them to be equally effective, although there was only
one study with small numbers.

Cuffed oropharyngeal airway

The COPA resembles a standard OPA as described above, but has a cuff
on the distal end that is intended to provide a complete seal at the orophar-
ynx to allow positive pressure ventilation. It is inserted in a similar way to
the standard OPA, following which the cuff is inflated. The use of the device
was compared with bag-mask ventilation by nonanesthetists in anesthetized
adults [66], and found to be at least as effective for providing effective pul-
monary ventilation in simulated respiratory arrest. There are descriptions of
its successful use in anesthetized children [67–69], but no pediatric studies of
its use for emergency airway management.
882 BINGHAM & PROCTOR

Needle cricothyrotomy
The technique of needle cricothyrotomy is commonly taught as the last re-
sort of pediatric airway management. Nevertheless, there are several potential
problems with this technique in children. The cricothyroid membrane is far
less well-defined than in adults, particularly in infants. In addition, the cricoid
ring is the narrowest part of the airway (but see above), and thus a needle
placed just below the thyroid cartilage may not bypass an airway obstruction.
In practice, it may be easier and more effective to insert a needle between two
prominent upper tracheal rings. The largest catheter-over-needle system that
will pass should be used (eg, 14G), but spontaneous ventilation will not be pos-
sible through this catheter. Ventilation must be supported, although positive
pressure ventilation through the catheter does not maintain normocarbia,
and oxygenation is the only realistic goal. The connector from a 3.0 mm (or
3.5 depending on the make) tracheal tube will connect to the luer lock of the
IV cannula, and can be used to connect to a self-inflating bag. Alternatively,
if a continuous oxygen source is available, the tubing can be connected to
a three-way stopcock (with all lumens open), which is in turn attached to
the cannula. With a flow rate of 1 L/min/year-of-age, intermittent occlusion
of the open port of the tap will insufflate gas into the trachea. This latter tech-
nique carries a high risk of barotrauma. Commercial insufflation devices that
provide luer-lock connections and medication ports are available.
Cricothyrotomy is rarely performed, even in adults [70], and data sup-
porting its use in children are absent. Nevertheless there are anecdotal
accounts of individual successes.

Education
Lastly, educational priorities continue to shape the application of the sci-
ence of resuscitation to its implementation. Some known advantageous
techniques may be delayed or discarded because of an inability to effectively
provide them to victims. For instance, although a more secure airway might
appear to be preferable, tracheal intubation does not improve the outcome
of resuscitation compared with bag-mask ventilation in many circumstances
[31]. It seems that the technique of tracheal intubation is too difficult to
teach in the current manner or to be retained long enough for potential ad-
vantages to outweigh the complications of routinely attempting intubation.
Other techniques, such as mouth-to-mouth breathing, are challenged by the
reluctance of potential rescuers to perform them. Rescuers may also be in-
hibited from treating children from the knowledge that there are differences
and fear of doing harm.
By understanding the barriers to performance, it may be that a change in
the approach to training will improve resuscitation outcome by bringing
established interventions to more patients.
 AIRWAY MANAGEMENT 883

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