Tip en El Manejo de La Dificultad y La Falla Ventilatoria

J u s t B re a t h e
Tips and Highlights for Managing Pediatric

Respiratory Distress and Failure
Megan J. Cobb, MD, DPT
KEYWORDS
Pediatric Airway Intubation Supraglottic airway Laryngoscopy
Noninvasive ventilation
KEY POINTS
The pediatric airway is more anterior and superior, with the subglottic region being most
narrow, and these differences are pronounced until at least age 8 years, when proportions
begin to resemble more closely those of adults.
Video laryngoscopy has become a common and successful technique used in several
airway management scenarios owing to improved glottic views and ease of training.
Noninvasive ventilation, including continuous positive airway pressure, bilevel positive
airway pressure, and high-flow nasal canula, is highly effective in treating pediatric respi-
ratory failure but does not replace intubation if needed.
When properly adjusted for size, cuffed tracheal tubes are safe to use with pediatric air-
ways, except in neonates, with fewer air leaks during assisted ventilation and less post-
extubation stridor than uncuffed tubes.
INTRODUCTION
Emergency physicians are highly trained in the management of threatened, injured, or

compromised airways. The expectation of emergency physicians is to successfully
complete this task, no matter the age or condition of the patient. In special circum-
stances, assistance from anesthesia, otolaryngology, or other surgical specialty
may be called on if available, which may facilitate securing the airway but does not
guarantee success. Few airway emergencies are as emotionally charged as a
crashing pediatric patient. The most common overall complication of managing a pe-
diatric airway is transient hypoxemia (<85%), with the most serious complication of
failed airway management being cardiac arrest.1 This article provides current emer-
gency physicians with tips, tricks, and strategies to more confidently enter the next pe-
diatric resuscitation and achieve the desired outcome. Moving forward, it is important
University of Maryland School of Medicine, Department of Emergency Medicine; Maryland

Emergency Medicine Network, Upper Chesapeake Emergency Medicine, 500 Upper Ches-
apeake Dr, Bel Air, MD 21014, USA
E-mail address: Megan.Cobb@som.umaryland.edu
Emerg Med Clin N Am 39 (2021) 493–508

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494 Cobb
to remember that the pediatric airway is different, not alien, and can be challenging,
but is not impossible.
ANATOMIC CONSIDERATIONS
The first, most glaring difference of the pediatric airway from that of the adult is size.
This size range can create anxiety given the margin of error in technique is also smaller
when intubating. The range of equipment sizes is larger and requires more forethought
as well. The larger omega-shaped epiglottis is longer, floppier, and more prone to
obscuring the view of the glottic opening. This difference in particular highlights the
benefit of using a straight laryngoscope blade, which can lift the epiglottis from view
and allow more direct visualization of the pediatric glottis when anatomic axes are
appropriately aligned. A list of available straight blades can be found in Box 1. Curved
blades, which can also be used to optimize glottic views, can be found in Box 2. Other
types of laryngoscope blades are listed in Box 3.
In the neonatal period, laryngeal structures are the most superior, aligned near the
second cervical vertebral body (C2). By adolescence, the larynx has dropped to near
the C5-C6 level. This change means that the angle from the base of the tongue to the
glottic opening is most acute with the youngest patients.2 The infant airway also has a
lower-lying posterior palate, and, with the proportionally larger epiglottis, the naso-
pharynx and hypopharynx are in closer proximity, which encourages obligate nasal
breathing that decreases risk of aspiration. These features, in addition to a more ante-
rior airway and smaller glottic opening, can increase the challenge of proper alignment
of anatomic axes and optimal intubating positioning.3
The next significant difference is the location of the narrowest point of the airway. In
a normal adult, the glottic opening is the narrowest, such that, once the tracheal tube
has been passed through the vocal cords, there should be no other restriction to
placement. However, in children up to 8 years of age, the subglottic area has the
most narrow dimensions, at the level of the cricoid.4 This narrowing can be even
more exaggerated in children with history of laryngotracheomalacia or tracheomalacia
(Fig. 1).
Box 1
Straight laryngoscope blades
Blade name:
Cranwall
Jackson
Janeway
Magill
Miller
Phillips
Robertshaw
Seward
Soper
Wis-Hipple
Wisconsin
Managing Pediatric Respiratory Distress 495
Box 2
Curved laryngoscope blades
Blade name:
Macintosh
Reduced Flange Macintosh
Parrott
Siker
Box 3
Other laryngoscope blades
Blade name:
McCoy
Vie Scope
Fig. 1. An adult airway (left) and pediatric airway (right). Note the cone-shaped narrowing
of the pediatric airway caused by inherent subglottic configuration. (Drawing used with
permission from Carlos Lugaro, Jr.)
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Pediatric airway cross-sectional area shows no significant difference with respect to

sex until after 14 years of age. After that time, the airways of male patients are approx-
imately 25% larger with respect to cross-sectional area.5 This difference is likely
caused by pubertal development and growth spurts.
Obesity and Airway
Obesity has been shown to have negative predictive value of airway size in adults,
thought to be caused by physical compressive forces, as well as the effects of thoracic
pressure. Similar findings have not yet been established in pediatrics; however, a
retrospective case series of computed tomography and MRI of the neck of 171 pedi-
atric patients at a tertiary care center showed a similar notable trend of smaller airway
size with higher body mass index.6 This trend did not meet statistical significance but
may inform future research and provide an additional consideration to airway manage-
ment, such that having the next-smaller tube size available is an important option at
time of intubation.
DIFFERENCES IN PHYSIOLOGY
Infants and children have higher diaphragms with proportionally larger abdominal con-
tents causing reduced lung volumes.4 Developing alveoli, smaller thoraces, and differ-
ences in tissue recoil are causes for a lower functional residual capacity (FRC) in
infants and children. Because FRC is the gas still in lungs at the end of normal tidal
expiration, it is also responsible for gas exchange.7 The smaller FRC in combination
with children’s higher metabolic rates and oxygen demand shortens the window dur-
ing which intubation can be performed with optimized oxygenation. Oxygen demand
is estimated at twice that of adults, and highlights the rationale for performing apneic
oxygenation during intubation.8 Data on apneic oxygenation for pediatric patients un-
dergoing emergent intubation in the pediatric emergency department are slightly
mixed; however, 2 recent studies, Vukovic and colleagues8 and Overmann and col-
leagues,9 used alternative methods, which likely account for the opposing findings.
Results supporting use of apneic oxygenation from Vukovic and colleagues8 in 2018
used standard nasal canula, 4 L/min for patients up to 2 years of age, 6 L/min between
2 and 12 years old, and 8 L/min for those greater than 12 years old.
APPROACH TO ACUTE RESPIRATORY FAILURE IN PEDIATRICS
Respiratory failure can be caused by a variety of parenchymal diseases or injury,

impending or acute airway obstruction, metabolic demand that exceeds that of the
patient’s respiratory function, and neurologic compromise such that the airway itself
cannot be self-protected. The underlying cause of the patient’s respiratory failure
can and should direct the approach to ventilatory support and supplemental oxygen-
ation. For example, for those patients with parenchymal disease, hypoxemia may be
caused by alveolar inflammation and fluid accumulation; therefore, it may be appro-
priate to start with noninvasive ventilation (NIV) before proceeding to intubation. For
children with severe thermal airway injury or acute epiglottitis, placing a tracheal
tube is an emergent procedure to prevent impending airway closure; noninvasive
measures are likely to be inadequate. Emergency physicians must also take a
measured approach in deciding the most appropriate airway interventions with
respect to transfer to definitive disposition, especially if such disposition requires
transport via ambulance or helicopter.
When resuscitation and support measures are underway, it is important to keep par-
ents and caregivers updated on the indications and plan for management. In addition
to consent, they can provide the much-needed emotional support, assist in calming
the child during anxiety-provoking procedures, and aid in redirection from attempts
at removing support lines and devices, such as high-flow nasal canula (HFNC) and
continuous positive airway pressure (CPAP).
NONINVASIVE VENTILATORY SUPPORT AND HIGH-FLOW NASAL CANULA
The benefits of NIV are numerous for both adults and children. Specifically, NIV sup-
ports patency of the upper airway, increases FRC, reverses hypoventilation, de-
creases work of breathing, and decreases oxygen consumption while improving
cardiac output.10 Simply stated, NIV has been an undeniable game changer in the
management of respiratory distress and failure for adults, children, and infants. NIV
can be considered before tracheal intubation in children with acute respiratory failure,
but, regardless of modality, it should not delay intubation if an invasive airway is
indicated.11
High-flow Nasal Canula

HFNC is a form of noninvasive support in respiratory failure for both oxygenation and
ventilation, albeit much more the former than the latter. The heated and humidified air
is delivered ideally at flow rates and fraction of inspired oxygen (FiO2) that match or
exceed the needs of the patient in distress. By doing so, the work of breathing is
reduced, and patients can find relief. Because the prongs are larger, higher flow rates
can be accommodated. When these high flow rates are coupled with a closed mouth,
there is an estimated 1 cm H2O of positive end-expiratory pressure (PEEP) for every
10 L/min.12 Although there are likely additional mechanisms at play, there is also alve-
olar recruitment and an increase in FRC.12 Additional advantages to HFNC include hu-
midification, which may also serve to loosen secretions and decrease mucus
plugging.13
When starting infants on HFNC, flow rates of 1.5 to 2 L/kg/min are recommended to
effectively decrease their work of breathing. Studies have found that the work of
breathing in infants with bronchiolitis is between 1.6 and 1.8 L/kg/min.10 FiO2 should
be titrated to reduce work of breathing and, as is generally accepted, maintain oxygen
saturations greater than 90%.
Continuous Positive Airway Pressure and Bilevel Positive Airway Pressure

By nasal apparatus or face mask, CPAP has successfully treated patients with pedi-
atric respiratory failure for some time. It has found particular success in supporting in-
fants and small children with bronchiolitis.13 The augmentation of end-expiratory
pressure and increased airway diameter effectively increases the FRC and decreases
the work of breathing. The nasal apparatus can provide adequate support because
many of these children are obligate nasal breathers and have difficulty overcoming
the copious nasal secretions. Regardless of application device used, effective
CPAP decreases capillary partial pressure of carbon dioxide, respiratory rate, heart
rate, and FiO2. CPAP has also been shown to be of use in pediatric pneumonia, heart
failure, and asthma, although the exact beneficial mechanisms are still pending
conclusive research, the mechanisms are likely similar to those known in adults.
Bilevel positive airway pressure (BiPAP) provides additional support in that there is
an intermittent increase of positive pressure, which attempts to mimic more normal
respiration by supporting inspiration. The benefits of BiPAP are similar to those of
CPAP, but it is often initiated when patients require more support, particularly with
ventilation or work of breathing. It is an option for severe asthma exacerbations in
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pediatric patients,14 as it is also used in adults with severe asthma, chronic obstructive
pulmonary disease, pneumonia, and heart failure.
Choice of Noninvasive Support

Choosing the correct modality of noninvasive support can be difficult. Numerous fac-
tors influence the decision. The degree of respiratory distress, the cause of respiratory
failure, and the patient’s age are among the primary considerations. Table 1 includes
additional considerations.
A prospective, multicenter study of pediatric intensive care unit (PICU) patients with
respiratory failure investigated whether use of NIV and HFNC before intubation was
associated with greater peri-intubation adverse events or more severe oxygen desa-
turation. There was no indication that using NIV before intubation was harmful to pe-
diatric patients or increased risk of peri-intubation adverse effects. It did find that
higher FiO2use (>70%) was associated with more severe peri-intubation desaturations;
however, this is a logical finding in that those patients who require a higher FiO2with
NIV and are still experiencing progressive respiratory failure are likely sicker and
would, therefore, have less physiologic reserve and tolerance for the brief period of
apnea associated with intubation.15
A 2019 retrospective study of infants and young children admitted to the PICU for
bronchiolitis observed a higher failure rate in those receiving HFNC as opposed to
Table 1
Considerations of noninvasive modality
Patient Factors Age

Weight
Degree of distress
Cause of failure
Underlying comorbidities
Concurrent illness or injuries
Diagnostic or
procedural indications
Mental status
Caregiver support
Last Meal
Physician Factors Training
Knowledge
Experience
Confidence
Support Staff Nursing experience
Nursing ratios
Respiratory therapists
Facility Additional physicians
Equipment
Supplies
Facility use
Availability of equipment
during times of increased need
Disposition Inpatient availability
Intensivist support
Transfer requirements
Time to disposition, mode of
transport, time to destination
BiPAP or CPAP. Subjects ranged from 1 month to 2 years of age, and those patients
placed on HFNC as the initial modality of choice tended to be older than those who
started on BiPAP or CPAP.16
Starting severe asthmatics on HFNC has shown a reduction in respiratory distress
early in treatment in the emergency department.17
DECISION TO DEFINITIVE AIRWAY
Ideally, patients are at least partially resuscitated to optimize conditions for intubation.
Pokrajac and colleagues18 found that pediatric patients less than the age of 1 year,
with persistent hypoxemia, or in whom clinicians were unable to obtain a pulse oxim-
etry reading before intubation, were more likely to experience peri-intubation cardiac
arrest in the pediatric emergency department.
View from the Top

Once the decision to place an invasive airway is decided, it is important to have a sys-
tematic approach to preparation and team organization (Table 2).
1. Bring bed up to appropriate level for the operator.
2. Ensure intravenous or intraosseous access is functional.
3. Optimize patient positioning, with particular consideration of the head. Because
children’s heads are larger in proportion to the rest of their bodies, optimal posi-
tioning often requires a shoulder roll or other support to bring the sternal notch
up to the level of the tragus, which in turn aligns the laryngeal axis.
4. Ensure multiple sizes of the adjunctive equipment, as well as the tracheal tube
sizes, with the corresponding stylets, and syringe for cuff inflation.
5. Proper monitoring equipment should also be thoughtfully applied, including prep-
aration for end-tidal capnography. When available, preintubation and postintuba-
tion end-tidal capnography can be a useful adjunct in airway management.
6. When the patient is properly positioned, equipment available, and team members
poised, it may be beneficial to perform a brief time-out confirming patient identifi-
cation and indication, and to ensure all involved are focused on the task at hand.
7. Detailed description of various intubation techniques is beyond the scope of this
article; however, they should be practiced and reviewed by emergency physicians
regularly for maintenance of skills.
The importance of thorough and thoughtful preparation before intubation cannot be
overstated. A retrospective study of pediatric acute respiratory compromise events
Table 2
Mnemonic for preparing to intubate
S Suction (Yankeur, flexible catheter, dual suction sources if available)

O Oxygen (always confirm by personal inspection, use wall/tower source when
possible)
A Adjuncts (OPA, NPA, bougie, bag-valve-mask setup)
P Pharmacology (sedation, paralytic, reversal, code medications) and people
M Machine (ventilator, power source, tubing, viral filter)
E Equipment (TT, direct laryngoscope, video laryngoscope, appropriate stylet,
end-tidal capnography)
Abbreviations: OPA, oropharyngeal airway; NPA, nasopharyngeal airway; TT, tracheal tube.
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found that failure of placement of invasive airway on the first attempt was associated
with increased risk of progression to cardiopulmonary arrest, adjusted odds ratio of
1.8 (95% confidence interval, 1.2–2.6).19 There were factors with greater odds ratios;
however, this finding still highlights the importance of making the first attempt the best
attempt. There is a direct correlation between number of attempts to obtain the airway
and adverse events, including aspiration, desaturation, esophageal intubation, hypo-
tension, dysrhythmia, and cardiac arrest.20 Studies have shown that female pediatric
patients are at increased risk for failed first attempts and inappropriate insertion
depths.21 It is important to be mindful that the first attempt should be the best attempt.
Underestimating the potential difficulty of the airway can prove disastrous.
CUFFED VERSUS UNCUFFED
A randomized controlled study among anesthesiologists at a tertiary children’s hospi-

tal assessed differences between cuffed and uncuffed tubes for elective pediatric sur-
gery before 16 years of age. Uncuffed tubes were found to require more adjustments
at the time of intubation to achieve the best size, and had greater volume of air leaks.22
The benefits of cuffed tracheal tubes have even shown decreased air leak and
reduction in postextubation stridor in children less than 5 years of age. Cuff pressures
should be kept less than 20 cm H2O.23
A neonatal intensive care unit at a tertiary children’s hospital studied cuffed and
uncuffed tracheal tubes for infants weighing less than 3 kg. Given that the infants
were intubated in the operating room and the Microcuff tubes are unlikely to be stan-
dardly stocked in most emergency departments, this study’s current applicability is
limited, but it will give way to future research regarding the safety and use of cuffed
versus uncuffed tubes for infants 3 kg or less.24
PREDICTION OF TUBE SIZE
Predicting the appropriate endotracheal tube size based on its internal diameter has
long been determined by the equation [(age/4) 1 4] for uncuffed tubes, and subtract-
ing 0.5 for cuffed tubes.25 There have been proposals for estimation of tube size based
on anthropometric characteristics as well. Use of the length of the middle finger in cen-
timeters, rounded up to the nearest 0.5, may estimate the appropriate tube size inter-
nal diameter in millimeters. This estimation has been shown to have a linear
relationship with best-fit tube size, as opposed to the age formula, which is nonlinear
and begins to show greatest variation at age 6 years old.25 The diameters of the distal
phalanx of the small and index fingers were also shown to have poor accuracy in pre-
dicting the tube of best fit for children aged 1 to 10 years.26
Each of these equations is incapable of predicting the perfect-fit tube size given the
endless variety of airway dimensions in pediatric development, nor do the equations
approximate the external diameter, which is the dimension of greatest concern
when attempting to avoid postintubation subglottic stenosis or poor fit leading to inad-
equate tidal volumes and ventilation. In every preparation to place an invasive airway,
a variety of tube sizes must be available with the clinician being able to quickly assess
the size of the glottic opening and choose the tube most likely to pass on first attempt
and optimize future function, while also limiting risk of injury (Table 3).
THE GREAT DEBATE: VIDEO VERSUS DIRECT LARYNGOSCOPY
Conventional teaching in management of the emergent airway has been strongly

based in skills of direct laryngoscopy (DL). A Miller or Macintosh laryngoscope blade
Table 3
Equations for tube size approximation
Tube
Source Type Equation Notes
Cole Uncuffed (age in years/4) 1 4 5 ID (mm) First published in 1957
Motoyama Cuffed (age in years /4) 1 3.5 5 ID (mm) For children older than 2 y
Khine Cuffed (age in years /4) 1 3 5 ID (mm) For children less than 2 y
Ritchie- Cuffed Length of middle Derived from equations that
McLeana finger (cm) 5 ID (mm) equate TT depth to 3 ID and
3 length of the middle finger
Abbreviation: ID, internal diameter of TT.

a
Ritchie-McLean S, Ferrier V, et al. (Anesthesia 2020) conducted a small study, examining the
predicted TT size by use of middle finger length compared with best-fit tube size as determined
by an anesthesiologist for the purposes of the planned procedure.
is sized for the approximate depth of the epiglottis or vallecula, respectively, and when
the pharyngeal and laryngeal axes align, the glottic opening comes into view. The tra-
chea tube is then passed directly through the vocal cords, with estimated insertion
depth to be 3 times that of tube size. Video laryngoscopy (VL) has the benefit of
providing full views of the glottic opening without necessary alignment of the pharyn-
geal and laryngeal axes.29 A review of datasets from the National Emergency Airway
Registry for children (NEAR4KIDS) published in 2016 showed increasing trends for VL
use with first-pass success rates of 97%.21
In simulation training for pediatric residents, GlideScope VL did not improve perfor-
mance of mannequin endotracheal intubation compared with DL for normal airway,
but it may prove the safer option to avoid upper jaw injury or with more
complex airways.27 Several other studies have found the opposite, and suggest that
the only clinically significant differences to be view of glottis, which is more complete
with VL, but longer time to intubation compared with DL.2 The increase in time to intu-
bation may be related to manipulation of the tube around the tongue and teeth, and
into the trachea, as opposed to direct line of sight and passage as is achieved with DL.
BOUGIE TALK
Use of a semirigid, flexible bougie adjunct has become more popular in recent years,
particularly in the emergency department. Although once considered primarily for
salvage or rescue in difficulty airway attempts, a 2018 randomized study by Driver
and colleagues28 showed increased first-pass success rate when used in the emer-
gency department for endotracheal intubation rather than tracheal tube plus standard
stylet. This benefit held true for groups of patients deemed to have at least 1 difficult
airway characteristic, as well as all comers requiring emergent intubation. This study
was specific to patients 18 years of age and older, and excluded those with upper
airway obstruction such as angioedema or epiglottitis.
There is not yet a comparable study of size and randomization in pediatric emer-
gency airway management. Limitations to use of pediatric-sized bougie may include
the less frequent opportunities for pediatric tracheal intubation in both training and
practice compared with adults. Learning proficiency in tracheal intubation can be
challenging, and use of a bougie, be it successful in first pass attempt or rescue tech-
nique, does require instruction and practice. With pediatric intubations occurring less
frequently than with adults, emergency medicine residents and attending physicians
alike may not be comfortable adding an additional piece of equipment to the milieu.
Although several airway management techniques are transferrable between pediatrics
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and adults, operator comfort does play a large role in how and when those tools are
used. Ideally, future emergency medicine research will address this topic and provide
further recommendations for bougie use, which may also support first-pass success in
infants and children, as in adults.
SUPRAGLOTTIC AIRWAYS
Supraglottic airways (SGAs) have been widely used in adult resuscitations as rescue
devices when tracheal intubation is not feasible or as the primary airway device in
select patients. SGAs include laryngeal mask airways (LMAs), which are the primary
reference of this article. They are highly popular in pediatric airway management as
well. Of particular benefit, SGAs can remove the obstruction caused by the tongue
and posterior pharyngeal tissues.29 In a 2017 study of pediatric anesthesia cases, Bur-
jek and colleagues found that there were similar rates of first-pass success between
VL and fiber-optic intubation via supraglottic airway. The first-pass rate was higher in
cases of difficult airways. Fiber-optic intubation via SGA also provides the additional
benefits of ongoing oxygenation and ventilation while the definitive airway is placed,
presumably thereby decreasing rates of peri-intubation hypoxemia.30
The research regarding the most effective or easiest-to-use LMA is ongoing, and the
landscape will continue to change with new medical technologies. For instance, the
i-gel, Pro-seal, and Classic LMAs were found to have no statistically significant differ-
ence in ease of insertion, air leak, or passage of gastric tube in a meta-analysis with
pediatric anesthesiologists.31 Another prospective study found no particular benefit
between the air-Q and i-Gel SGAs with respect to time to insertion, bronchoscope
insertion, or bronchoscopic glottic views.29
Even though some of these devices have shown up to 100% first-attempt success
with pediatric anesthesiologists, the unruly conditions of the emergency department
may not allow the same guaranteed performance. The operating room allows metic-
ulously controlled circumstances (eg, last meal, medical history, need for intubation,
hemodynamic stability), which are not applicable in the emergency department.
EARLY VENTILATOR MANAGEMENT
Per review recommendations from the Pediatric Mechanical Ventilation Consensus

Conference published in 2017, there are no standardized recommendations for the
most effective ventilator modes or strategies for mechanical ventilation of critically ill
children.11 Several summary publications recommend that clinicians choose a me-
chanical ventilation mode based on clinical experience and with the understanding
of the causative pathophysiology.11,32,33 Pressure-regulated volume control, volume
control, and pressure control modes are commonly used, but there is use of airway
pressure release ventilation in pediatric critical care as well. The names of ventilator
modes may vary by brand of physical machine, unit, and regional differences.
Once an invasive airway has been placed, it is recommended to choose settings
that allow the greatest degree of patient-ventilator synchrony. Asynchrony, a common
problem, is caused by delay between the neural onset of the patient attempting a
breath and the ventilator’s response.33 As asynchrony increases, so does the degree
of discomfort and challenge in managing the ventilated patient. When the inspiratory (I)
and expiratory (E) times and triggers are set, careful consideration should be taken to
avoid flow cutoffs, which may cause air trapping; however, there are no definitive rec-
ommendations on I/E ratios or times. Air trapping can lead to inadequate ventilation,
increased intrathoracic pressure, risks impairing venous return, and, subsequently,
cardiac output. Sensitivity of triggers, as well as I and E times, should ideally support
spontaneous respirations by the patient. However, with increasing respiratory failure

requiring more aggressive settings, such as high FiO2, and increasing peak and
plateau pressures, patients may benefit from increased sedation and intermittent
neuromuscular blockade to facilitate synchrony and the effectiveness of mechanical
ventilation.11
Selecting modes and setting triggers only achieve a portion of the ventilatory goals.
PEEP, peak inspiratory pressure, and delta pressure (DP) should be titrated to
maximal effect for the patient, while also limiting risk for barotrauma. Studies of
healthy infant lungs have shown usual PEEP of 3 to 5 cm H2O, so PEEP must at least
match the patient’s intrinsic end-expiratory pressure to preserve alveolar integrity and
prevent detrimental atelectasis. PEEP can then be uptitrated as needed, particularly
when troubleshooting hypoxemia.11 Similar to adult recommendations, plateau pres-
sure should not exceed 28 cm H2O.11
Last, but of particular importance, is the management of tidal volume. Lung-
protective strategies, which have been shown to have multiple benefits in adult acute
respiratory distress syndrome (ARDS), are also recommended in pediatric ARDS. Tar-
geting tidal volumes between 3 and 6 mL/kg of ideal body weight is preferred.32 It is
worth noting that, in the setting of significant childhood obesity, estimation may
require more finesse and consideration than blind multiplication. In otherwise healthy
lungs of patients who have been intubated for airway protection, volumes approaching
6 to 8 mL/kg of ideal body weight are acceptable. In a pressure-regulated mode, tidal
volumes may vary breath to breath based on compliance of the lungs and how quickly
the peak inspiratory pressure is reached.32
PHARMACOLOGY
Rapid sequence intubation (RSI) is a commonly used technique in the pharmacologic

facilitation of an invasive airway, and although a full discussion of this topic is beyond
the scope of this article, there are several trends and recent findings that may be help-
ful. For example, RSI was noted to be 3.4 times more likely to be followed by first-pass
success than sedation alone in a surveillance study from 2016.21 That same study also
showed an increasing trend in the use of etomidate and rocuronium, whereas an over-
all declining use of succinylcholine was also observed. However, succinylcholine does
continue to be the primary paralytic used in pediatric patients.21 There was also a clear
tendency to avoid use of a paralytic in those patients less than 2 years of age.21
Regional and international differences in RSI exist that are also worth noting. A study
from the United Kingdom published in 2020 found that the 2 most common induction
agents used for pediatric patients with trauma, in particular those with traumatic brain
injury, were propofol and midazolam.34 This trial was in a single-center, tertiary hospi-
tal and, therefore, may not represent the entire country; however, it is worth noting and
suggests the importance of being well versed in several sedation medications for RSI
to adapt and succeed in a variety of settings.
The adverse effects of the induction agent should always be acknowledged before
use. For instance, propofol is well known to induce hypotension following administra-
tion, and has been shown to increase Injury Severity Scores of pediatric patients with
trauma after use.34 Alternatively, ketamine has shown a lower association of adverse
effects when used as the induction agent in pediatric patients with sepsis and/or
shock during tracheal intubation.35 With regard to etomidate, there are still many cli-
nicians who avoid its use during the intubation of patients with sepsis because of re-
ported risk of adrenal insufficiency and increased mortality; however, pediatric studies
are still lacking and provide no definitive evidence to prohibit its use during RSI.36
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SPECIAL POPULATIONS
Cardiac Arrest
The airway management in pediatric cardiac arrest varies widely and is largely influ-
enced by in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA).
Up to 80% of pediatric patients with IHCA had an airway in place at the time of ar-
rest.37 For nontraumatic OHCA in patients less than 18 years of age, a recently pub-
lished prospective observational study found that tracheal intubation was successful
in slightly less than 60% on first-pass attempt, whereas placement of SGA (namely the
i-gel and King laryngeal tube) was successful in nearly 95% of first attempts.38
Regardless of airway management device, attempts at monitoring end-tidal cap-
nography (EtCO2) should be made. Those pediatric cardiopulmonary resuscitation
events that were conducted with EtCO2 (which can indicate adequacy of compres-
sions, as well as rapidly increase before return of spontaneous circulation) were asso-
ciated with increased occurrence of return of spontaneous circulation. Resuscitative
efforts also tended to last longer than those that did not use EtCO2.39
Coronavirus Disease 2019

Discussed in more detail elsewhere in this issue, it is worth mentioning that pediatric
patients with symptomatic severe acute respiratory syndrome coronavirus-2 do not
frequently require advanced resuscitative care; however, those requiring intubation
have occurred.40 Pediatric patients may present with respiratory failure as a result
of bilateral pulmonary infiltrates, or may require NIV or intubation for hypoxemia
caused by myocarditis and fulminant heart failure.41 In addition to standard eyewear,
the physician and staff should wear N95 respirators, gowns, and consider full-face
masks to minimize aerosol exposure. The ventilator should also be equipped with a
viral filter. The exact approach to airway control may depend on the institutional policy
on airborne-generating procedures.
Neuromuscular Disease
The most common neuromuscular diseases (NMDs) requiring NIV are Duchenne
muscular dystrophy and spinal muscular atrophy.42 Other NMDs include Guillain-
Barré syndrome (GBS), amyotrophic lateral sclerosis, myasthenia gravis, polymyosi-
tis, and dermatomyositis.43 Given the progressive nature of the chronic
diseases, fatigue and alveolar hypoventilation can have insidious onsets such that,
when ill, there may be a rapid decline in respiratory function in what may initially
seem to be a minor illness. The patient may or may not already have been started
on NIV for sleeping or intermittent daytime alveolar maintenance depending on the
severity of the chronic illness, such that escalation of support may require starting
with more advanced modalities than standard-flow nasal canula. For the acute dis-
eases, such as GBS, the rapid decline in strength of respiratory muscles can create
precipitous respiratory failure and airway compromise. If an invasive airway is indi-
cated, it is important to remember that succinylcholine is generally contraindicated
because of risk of hyperkalemia from acetylcholine receptor upregulation in chronic
denervating diseases or acute disease after 48 to 72 hours.44
Craniofacial and Skeletal Dysplasia

The common teachings for successful intubation are based on the assumption of a
typical anatomy; however, patients born with craniofacial or skeletal dysplasia do not
tend to follow within the typical spectrum. Craniofacial abnormalities may be caused
by genetic or intrauterine abnormalities, teratogenic effects, and infantile or early
childhood injuries. Although resultant injury patterns can be unpredictable, the identifica-
tion of several congenital syndromes and associations can provide guidance regarding
the expected abnormalities. For instance, Goldenhar syndrome, or oculoauricular skel-
etal dysplasia, which occurs every 1 in 3000 to 7000 live births, is often associated with
hemifacial microsomia and micrognathia. In addition to the complex positioning and
configuration of the airway, they are also prone to odontoid hypoplasia and atlantoaxial
instability, which increase the risk of cervical spine injury during typical positioning and
manipulation of intubation.45,46 Down syndrome is associated with atlantoaxial insta-
bility, and should also inspire caution with spinal manipulation during intubation.
Other craniofacial dysplasias, particularly craniosynostoses causing midface hypo-
plasia, necessitate an alternative set of special precautions and considerations. The
most common craniosynostosis are Apert syndrome, Crouzon syndrome, Pfeiffer syn-
drome, Saethre-Chotzen syndrome, and Carpenter syndrome.47 Most are autosomal
dominant and have variable expression, and, despite several differences, they are all
associated with unusual cranial shape, often oblique and/or asymmetric, and midface
hypoplasia, which reduces or eliminates the nasopharynx and hypopharynx.47 The
resultant upper airway configuration causes significant obstructive sleep apnea and
chronic respiratory problems. Achondroplasia often features atypical facies accompa-
nied by a large occiput, narrow foramen magnum, and hypoplastic ribs.48 For all of
these patients, emergency physicians should anticipate difficulty with alignment of
anatomic axes, challenges with bag-valve-mask ventilation, and equipment sizes
that are difficult to estimate.
CLINICS CARE POINTS
Before intubation, it is reasonable to attempt noninvasive positive-pressure ventilation or

HFNC in pediatric patients with respiratory distress, because failure of these modalities
does not worsen clinical outcomes.
Both direct and videolaryngoscopy can be used to successfully intubate pediatric patients,
with first-pass success depending on operator training and preference, but
videolaryngoscopy has been shown to increase total duration of intubation attempt.
Peri-intubation hypoxemia and cardiac arrest portend worse clinical outcomes regardless of
cause of respiratory failure.
Rocuronium and succinylcholine are both used successfully in pediatric RSI, but
succinylcholine should be avoided in patients with suspected or known NMD.
For patients with syndromic or asymmetric skeletal appearance, physicians should be
prepared for a more difficult airway because the anatomic axes may not align to typical
expectations. In these cases, videolaryngoscopy may be helpful because direct alignment and
visualization is not required.
DISCLOSURE
The author has no financial disclosures.
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J u s t B re a t h e

Tips and Highlights for Managing Pediatric

Megan J. Cobb, MD, DPT

Emergency physicians are highly trained in the management of threatened, injured, or

University of Maryland School of Medicine, Department of Emergency Medicine; Maryland

Emerg Med Clin N Am 39 (2021) 493–508

Pediatric airway cross-sectional area shows no significant difference with respect to

APPROACH TO ACUTE RESPIRATORY FAILURE IN PEDIATRICS

Respiratory failure can be caused by a variety of parenchymal diseases or injury,

NONINVASIVE VENTILATORY SUPPORT AND HIGH-FLOW NASAL CANULA

High-flow Nasal Canula

Continuous Positive Airway Pressure and Bilevel Positive Airway Pressure

Choice of Noninvasive Support

Patient Factors Age

DECISION TO DEFINITIVE AIRWAY

View from the Top

S Suction (Yankeur, flexible catheter, dual suction sources if available)

CUFFED VERSUS UNCUFFED

A randomized controlled study among anesthesiologists at a tertiary children’s hospi-

PREDICTION OF TUBE SIZE

THE GREAT DEBATE: VIDEO VERSUS DIRECT LARYNGOSCOPY

Conventional teaching in management of the emergent airway has been strongly

Abbreviation: ID, internal diameter of TT.

EARLY VENTILATOR MANAGEMENT

Per review recommendations from the Pediatric Mechanical Ventilation Consensus

spontaneous respirations by the patient. However, with increasing respiratory failure

Rapid sequence intubation (RSI) is a commonly used technique in the pharmacologic

Coronavirus Disease 2019

Craniofacial and Skeletal Dysplasia

CLINICS CARE POINTS

 Before intubation, it is reasonable to attempt noninvasive positive-pressure ventilation or

The author has no financial disclosures.

1. Jagannathan N, Sohn L, Fiadjoe J. Paediatric difficult airway management: what

41. González-Dambrauskas S, Vásquez-Hoyos P, Camporesi A, et al. Pediatric crit-

You might also like

Before intubation, it is reasonable to attempt noninvasive positive-pressure ventilation or