The paediatric airway: anatomy, physiology and management

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Red flags

• A child with stridor at rest, tracheal tug, intercostal recession or accessory-muscle use is at high risk of obstruction on induction — keep them upright and breathing spontaneously until the airway is secured.
• A febrile, toxic, drooling child sitting forward in tripodi is epiglottitis until proven otherwise — do not lie them flat or instrument the airway awake; call for senior anaesthetic and ENT help.
• Saturations fall into the seventies within under a minute of apnoea in a small child — preoxygenation is harder and the safe apnoeic window is far shorter than in adults.
• A barking cough and inspiratory stridor after a recent upper respiratory infection signals croup; a recent URTI multiplies the risk of perioperative airway adverse events.
• Repeated laryngoscopy attempts cause oedema in the narrow paediatric subglottis; each attempt narrows the airway further — limit attempts and escalate early.
• In the neonate or infant the cricothyroid membrane is tiny and a needle cricothyroidotomy is preferred over the open scalpel technique used in adults.