Sunteți pe pagina 1din 24

THE ANATOMY OF THE PEDIATRIC AIRWAY

by

Esther Weathers
RRT, RCP

V7110 HC 02

RC Educational Consulting Services, Inc.


P.O. Box 1930, Brockton, MA 02303-1930
(800) 441-LUNG / (877) 367-NURS
www.RCECS.com

THE ANATOMY OF THE PEDIATRIC AIRWAY


BEHAVIORAL OBJECTIVES
UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE
ABLE TO:
1. Identify the ways in which pediatric airway anatomy differs from that of an adult patient.
2. Indicate how pediatric airway anatomy differences may manifest in clinical practice.
3. Apply simple interventions to overcome the clinical problem that may manifest as a
result of pediatric airway anatomy.
4. Identify ways in which respiratory distress may differ from an adult patient.
5. Give an example of both upper and lower airway disease in patients with Downs
Syndrome.
6. Express a basic knowledge of craniovertebral instability, as it relates to patients with
Downs Syndrome.
7. Identify what precaution may be taken to protect the patient while placing a definitive
airway in the patient with Downs Syndrome.

COPYRIGHT 2010 BY RC EDUCATIONAL CONSULTING SERVICES, INC.

AUTHORED (2010) BY ESTHER WEATHERS, RRT, RCP

ALL RIGHTS RESERVED

This course is for reference and education only. Every effort is made to ensure that the
clinical principles, procedures and practices are based on current knowledge and state of
the art information from acknowledged authorities, text and journals. This information is
not intended as a substitution for diagnosis or treatment given in consultation with a
qualified health care professional.
This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


TABLE OF CONTENTS
INTRODUCTION .............................................................................................................. 4
ANATOMICAL DIFFERENCES ...................................................................................... 4
THORAX....................................................................................................................... 4
HEAD AND NECK....................................................................................................... 4
AIRWAY ANATOMY.................................................................................................. 6
PEDIATRIC RESPIRATORY DISTRESS........................................................................ 8
RESPIRATORY RATE (RR)........................................................................................ 8
NASAL FLARING........................................................................................................ 9
TRACHEAL TUG ......................................................................................................... 9
INDRAWING ................................................................................................................ 9
GRUNTING................................................................................................................... 9
ACTIVE EXPIRATORY PHASE............................................................................... 10
STRIDOR .................................................................................................................... 10
DECREASED EFFORT .............................................................................................. 10
OTHER CLINICAL INDICATORS ................................................................................ 10
LEVEL OF CONSCIOUSNESS ................................................................................. 10
HEART RATE............................................................................................................. 11
COLOR AND TEMPERATURE ................................................................................ 11
BLOOD PRESSURE ................................................................................................... 11
SPECIAL CONSIDERATIONS IN CHILDREN WITH DOWNS SYNDROME ........ 11
UPPER AIRWAY DISEASE ...................................................................................... 11
LOWER AIRWAY DISEASE .................................................................................... 12

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


CRANIOVERTEBRAL INSTABILITY..................................................................... 13
ANATOMY ................................................................................................................. 13
NEUROLOGIC MANIFESTATIONS OF SYMPTOMATIC
ATLANTO-AXIAL INSTABILITY (AAI) ................................................................ 13
CONCLUSION................................................................................................................. 15
SUGGESTED READING AND REFERENCES ............................................................ 16

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


INTRODUCTION

he pediatric patient is not just a little adult, when it comes to airway anatomy. In fact,
there are many significant differences often overlooked in general practice, especially for
those clinicians who have not specialized in pediatric critical care. In recognizing the
anatomical differences, the clinician is easily able to apply simple interventions that may
alleviate respiratory distress, or ensure a definitive airway can be secured in a timely manner.
Special considerations for patients with Downs Syndrome (DS) are also discussed, as there are
many respiratory factors associated with Trisomy 21 (Downs Syndrome).
ANATOMICAL DIFFERENCES
Thorax

he ribs of the infant and young child are more horizontally oriented, making anteriorposterior displacement of the chest less during inspiration. This is loss of the buckethandle effect.

Rib cartilage is more compliant in younger patients than older children and adults.
Manifestation: During episodes of respiratory distress the chest wall may actually
retract, decreasing the childs ability to maintain functional residual capacity or increase
their tidal volume.
Intercostal muscles are not fully developed until school age, acting primarily to stabilize the
chest wall. They do not have the leverage nor the strength necessary to lift the ribs.
As with the adult patient, the childs chief muscle of respiration is the diaphragm. However, the
muscles of the diaphragm are inset horizontally to the ribs, as opposed to obliquely.
Manifestation: Placing the infant/young child in a supine position may compromise
diaphragmatic function, in that contraction may draw the ribs inwards rather than expand
the chest out. This creates paradoxical chest movement.
Intervention: Elevating the head of the bed improves diaphragmatic function, and
may completely alleviate paradoxical work of breathing (WOB). This is an
important action to remember even in patients receiving mechanical ventilation, if
they have spontaneous efforts.
Head And Neck
Children tend to have a large occiput that can compromise the airway. Also, while laying
supine, which is considered the natural position, the neck is flexed causing an obstructive or
partially obstructed airway.

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


Manifestation: Patients in the flexed position will exhibit signs of airway obstruction,
such as, snoring or an obstructive respiratory breathing pattern with possible mild stridor.
Intervention: Placing a small roll behind the shoulders to maintain airway
neutrality and airway patency in the neonatal and young pediatric patient is
essential. In a neonatal or young pediatric patient, a small flannel sheet formed
into a roll, or two face cloths folded together in quarters and placed directly and
evenly (avoid patient rotation, as assessed by chin-sternal notch-navel in
alignment when viewed from the head of the patient) behind the shoulders and
upper thorax. This should be sufficient to elevate the thorax and move the occiput
back. The goal is to have the airway in a neutral position, neither in flexion nor
extension.
The common sniffing position works well on adolescents, as in adults. A good
way to check for this is to align the external auditory canal with the anterior
shoulder for best alignment of the airway axes. (Airway axes: oral, pharyngeal
and tracheal axes).
Note: The old PALS manual (2002, see references end of course) has a wonderful illustration of
the oral, pharyngeal and tracheal axes in the adolescent patient.
If you are unfamiliar with the terms of airway axes and cannot picture them, try this. Slide the
laryngoscope into the patients mouth. This is the oral axis. Advance the laryngoscope blade to
the base of the tongue, searching for the epiglottis. This is the pharyngeal axis. Lift up the
epiglottis or insert your blade into the valeculla, viewing the glottic inlet, this is the tracheal axis.
If the airway axes are in alignment, you will have a view of the vocal cords and glottic inlet. It
will also allow the patient to breathe free of obstruction, and will best facilitate successful bagvalve-mask ventilation.
Infants and young children also have a large tongue in comparison to their oropharyngeal space.
Manifestation: Predisposition to soft tissue airway obstruction from the tongue is always
a possibility. Also, be cognizant of the tongue/oropharyngeal space ratio in clinical
scenarios of known airway edema, such as, recent dental work, tongue-lip adhesion
surgery, etc.
Infants and younger children are predominantly nose breathers.
Manifestation: Pediatric patients who present with respiratory distress (RD) that have an
upper respiratory tract infection may have an ineffective ventilatory pattern. Often it is
just upper airway congestion/stuffiness.
Intervention: Simple nasal suction may alleviate this distress.

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


The small relative internal diameter of both the upper and lower airways predisposes the child to
higher airway resistance. In a simplified illustration of Pouseilles law, if the radius decreases by
half, the resistance increases by sixteen times. To negate the effects of this change, it is
necessary to increase the pressure gradient or decrease the flow in the system.
Manifestation: An infant or child with even mild airway obstruction or inflammation
will present with moderate to severe respiratory distress. They are increasing the
pressure in the system.
Intervention: Depending on the clinical scenario and patients physician, cool
aerosols and/or corticosteroids, inhaled epinephrine and inhaled antibiotics may
be useful in relieving airway infection, inflammation and edema of the trachea.

Infant
Trachea

Adult
Trachea

16x

2 mm

R 2.4x

Figure 1. Schematic Illustration of Airway Resistance using Pouseilles Law. R =


Resistance. This cross sectional view of the infant and adult tracheas provides an illustration of
the increase in airway resistance that occurs when edema is present.
Airway Anatomy
Perhaps the best known anatomical difference in neonatal and pediatric patients is the cricoid
cartilage. The narrowest portion of the pediatric airway is subglottic. The airway itself is funnel
shaped, as compared to the cylinder shape seen in the adult patient, with the cricoid ring being
the most narrow point, which is the rational use is to avoid pressure at the cricoid ring.
Historically, this has been part of the basis for choosing uncuffed endotracheal tubes (ETT) for

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


neonatal and pediatric patients, though recent evidence strongly suggests with proper care in
selection and sizing of a cuffed ETT, this is no longer a factor. (See RCECS course: Neonatal
and Pediatric Cuffed Endotracheal Tubes: Safety and Use.)
Manifestation: Any subglottic partial airway obstruction will be very poorly tolerated
when compared to an older patient. Clinical examples are: post extubation subglottic
edema, foreign body aspiration, mass lesions inside the trachea.
Thyroid
Cartilage

Thyroid
Cartilage

Cricoid
Ring

Cricoid
Ring

Adult
Trachea

Infant
Trachea

Figure 2. Schematic Illustration of the Adult and Infant Tracheas.


The adult airway is cylinder shaped. The pediatric airway is on the right, note the funnel shape
with the narrowest portion being at the level of the cricoid ring. Uncuffed endotracheal tubes are
thought to seal at this point.
The infant and pediatric epiglottis is typically floppier and articulates at a more acute angle with
the larynx.
Manifestation: The epiglottis will be more difficult to displace with a laryngoscope.
Intervention: Historically one of the reasons why a Miller or Wisconsin
laryngoscope blade is chosen for intubation, as the entire epiglottis is lifted out of
the field of view.
The larynx is located more anterior and cephalad, with the glottis being located at the level of
C3-4, compared with C5 in the adult patient.
Manifestation: Often difficult to view the glottic inlet while performing laryngoscopy.

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


Intervention: Ensure proper alignment of the airway axes with patient positioning
aids, alternately external laryngeal manipulation may be necessary to improve
operator view of the vocal cords. (See RCECS Course Pediatric Airway
Assessment for further information).
Pediatric and neonatal vocal cords are more inclined, versus flat in the adult patient.
Manifestation: Endotracheal tubes may be difficult to pass though the glottic opening, as
it may get hung up on the cords.
Intervention: A slight twist or rotation of the endotracheal tube by the intubators
assistant may facilitate passage of the endotracheal tube into the trachea.
The infant trachea is more mobile and has a posterior descent into the thorax, whereas the adult
trachea is more stationary and has a vertical descent. This may in part be due to immature
cartilage of the young airway.
PEDIATRIC RESPIRATORY DISTRESS

s previously discussed, pediatric and neonatal airways are, in a nutshell, smaller,


floppier, more prone to obstruction and have less developed musculature. Due to some
of these anatomical differences, they are often unable to manifest signs of increased
work of breathing. They have more reasons to exhibit signs of respiratory distress, yet less
power to manifest them. It makes it easier when the clinician is familiar with the pediatric
anatomy, and manifestations of respiratory distress, so they can properly perform a respiratory
assessment, and appropriately apply treatment in a timely fashion. Keep in mind, the younger a
patient is, the less likely they will be to exhibit classic signs of respiratory distress.
Respiratory Rate (RR)
Just like heart rate is the single way in which young children are able to effectively improve their
cardiac output, an increased respiratory rate may be the only sign of increased work of breathing.
Tachypnea in any patient at a rate greater than 60 breaths per minute (bpm) is an ominous sign,
even a neonate, as respiratory muscles fatigue.
Bradypnea in any patient is a sign of central nervous system (CNS) impairment and bodes ill, as
does any irregularity to the respiratory pattern or depth. However, it is important to note that
patients who are tiring may vary their respiratory rate and tidal volume as a result of respiratory
muscle fatigue, and not central nervous system depression. As a rule of thumb, a respiratory rate
less than 8 bpm can be applied to all patients and constitutes respiratory failure. Certain
situations excepted, assisted ventilations should be initiated if this is a clinical finding.
Take note of the physiologic normals of respiratory rate for age, and apply them when
performing a respiratory assessment at the bedside. Typically, these are:

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY

Neonate 20-40 bpm

Child 20-30 bpm

Adolescent 12-20 bpm

A normal respiratory rate is inversely proportional to patient age, namely, the younger a patient,
the higher the expected respiratory rate will be. As a clinician you will be less concerned about a
neonate breathing at a rate of 60 bpm, than a 10 year old.
Nasal Flaring
Nasal flaring is common across all age groups. Do not brush off moderate nasal flaring in an
infant as nothing when performing a respiratory assessment. Take note and use other clinical
indicators (to be discussed) to aid you in completing your assessment.
Tracheal Tug
While tracheal tug may be a late or unspecific sign of increased work of breathing in an adult
patient, it is very common in the pediatric patient, perhaps almost as prevalent as nasal flaring.
Often a slight gasp may be noted audibly on inspiration as well, which can seem to be associated
with head-bobbing. (It is the authors opinion that head bobbing is not a sign of work of
breathing, rather a physiological result of it).
Indrawing
Indrawing is grouped in one large heading when discussing pediatric respiratory distress. As
previously noted, infants and young children have under developed musculature and classic
retractions, such as intercostals, may be absent. This is not to say that indrawing will never exist
in the young patient, as it often does, rather to reinforce the anatomical differences may make it
appear less obvious or severe. In overweight infants and younger children, substernal and
intercostal indrawing may be all that is evident. Children who have been hospitalized for longer
periods of time, or appear as if they are failure to thrive have a thinner chest wall, and
retractions can be more evident. Keep in mind that patient position can affect work of breathing,
remember that simply elevating the head of the bed that improve diaphragmatic function and
improve signs of respiratory distress.
Grunting
Similar to pursed lip breathing, grunting is a way in which the neonate and young pediatric
attempts to maintain an open airway, essentially splinting the airways in an attempt to prevent
airway collapse and improve oxygenation and ventilation.

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


Active Expiratory Phase
As you are aware, expiration is a passive event, and should have no work associated with it. If
you notice a patient actively trying to exhale, or audibly wheezing, it is generally evidence of air
trapping. Due to the increased compliance of the chest wall (and loss of the bucket-handle
effect) this can very easily occur, especially in situations of increased minute volume demands,
or obstructive lung disease.
Stridor
As in all patients, stridor denotes an upper airway obstruction. On assessment, the clinician
should note the quality of the stridor, is it high pitched and consistent on each breath, biphasic in
nature? A very important piece of the assessment is the aucultory findings, ask yourself, does
every breath move air? When and if the stridor disappears, does airflow remain? A history
needs to be elicited from the caregiver. Does the patient have a fixed airway obstruction or
increasing in size? Has it been treated with inhaled epinephrine or steroids to decrease the
inflammation? Be very careful of agitating the patient with your assessment, and/or treatments,
as their airway is already compromised. Allow them to remain in the position of greatest
comfort, or with a parent or caregiver. This advice also stands for all patients with increased
respiratory distress and O2 requirements, as any stressors can tip the scales the wrong way.
Decreased Effort
As with bradypnea and irregularity to rate and depth, watch your patient very closely for changes
to their work of breathing. Do not simply assume that there condition has improved, and that
explains their decrease in work of breathing. A decrease in noted work of breathing may simply
be fatigue. Use other clinical indicators and the assessments of other healthcare professionals
and parents and caregivers to aid your decision making.
OTHER CLINICAL INDICATORS
Level of Consciousness

hile it may not be routine to do central nervous system scoring on children for
respiratory admissions, or the Respiratory Care Practitioner may be unfamiliar with
what the grading means, the idea is simple. How alert is the child? When you walk
into the room, do they look up and greet you? Are they responsive to parents? Smiling,
grouchy, changes from the last time you saw them? Beware of the agitated child, who can not be
consoled, and/or with a high pitched cry. Though unspecific, it can be an indicator of poor
cerebral oxygenation. One simple system to use is AVPU: A awake; V verbal; P pain; U unresponsive. Keep in mind changes from baseline are very important to note, and for
physicians to be made aware of.

10

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


Heart Rate
A rapid heart rate can indicate the body is trying to provide more oxygen to the tissues. A slow
heart rate, just like a slow respiratory rate is ominous sign. Cardiopulmonary arrest (CPA) in
children is most commonly a result of respiratory failure, and outcome is dismal if respiratory
failure progresses to the point of cardiopulmonary arrest.
Color and Temperature
The color of a patient is a simple assessment tool that can be readily used by the Respiratory
Care Practitioner when approaching the patient while still at rest, prior to being disturbed for a
treatment or physical assessment. Obvious peripheral or cicumoral cyanosis? Mottling of
extremities? Pale, sweaty, flushed cheeks, changes from baseline, etc. On closer exam the
Respiratory Care Practitioner can discern if the patient is diaphoretic, if the skin is hot to touch,
if the extremities are cool. The so called blanket of perfusion comes into play here as well.
Imagine the child covered in a blanket, now lift that blanket slowly off the child from the center
of their body, stopping where the they warm up, or where the skin color changes..this is the
blanket of perfusion.
Blood Pressure
Though not as widely available a tool to the Respiratory Care Practitioner, blood pressure can be
useful in aiding assessment. Infants and young children are remarkably able to cope with
respiratory failure and shock, with simple measures to increase oxygenation to the tissues such as
increased minute ventilation and stroke volume by heart rate increase. A decrease in blood
pressure in a pediatric patient is a very ominous sign of shock and must be acted upon quickly to
prevent cardiopulmonary arrest.
SPECIAL CONSIDERATIONS IN CHILDREN WITH DOWNS SYNDROME

risomy 21 is a fairly common syndrome, occurring in 1/733 live births.1 While we can
easily identify a patient with Downs Syndrome, we may not realize and/or account for all
of the contributing factors to the respiratory system.

Upper Airway Disease


There are many factors which contribute to airway problems, many of which are under
diagnosed in the Downs Syndrome patient. One study done in 1991 showed that 45% of
patients with Downs Syndrome had Obstructive Sleep Apnea.2 Most patients have relief of
symptoms with a tonsil and adenoidectomy, or rarely a uvulopalatopharyngoplasty (UPP).
Predisposing factors include:

hypotonia

midface hypoplasia (flattened mid face, narrowed nasalpharyngeal area)


This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

11

THE ANATOMY OF THE PEDIATRIC AIRWAY

obesity (not as common in the younger child, increases into adulthood)

relative glossoptosis

enlarged tonsils and adenoids

increased secretions, chronic nasal congestion


Intervention: Treat problems as they arise, keeping in mind most of the factors
noted above will not be an issue until the patient is being treated for an upper
respiratory tract infection (URTI). Also, take note of the respiratory pattern of the
child at night. Many of the patients with Downs Syndrome go undiagnosed with
Obstructive Sleep Apnea (OSA) due to it being normal for them. If you note an
obstructive pattern, drops in SpO2, excessive snoring, or absence of airflow,
ensure a note is made in the patient chart and the physician is made aware. It is
possible a screening sleep study is needed. Obstructive Sleep Apnea, if left
untreated, potentiates pulmonary hypertension (PH) and worsens heart failure.

Lower Airway Disease


Congenital lower airway problems are more common in patients with Downs Syndrome,
particularly if there are associated cardiac defects. Cardiac defects are present in about 50% of
all patients with Downs Syndrome.1 Some things to look out for in a neonate are compression of
the airways due to vascular rings, slings or from the heart itself. Tracheo, laryngo, and
bronchomalacia are often present.
Pulmonary vascular disease is often present with Downs Syndrome. They have an increased
risk for pulmonary hypertension (PH) and related Congenital Heart Disease. This can be
explained by pulmonary hypoplasia and the presence of OSA. As the capillary bed parallels
alveolar surface area, pulmonary vascular size is decreased linearly with the decreased number of
alveoli present.
And finally, gastroesophagealreflux (GER). Often this is overlooked, misdiagnosed as asthma.
It is interesting to note that animal studies have shown that there is an increase in the work of
breathing simply with the presence of acid in the esophagus and esophageal distention,
regardless if there aspiration present.
Intervention: Recall this information when treating a patient with Downs
Syndrome, ensure O2 levels are adequate, apply CPAP or noninvasive ventilation
(NIV) therapies sooner than you would for other patients due to possible malacia,
risk of pulmonary hypertension (PH), etc.

12

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


Craniovertebral Instability
10-30% of Downs Syndrome patients have been reported as having Atlanto-axial instability
(AAI), with or without subluxation. Occipital-atlanto instability (OAI) is also an issue for some
patients, though poorly understood.3 These patients often have congenital anomalies of the
odontoid or lax transverse ligaments, predisposing them to instability or subluxation at either
point. Atlanto-axial instability is more prevalent than Occipital-atlanto instability in Downs
Syndrome. Occipital-atlanto instability subluxation can occur with or without Atlanto-axial
instability. Almost all patients with Atlanto-axial instability are asymptomatic, and can only be
diagnosed with X-rays.
Anatomy
The occiput, atlas (C1) and axis (C2) are characterized by a high degree of mobility and little
bony stability. The axis has a protrusion on it called the ondontoid. Strong ligaments facilitate
movement and keep the structures in place. Most of the rotation of the head occurs at this
junction. The atlanto-occipital joint allows both flexion and extension. With flexion, there is
anterior translation of C1 on C2. Any changes to the odontoid or function of the ligaments can
increase the displacement that is normal, and pressure from the vertebrae compresses the spinal
cord.
Neurologic Manifestations of Symptomatic Atlanto-axial instability (AAI)
These are often the result of compression of the cervical nerve roots and/or spinal cord. These
findings can be difficult to elicit in the Downs Syndrome patient, primarily motor system
abnormalities.
Non Specific Indicators - Changes from baseline:

In gait

hand preference

participation in activities

loss of continence

Root compression at C1 and C2 will produce pain to the upper C spine, neck and occipital area.
This pain can extend to the head eyes, ears and throat.
The patient may also have:

dizziness

vertigo
This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

13

THE ANATOMY OF THE PEDIATRIC AIRWAY

tinnitis

syncope

one sided or bilateral tingling/numbness

Torticollis
The presence of torticollis in a person with Downs Syndrome indicates Atlanto-axial
instability until proven otherwise.

In many cases infections of the upper respiratory tract, middle ear or pharynx precede symptoms
of Atlanto-axial instability. Trauma rarely causes an initial appearance or progression of
symptoms.1
The inflammatory processes associated with upper respiratory tract infections and rheumatoid
arthritis can produce laxity of the transverse ligaments. The lymphatic drainage of this joint is
into the retropharyngeal glands, which also drains the nasopharynx and ends up in the deep
cervical glands. The disruption of the drainage may also have an effect on the ligaments laxity.
Due to the inherent abnormality, even minor trauma or acute nasalpharyngeal infections can
cause a subluxation.
There is wide spectrum of both congenital and acquired lesions that can produce Atlanto-axial
instability, and less frequently, occipital-atlanto instability. Signs of Atlanto-axial instability
precede almost all cases of atlanto-axial subluxation in Downs Syndrome. While the risk
remains relatively low (not all patients have the anomalies to the ligaments or bony structures)
the consequences are high enough to warrant full airway precautions. Remember that flexion
also poses a significant risk.
Intervention: When you are called upon to bag-valve-mask ventilate or assist in
intubating a patient with Downs Syndrome, consider the fact that they may have
Atlanto-axial instability or occiptal-atlanto instability, suggest the use of a jaw
thrust and C spine control and not a head tilt-chin-lift. If there is bradycardia
noted on any airway attempts with extension, immediately discontinue the
maneuver, assume a neutral airway position and try again as described above.
What is likely occurring is compression of the spinal cord and cervical arteries.

14

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


CONCLUSION

nowing anatomical differences in the pediatric airway will make you more prepared as a
practitioner to provide appropriate care, and anticipate airway emergencies. By being
aware of the anatomy, you will not only recognize how it manifests in your clinical
practice, but be able to intervene in even simple ways to improve to respiratory function of your
youngest patients. A basic knowledge of the traits associated with Downs Syndrome will also
expand your services and, though low, given the risks with atlanto-axial or occipital-atlanto
instability, improve safety for this patient population.

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

15

THE ANATOMY OF THE PEDIATRIC AIRWAY


SUGGESTED READING AND REFERENCES
1. www.ndss.org/index 2009
2. Marcus, CL et al. (1991) Obstructive Sleep Apnea in Children with Down Syndrome.
Pediatrics. 88 (1): 132-139
3. Brockmeyer, D. (1999) Down syndrome and Craniovertebral instability: Topic review and
treatment recommendations. Pediatric Neurosurgery. Aug; 31 (2): 71-7
4. Bertrand, P. (2003) Airway Anomalies in Children with Down Syndrome: Endoscopic
Findings. Pediatric Pulmonology. Aug; 36(2):137-41
5. Hazinski, M.F., (Ed.) (2002) Textbook of Advanced Pediatric Life Support. American
Heart Association.
6. Kacmarek, RM., et al (Ed.) (1990) The Essentials of Respiratory Care, 3rd Edition. MosbyYear Book, Inc.

16

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


POST TEST
DIRECTIONS: Use the FasTrax answer sheet enclosed with your order to respond to all the test
questions that follow. Leave the remaining answer circles on the FasTrax answer sheet blank. Be
sure to fill in circles completely using blue or black ink. The FasTrax grading system will not
read pencil. If you make an error, you may use correction fluid (such as White Out) to correct it.
FasTrax answer sheets are preprinted with your name and address and the course title. If you are
completing more than one course, be sure to record your answers on the correct corresponding
answer sheet.
RETURN TO: RCECS, P.O. Box 1930, Brockton, MA 02303-1930 or FAX TO: (508)-894-0172.
1. Name one way in which the anatomy of the thorax of a child differs from an adult.
a.
b.
c.
d.
e.

rib cartilage more compliant


ribs horizontally oriented
intercostals underdeveloped
diaphragm muscles inset
all of the above

2. The natural position of the airway of a child when laying flat is neutral.
a. True
b. False
3. To ensure airway neutrality in any patient regardless of age, what two anatomical landmarks
much be aligned?
a.
b.
c.
d.

sternal notch and navel


chin and sternal notch
external auditory canal and anterior shoulder
external auditory canal and sternal notch

4. Infants and young children are predominately nose breathers.


a. True
b. False
5. The internal diameter of a young child is smaller than that of an adult, therefore airway
resistance is lower.
a. True
b. False

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

17

THE ANATOMY OF THE PEDIATRIC AIRWAY


6. The narrowest portion of an infant trachea is above the level of the glottis, at the cricoid
cartilage.
a. True
b. False
7. The infant/pediatric epiglottis is more floppy and difficult to displace with a laryngoscope
than an adult epiglottis.
c. True
a. False
8. It is 0700. You are called by the day shift RN to assess a 3 year old female patient who has
been breathing at a respiratory rate of 60 all night and is distressed. When you arrive at the
patients room, what should your first action be? Choose the most correct answer.
a. nothing, enter the room
b. look at the patient for signs of respiratory distress, then enter
c. look at the patient for signs of respiratory distress, check alert, voice, pain,
unresponsive (AVPU), call the patient name if necessary, enter the room
d. get report from the nurse first
9. The 3 year old female is lying flat in the bed, in obvious distress, with nasal flaring, and
intercostal indrawing noted. She barely glanced up as you entered the room. The respiratory
rate is 64, with some variation in rhythm, and there are coarse crackles scattered through out
on auscultation. Her skin feels hot to the touch. She is wearing an oxygen mask and her
saturations are 95%. The most appropriate action at this time is:
a. turn up her O2, get further report from other healthcare personnel and document your
assessment in the patient record.
b. elevate the head of the bed, get further report, and document your assessment in the
patient record.
c. take a room air saturation, get further report, and document your assessment in the
patient record.
d. press the emergency call button and start CPR
10. Obstructive sleep apnea is not present in patients with Downs syndrome.
a. True
b. False

18

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY


11. Lower airway disease is common in children with Down Syndrome, especially if there is
associated cardiac defects. Which of the following is not commonly associated with Down
Syndrome?
a.
b.
c.
d.

asthma
pulmonary vascular disease
bronchomalacia
tracheomalacia

12. 50% of patients with Downs Syndrome have atlanto-axial instability (AAI).
a. True
b. False
13. Atlanto-axial instability can be asyptomatic.
a. True
b. False
14. Which of the following is not a sign of symptomatic Atlanto-axial instability (AAI)?
a.
b.
c.
d.

dizziness
loss of continence
drooling
torticollis

15. What precaution is recommended to be taken when bag-valve-mask ventilating or intubating


a patient with Downs Syndrome?
a.
b.
c.
d.

head tilt/chin lift


premedication with lidocaine
jaw thrust and control of cervical spines
extreme sweep of tongue to the left

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

19

THE ANATOMY OF THE PEDIATRIC AIRWAY


COURSE EVALUATION
RC Educational Consulting Services, Inc. wishes to provide our customers with the highest
quality continuing education materials possible. Your honest feedback will help us to continually
improve our courses and meet state regulations. Responses to the following evaluation questions
should be recorded in the far right hand column of the FasTrax answer sheet, in the section
marked Evaluation. Mark A for Yes and B for No. Thank you
YES (A)

1. Were the objectives of the course met?

NO (B)

___

2. Was the material presented in a clear


and understandable manner?

______

3. Was the material well-organized?

______

4. Was the content presented without bias


of any commercial product or drug?

______

______

5. Was the material relevant to your job?

______

6. Did you learn something new?

______

7. Was the material interesting?

______

8. Were the illustrations, if any, helpful?

______

9. Would you recommend this course to a friend?

______

20

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

THE ANATOMY OF THE PEDIATRIC AIRWAY

This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by
law.

21