Anatomy and Physiology

Children have large occiputs and require a shoulder roll to elevate the chest in order to align the airway. The large tongue, small mouth, anterior larynx and large, floppy epiglottis can make the mechanics of intubation difficult. And the trachea is very short which makes it easier to mainstem the tube and also easy for the child to dislodge the tube, especially in infants.

Children have a higher oxygen consumption rate compared to adults due to their higher metabolic rate. This means that adequate preoxygenation only allows children approximately 2-3 minutes of apnea before desaturation compared to 5-6 minutes in adults. Additionally, children have a decreased functional residual capacity which contributes to their quicker desaturation.

Also, just like in adults, any child with a history of obstructive sleep apnea, prior difficult intubation, facial/neck trauma, or dysmorphic facial features should be considered a more difficult airway and you should prepare for these patients accordingly. Age of the patient has been shown to be an independent effector of first-pass success rate, with infants at highest risk of first-attempt failure (anatomic and physiologic differences are most pronounced in this age group)


Airway equipment comes in all shapes and sizes for children – be sure to know what your institution carries. Previously, cuffed tubes were not used in pediatric patients due to concern for subglottic stenosis (which was found in prolonged intubation with an overinflated cuff) but in the acute setting this hasn’t been shown to be as much of an issue, so go ahead and use those cuffed tubes in kids!

Who places the tube?

Pediatric intubation and airway management performed by trainees in academic institutions with attending physician supervision is safe and several studies have documented high success rates and low complication rates – so teach those trainees and get them involved in the RSI process early on. In the most critically ill patients, or in those with a predicted difficult airway the most experienced laryngoscopist should get the first attempt.


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