Top Tips for Managing the Paediatric Airway

In this article, Dr Elena Fernandez now summarises her top tips to ensure management of the paediatric airway is both safe and successful.

Paediatric airway management requires specialist equipment. A wide range of sizes of this airway equipment should be available in all areas where children are regularly treated. Ideally, advanced airway equipment should be available in a dedicated paediatric difficult airway trolley [1].


In children under 3 years of age the head should be maintained in a neutral position. In neonates and infants with prominent occiputs, a shoulder roll is often required to achieve a neutral position and open the airway [2]. Have a look at the picture below. Can you see how a simple tilt of the head and use of a should roll can open the airway and relieve airway obstruction?

Facemask ventilation

A correctly sized facemask should cover the bridge of the nose to the chin.
For effective facemask ventilation, the thumb and index finger should be placed on the mask (‘C’ shape) with the rest of the fingers lifting the mandible (‘E’ shape). How to hold a facemask Care should be taken not to compress the soft tissues in the floor of the mouth which will cause airway obstruction [2]. Difficulty with mask ventilation should be managed in first instance with airway opening manoeuvres (head tilt, chin lift and jaw thrust), airway adjuncts, a two-hand-two-person technique, CPAP and deepening of anaesthesia. Inflation of the stomach is common during facemask ventilation in children, aspiration with a nasogastric tube aids lungs’ expansion and ventilation.

Airway adjuncts

Insertion of an oropharyngeal airway will relieve the obstruction caused by the posterior displacement of the tongue in children and help mask ventilation [2]. The appropriate size is measured from the centre of the mouth to the angle of the jaw. In small children care should be taken not to damage the fragile structures of the oropharynx during insertion. Insertion of oropharyngeal airway

Supraglottic airway device (SAD)

SADs are well established in paediatric routine and difficult airway management. Size selection is according to the child’s weight, and is written on the packet. It should be introduced in the midline of the mouth, without rotation, sliding it over the tongue until resistance is felt. The commonest problem with small sizes is down folding of the epiglottis, which can be minimized by performing a jaw thrust manoeuvre during insertion [3]. Cuff pressure should be monitored to avoid damage to the airway mucosa and sore throat. SAD insertion

Tracheal intubation

Prior and during intubation, children should have full monitoring including continuous end-tidal CO2. Adequate depth of anaesthesia and relaxation of the vocal cords should be confirmed.

The straight laryngoscope facilitates lifting of the epiglottis during tracheal intubation in infants under six months. In this technique, the blade of the laryngoscope is positioned below the epiglottis, which is lifted forward to expose the larynx. Bradycardia and hypotension may occur as a result of a vagal reflex[4]. Laryngoscopy with straight blade

From six months of age, a curved laryngoscope is used to indirectly elevate the epiglottis by placing the tip of the blade in the vallecula. Laryngoscopy with curved blade

Tube sizes

Above one year of age, internal diameter and length of tracheal tubes is calculated using the formulas:

Internal diameter (mm) = Age (years)/4 + 4 for uncufffed tubes

Internal diameter (mm) = Age (years)/4 + 3 for cuffed tubes

Length = age (years)/2 + 12cm for an oral tube

Length = age (years)/2 + 15cm for a nasal tube

Cuffed endotracheal tubes are increasingly being used in small children and infants. There is evidence that the newer designs with high-volume, low-pressure cuffs are safe and offer advantages over uncuffed tubes (fewer tube changes, fewer complications, improved controlled ventilation and protection of the airway) [3].

Cuff pressure should be monitored regularly to prevent damage to the airway mucosa. Position of the tube in the trachea is confirmed by the presence of an end-tidal CO2 trace and auscultation of the lungs. To prevent tube displacement, tracheal tubes in children are secured with tape. Position of the tube should be re-checked after changes in head position.

To summarise:

The specific anatomical and physiological characteristics of the paediatric airway determine the choice of techniques and equipment used in airway management.

Due to their high metabolic rate and low oxygen reserves, small children developed hypoxaemia rapidly during apnoea. The primary goal of paediatric airway management is to ensure effective oxygenation and ventilation and the gold standard technique to achieve this is facemask ventilation.

How confident are you at managing a paediatric airway? How are elective and emergency paediatric cases managed in your workplace? Are you ever faced with children on-call when you don’t work with them electively? Are there mnemonic aids or is the equipment organised is such way to make it easier for you to select the appropriate dosage of drug or tool? How can design and ergonomics help?

In the next step, you will learn how to manage the frightening situation of a child with a compromised airway as well as reviewing the DAS Paediatric Difficult Airway Guidelines.


1. 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Major complications of airway management in the United Kingdom. Report and findings March 2011.

2. Chapter 19: Equipment and basic anaesthesia techniques. Bingham R, Lloyd-Thomas A, Sury M. Ear, nose and throat surgery. In: Hatch & Sumner’s Textbook of Paediatric Anaesthesia. Third Edition. London: Edward Arnold (Publishers) Ltd. 2008; 273-8, 287-90.

3. Sims C, von Ungern-Sternberg BS. The normal and the challenging pediatric airway. Paediatr Anaesth. 2012;22:521–6.

4. Adewale L. Anatomy and assessment of the paediatric airway. Pediatr Anesth 2009; 19(suppl 1): 1e8.

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This article is from the free online course:

Airway Matters

UCL (University College London)