The Challenging Pediatric Airway: New Solutions for "Old" Problems

Judy Audas CRNA, DNAP, MSN

Overview• Developmental airway anatomy• Compare/contrast the pediatric and adult airways• Airway challenges in children• Airway assessment and congenital anomalies• To cuff or not to cuff …… the ETT• The dreaded laryngospasm • "Old" surgical strategies• "New" surgical strategies

Developmental Airway Anatomy• Carnegie system• Majority of

airway structural growth is in the 1st 8 weeks of gestation

• As the respiratory and alimentary systems develop, the vertical position of the larynx changes

Developmental Airway Anatomy• Pharyngeal arches

develop into laryngeal and tracheal structures

• Facial nerve, glossopharyngeal nerve, superior laryngeal nerve, recurrent laryngeal nerve development

• Complete by 8 weeks (stage 23)

Developmental Airway Anatomy

Pediatric vs Adult Airway

• 5 notable differences• the position of the

larynx• the shape of the

epiglottis• the vocal cords• the mucous

membranes• the cricoid ring

Origin of Airway Problems• Infectious/inflammatory

• Acute epiglottitis, croup, bacterial tracheitis, bronchiolitis, retropharyngeal abscess

• Trauma/accidents• Foreign body aspiration, airway burn, external trauma, post-

intubation injury• Congenital

• Choanal atresia, laryngotracheomalacia, midface or mandibular anomaly, syndromic anomalies

• Other factors• Tumors, intrinsic pulmonary disease (BPD), cardiac defects,

central nervous system defects, metabolic causes

Pediatric Airway Assessment

• Mallampati score………..……..good luck with that!• Parental History******• Observation of breathing patterns• Sound of cough

Pediatric Airway Differential Diagnosis• Signs & symptoms of obstruction

• Stridor• Inspiratory - indicates obstruction is extrathoracic (croup,

epiglottitis)• Expiratory – indicates obstruction is intrathoracic

(tracheomalacia, bronchomalacia)• Wheezing

• RSV bronchiolitis croup• Drooling, dysphagia, sore throat, laryngeal tenderness

• Obstruction is likely above the glottis• Barky cough with loud inspiratory stridor = subglottic

and extrathoracic (foreign body in airway)

Common Airway Challenges• Croup – from URI

• Fever (usually low grade)• Hoarseness, barky cough, variable

degree of inspiratory stridor, and respiratory distress

• Inflammation and edema in the tracheobronchial tree

• Also called laryngotracheobronchitis• Symptoms are r/t subglottic

edema/inflammation• Less than 5 years of age

Common Airway Challenges Inflammatory

• Acute Epiglottitis

Common Airway Challenges Inflammatory

• Bacterial tracheitis

Common Airway Challenges Syndromes

• Apert syndrome• Beckwith-Weideman• Crouzan• Down• Goldenhar• Klippel-Feil• Pierre Robin• Pfeiffer• Treacher Collins

Common Airway Challenges

Cuffed ETTs in Pediatrics……What?!?