Salah satu keterampilan dari seorang dokter umum adalah manajemen jalan napas.

Agar berhasil dalam melakukan

manajemen ini dengan baik, penting bagi dokter untuk memiliki pengetahuan tentang anatomi, fisiologis, dan
patologis penting yang terkait dengan jalan napas serta pengetahuan tentang berbagai alat dan metode yang telah
dikembangkan untuk tujuan ini. Dalam bidang ini sebagian besar dokter atau ahli anestesi sangat terampil dalam
mengelola saluran napas dewasa dengan sukses. Namun berbeda pada bayi atau anak. Anak-anak bukan hanya orang
dewasa kecil. Ada perbedaan penting pada manajemen jalan napas aanak yang memerlukan pendekatan atau teknik
yang berbeda.
Saluran napas anak secara substansial berbeda dari saluran udara dewasa dan obstruksi pada jalan napas menyebabkan
desaturasi secara cepat pada bayi dan anak kecil. Obstruksi jalan napas dapat dihindari dengan memperhatikan posisi
kepala anak dan dengan menjaga mulut anak tetap terbuka selama ventilasi masker. Penggunaan peralatan seperti saluran
napas oral dan nasofaring, saluran udara masker laring, dan tube endotrakeal akan dibahas dengan referensi khusus untuk
keadaan pada anak dan bayi. Tulisan ini bertujuan untuk memberikan gambaran dan prinsip yang aman untuk manajemen
saluran napas anak dasar.

Saluran udara memanjang dari nares eksternal ke persimpangan laring dengan trakea. Ini termasuk hidung, sinus
paranasal, pharynx dan laring. Fungsi saluran napas termasuk fonasi, penciuman, pencernaan, humidifikasi dan
pemanasan udara yang diilhami. Saluran napas anak berbeda dari saluran nafas dewasa terutama pada masa bayi,
dengan perbedaan yang semakin sedikit ditandai dengan bertambahnya usia anak. Selama anestesi anak, komplikasi
saluran napas dan pernapasan adalah penyebab paling umum morbiditas dan sering terjadi pada anak-anak yang
sehat, terutama bayi. Metode komprehensif untuk penilaian saluran napas anak sangat difasilitasi oleh pengetahuan
anatomi normal.

Memahami anatomi dan fisiologi jalan napas anak memfasilitasi serangkaian pengembangan strategi
rasional untuk mengelola jalan nafas pada pasien anak dengan kondisi yang normal ataupun sulit. Bila
perbedaan tersebut dapat dipahami, akan jelas bahwa jalan napas anak merupakan jalan napas yang
berbeda dan bukan jalan nafas yang sulit
The first anatomical difference between the pediatric and adult patient becomes important when positioning the
child prior to or immediately after the induction of anesthesia. The head of a pediatric patient is larger relative to
body size, with a prominent occiput. This predisposes to airway obstruction in asleep children, because the neck is in
flexed when they lie on a flat surface. A folded towel is often required as a shoulder roll to achieve a neutral position
of the neck and open up the airway. This is demonstrated visually in Figure 1. The larger occiput combined with a
shorter neck makes laryngoscopy relatively more difficult by providing obstacles to the alignment of the oral,
laryngeal, and tracheal axes

Perbedaan anatomi pertama antara pasien anak dan orang dewasa menjadi penting ketika
memposisikan anak sebelum atau segera setelah intubasi. Kepala pasien anak lebih besar dibandingkan
ukuran tubuh, dengan oksiput yang menonjol. Ini merupakan predisposisi terhadap obstruksi jalan
napas pada anak-anak yang tertidur, karena leher tertekuk ketika mereka berbaring di permukaan yang
datar. Handuk yang dilipat sering diperlukan sebagai gulungan bahu untuk mencapai posisi netral leher
dan membuka jalan napas. Hal ini ditunjukkan secara visual pada Gambar 1. Oksiput yang lebih besar
dikombinasikan dengan leher yang lebih pendek membuat laringoskopi relatif lebih sulit dengan
memberikan hambatan pada penyelarasan dari kapak oral, laring, dan trakea.

The skull develops from a membranous and cartilaginousneurocranium. Themembranousneurocranium gives rise to
the flatbonesof the skull (the cranial vault) and the cartilaginous neurocranium (chondrocranium) forms the skull
base. The shaping of the skull base is a dynamic process involving reciprocal influences between the cranial base,
the pharynx, the face and the palate. In the fetus, the rapid growth of the brain leads to a predominance of neural
influences; whilst in the neonateandyoungchild, nasal influences play a major role. Later, because of changing
nutritional requirements and the development of speech, the pharynx also influences the development of the skull
base. Children have a proportionally larger head and occiput relative to body size. This causes neck flexion, leading
to potential airway obstruction when lying supine.

Nose
The nose originates in the cranial ectoderm and is composed of the external nose and the nasal cavity. The external
nose is made up of the nasal bones, the nasal part of the frontal bones and the frontal processes of the maxillae. The
nasal cavity is subdivided by the nasal septum into two separate compartments that open to the exterior via the nares
and into the nasopharynx via the choanae or posterior nasal apertures. Immediately within the nares lies the
vestibule, which contains an area of arterial anastomosis known as Little’s area. Epistaxis commonly occurs from
this zone. The sensory innervation of the nasal mucosa is via the maxillary division of the trigeminal nerve. During
development, the nasal cavities extend under the influence of the posteriorly directed fusion of the palatal processes.
These changes cause the membrane that separates the palatal processes from the oral cavity to become progressively
thinner and eventually rupture to form the choanae or posterior nasal apertures. Failure of this membrane to rupture
results in choanal atresia. In a child, the nose is soft and distensible, with relatively more mucosa and lymphoid
tissue than in the adult. Deviation of the nasal septum occurs in all ages of children and may be the result of nasal
injury or irregular development of the nasomaxillary complex. Racial differences in the dimensions of the nasal
cavity have also been described. Each side of the nose has a roof, a floor, a medial wall and a lateral wall. The roof
slopes upwards and backwards to form the bridge of the nose, with the floor being concave from side to side. The
medial wall is the nasal septum and the lateral wall has a bony framework which includes three scroll-like conchae
or turbinate bones. The major nasal air passage lies beneath the inferior turbinate, and during nasal intubation the
endotracheal tube should be encouraged to follow this route by passing it directly backwards along the floor of the
nose. The posterior end of the inferior turbinate may occasionally be hypertrophied, resulting in resistance to the
passage of the tube. Nasal breathing increases the resistance to airflow. In children, the smaller nasal apertures are
easily obstructed by secretions, edema or blood. As infants are obligate nasal breathers, such conditions may
increase the work of breathing, and similarly contribute to difficulties with management of the airway under general
anesthesia.

Pharynx
The pharynx forms the common upper pathway of the respiratory and alimentary tracts. It is in free communication
with the nasal cavity, the mouth and the larynx, forming the nasopharynx, oropharynx and laryngopharynx,
respectively.

Nasopharynx

The nasopharynx lies behind the nasal cavity and above the soft palate. It communicates with the oropharynx via the
pharyngeal isthmus, which becomes closed off during the act of swallowing. Its sensory innervation is derived from
the trigeminal nerve and the glossopharyngeal nerve. During development, the depth of the nasopharynx increases as
a result of remodeling of the palate as well as changes in angulation of the skull base, eventually producing an
enlarged nasal airway in the adult.

The pharyngeal opening of the pharyngotympanic (Eustachian) tube lies on the lateral wall of the nasopharynx. The
nasopharyngeal tonsils (adenoids) lie on the roof and posterior wall of the nasopharynx in children. Although these
atrophy with age, enlargement in early childhood may obstruct breathing through the nose. Nasopharyngeal tonsils
may also become dislodged during instrumentation of the nose.

Oropharynx
The oropharynx extends from the soft palate to the tip of the epiglottis. It is attached anteriorly to the base of the
tongue via the glossoepiglottic folds. Between these folds lie the valleculae. The sensory innervation of the
oropharynx is derived from the glossopharyngeal nerve and the superior laryngeal branch of the vagus nerve, which
transmits afferent impulses from the base of the tongue and the valleculae. The reflex circulatory responses to direct
laryngoscopy and tracheal intubation result largely from stimulation of the pharyngeal wall by the laryngoscope
blade. A smaller additional response is produced by the passage of an endotracheal tube through the vocal cords.

At the entrance to the oropharynx is a collection of lymphoid tissue known as Waldeyer’s ring. This consists of the
lingual tonsil at the base of the tongue and bilateral palatine tonsils. The nasopharyngeal and tubal tonsils also form
part of this ring. Inflammation of these lymphoid tissues may obstruct breathing efforts in conscious patients and
may make layngoscopy difficult because of an increase in size of the tissue or associated masseter spasm. Gender
and ethnic variations in the dimensions of the oropharynx have been demonstrated, together with a relationship
between oropharyngeal dimensions and sleep disordered breathing. Tonsillar asymmetry has been reported to occur
in the absence of pathology in some children.

The relatively large tongue decreases the size of the oral cavity in children and more easily obstructs the airway.
Decreased muscle tone also contributes to passive obstruction of the airway by the tongue. In infants lying supine,
the tongue tends to flatten out against the soft palate in inspiration and may remain in the same position for the
passive expiration through the nose. Extension of the head at the atlanto-occipital joint, with anterior displacement
of the cervical spine, may result in improved hypopharyngeal airway patency but does not necessarily change the
position of the tongue.

Laryngopharynx
The laryngopharynx extends from the tip of the epiglottis to the lower border of the cricoid cartilage. The larynx
bulges back into the center of the laryngopharynx, leaving a recess on either side, known as the piriform fossa. This
is a common site for impaction of swallowed sharp foreign bodies.

Larynx
The larynx is situated between the pharynx and trachea, extending from the base of the tongue to the cricoid
cartilage. It is the organ of phonation and protects the tracheobronchial tree during swallowing and coughing. The
development of the respiratory system begins at approximately 3 weeks of gestational age, with the formation of the
laryngotracheal tube from the ventral wall of the foregut. A definite larynx can usually be identified by 41 days
gestation. The cricoid and thyroid cartilages begin chondrification at about 7 weeks of gestation. The primitive
glottis is formed at 10 weeks gestation when the true vocal cords split. Failure of this process results in a congenital
laryngeal web, or in some cases, congenital atresia of the larynx. Incomplete division of the embryonic foregut into
the anteriorly positioned trachea and the posteriorly positioned esophagus results in tracheo-oesophageal fistula.

The larynx consists of the thyroid cartilage, the cricoid cartilage, the paired arytenoids and the epiglottis, together
with the small corniculate and cuneiform cartilages. These form a framework of articulating cartilages linked
together by ligaments, which move in relation to each other by the action of the laryngeal muscles. The largest of
these cartilages is the thyroid cartilage, which is open posteriorly and forms the laryngeal prominence (Adam’s
apple) anteriorly. Beneath the thyroid cartilage is the cricoid cartilage, in the shape of a signet ring with the widest
portion lying posteriorly. This is the only complete cartilage ring found in the respiratory tract. At birth, the lower
border of the cricoid cartilage lies opposite the lower border of the fourth cervical vertebra. At 6 years of age it is at
the level of the fifth cervical vertebra and in the adult it lies at the level of the sixth cervical vertebra. Because of the
small size of the cricoid cartilage in children, and the fact that it is a complete ring, the presence of mucosal edema
at this site will severely compromise the airway. Young children are also at risk of acquired subglottic stenosis when
exposed to prolonged or repeated tracheal intubation (Figures 4 and 5).

The paired arytenoid cartilages articulate at the posterosuperior aspect of the cricoid cartilage (10). Each arytenoid
has an anterior process, the vocal process, to which the vocal ligament is attached. At the apex of each arytenoid lies
a triangular corniculate cartilage, attached by a perichondrium. The vestibular folds, or false cords, are created by
the mucosa that covers the thyroarytenoid muscles. The true vocal cords are the vocal folds covered by mucosa.
Reflex adduction of the true and false cords is known as laryngospasm and may result from local stimulation of the
larynx, or from surgical stimulation in the absence of adequate anesthesia. The cricothyroid membrane is a tough,
elastic connective tissue sheet that spans the joint between the inferior process of the thyroid cartilage and the
cricoid cartilage. Puncture or incision of this membrane allows the creation of a surgical airway when acute airway
obstruction occurs at or above the larynx.

The epiglottis is a leaf-shaped structure attached to the posterior border of the thyroid cartilage by the thyroepiglottic
ligament. In the adult, the epiglottis is broad, with its axis parallel to that of the trachea. The epiglottis in the infant is
narrower, softer and more horizontally positioned than in the adult. The straight laryngoscope blade facilitates lifting
of the epiglottis and is therefore useful during tracheal intubation in younger children. At laryngoscopy, the
epiglottis in the neonate appears more deeply furrowed at its free end, and in some babies it has a V-shaped
appearance. By the age of 4 or 5 years, the epiglottis is usually firm enough to allow visualization of the vocal cords
using a curve laryngoscope blade. The cuneiform cartilages lie anterior to the corniculate cartilages, in the
aryepiglottic folds.

The more superior location of the larynx in children may create difficulty in visualizing laryngeal structures because
of the more acute angulation between the base of the tongue and the laryngeal opening. During laryngoscopy, a neck
or shoulder roll will relieve the hyperflexion of the infant’s neck caused by the relatively large occiput.

The nerve supply to the larynx is from the vagus nerve, via its superior and recurrent laryngeal branches. The
superior laryngeal nerve gives rise to an internal laryngeal branch which runs beneath the mucosa of the piriform
fossa. In this position, it is easily blocked by the topical application of a local anesthetic agent to provide anesthesia
for laryngoscopy and bronchoscopy. The laryngeal inlet and the inferior surface of the epiglottis are innervated by
the vagus nerve. When the epiglottis is lifted with a straight laryngoscope blade, bradycardia and hypotension may
occur as a result of a vagal reflex. When a curved blade is used, the tip is placed in the angle between the epiglottis
and the base of the tongue. This theoretically reduces the risk of bradycardia because the superior surface of the
epiglottis and the valleculae are innervated by the glossopharyngeal nerve. Damage to the recurrent laryngeal nerve
results in paralysis of the corresponding vocal cord, causing it to lie motionless in the midline and at a lower level
than the opposite side. Bilateral paralysis results in complete loss of vocal power. The two paralyzed cords may then
flap together to cause a valve-like obstruction during inspiration, producing dyspnea and inspiratory stidor.

The pediatric airway is highly compliant and the cartilaginous support is less developed than in the adult airway.
This leads to increased susceptibility to dynamic airway collapse in the presence of airway obstruction. Studies have
demonstrated that airway obstruction during general anesthesia is related to a reduction in laryngeal muscle tone.
Loss of muscle tone in the pharynx leads to airway obstruction at the level of the soft palate and epiglottis.
Laryngomalacia is a congenital abnormality of the larynx and results from the laryngeal structures being more
pliable and less rigid than in the adult

The tongue is larger and the mandible shorter in the young child. In infancy, the child is an obligate nasal breather
until 5 months of age. Prominent adenoids and tonsils are frequently found in preschool age children and are a
frequent reason to present for elective ENT surgery. These factors all contribute to loss of upper airway space which
can lead to difficulty with mask ventilation, obstruction during spontaneous ventilation, and can make laryngoscopy
more difficult. In addition, sedatives, hypnotic, and anesthetic drugs cause loss of tone of upper airway muscles
which can itself result in potential upper airway obstruction.
The hypopharynx of the pediatric patient is relatively shorter in height and narrower in width. On cross section, the
airway of an adult is more elliptical than that of the child.This has implication for supraglottic airway placement.
The larynx is relatively higher in the neck in children. In some positions, the mandible may lie in line with the upper
glottic structures. The cricoid ring is located approximately at the level of the C4 vertebrae at birth, C5 at age 6, and
C6 as adult.Vocal cords are not typically found at a right angle (90°) to the trachea. They are angled in an
anterior‑inferior to posterior‑superior fashion. While this typically does not affect laryngoscopic view, it can make
insertion of the endotracheal tube more challenging or more traumatic. Especially in suboptimal views or with
indirect video laryngoscopy, the endotracheal tube will have a higher tendency to collide with or become obstructed
on the anterior commissure of the vocal folds.
The epiglottis in children is more “U” shaped (compared to flat in adults) and it is less in line with the trachea and
may lie across the glottic opening. This feature makes many anesthesiologists prefer semi‑straight laryngoscope
blades such as a Miller which are designed to directly lift the epiglottis out of view compared to a curved Macintosh
blade which relies on ligamentous connection from the vallecula with the epiglottis to lift it out of view [Figure 2].
The hyoid bone is the first airway structure to ossify. The cartilaginous portions of the airway are soft and
compliant. Calcification of the larynx and trachea typically does not occur until the teenage years. The flexible
cartilaginous rings of the trachea can predispose to dynamic obstruction with negative pressure ventilation,
especially when any partial airway obstruction exists. Based on cadaveric studies, it has been a commonly held
belief that the pediatric airway is funnel‑shaped with the narrowest portion of the airway being found at the level of
the cricoid. This was contrasted to the adult airway, where the narrowest portion is the glottis and the airway is
described as cylindrical. These refer to the more rigid structures of the larynx as outlined by the laryngeal and
tracheal cartilages. Recent in vivo measurements taking into account the functional location of the softer tissues,
specifically the vocal folds present a somewhat different picture. Measurements of the size of the airway of children
using bronchoscopic images as well as magnetic resonance imaging images were consistently found to have glottic
openings smaller than at the cricoid. However, the distensibilty of the glottic tissues and the relatively nondistensible
cricoid cartilage may still lead to the effect of the cricoid being functionally the narrowest part of the airway. This
cartilaginous ring is the only circumferential complete structure in the airway and an endotracheal tube that passes
easily though the vocal cords may not pass through the cricoid ring. The cricoid ring in an infant is elliptical, not
circular, being oflarger diameter in the Antero-posterior dimension. This affects the seal of cuffed and uncuffed
endotracheal tubes and may guide selection of tracheal tubes.

The initial airway assessment starts with a good history. Questions are directed toward eliciting indications of a
potentially difficult airway. This would include any complications of birth or delivery, any history of prior trauma or
surgery to the airway or adjacent structures, or of prior anesthetics. Additionally, one should inquire about current or
recent symptoms suggesting upper respiratory infection (URI), difficulty in s peaking, difficulty breathing, difficulty
feeding, hoarseness, and noisy breathing. Questions such as a history of snoring, day time drowsiness, or stopping
breathing during sleep, may help to identify children with obstructive sleep apnea. Many syndromes are associated
with potentially difficult airway management. A nonexhaustive list of syndromes with potential airway
complications is summarized in Table 1.

Many physical exam findings which may be well‑known in the adult difficult airway literature also apply to
children. Limited head extension, reduced mandibular space, and increased tongue thickness have been shown to be
the most reliable predictors of difficult intubation. Some studies have attempted to use scores calculated from
various facial measurements to predict difficult laryngoscopic views. However, these scoring systems can be
difficult to use in clinical practice. Some series of cases have demonstrated a relationship between mandible length
and lip to chin distance being associated with Cormack and Lehane view classification. In one study, bilateral
microtia was associated with a 42% incidence of difficult laryngoscopy. However, even if no specific diagnosis is
known severity of disease or certain types of surgery are associated with increased risk for airway management
complications. In one large case series the rate of difficult laryngoscopy, as defined as Cormack and Lehane grade
III or IV, was found to be 1.35%. Some factors that increased likelihood of difficult visualization included age <1
year, cardiac surgery, ASA status III and IV, Mallampati III or IV, and low body mass index.

Head positioning is extremely important during airway management in small children. The optimal
position is obtained when the neck is in a neutral or a slightly extended position (Fig. 1). The head,
and especially the back of the head, is relatively large, and the younger the child is, the more
pronounced this is. Therefore, in neonates and premature children, airway management should be
performed with a small towel under the shoulders to avoid flexion of the neck. A foam ring to
stabilise the head may cause neck flexion that makes airway management more difficult, but this can
be compensated for by placing gel pads or similar objects under the back of the child.
Many different types of face masks are available on the market. A transparent, disposable mask with
a large and soft cuff is recommended, as this feature makes it very easy to establish an airtight seal
to the face. At the same time, the transparency is useful, and the children seem to find them less
frightening than the black masks. It is important to choose a face mask large enough to allow the
mouth of the child to be open during ventilation, but at the same time the mask should not cover the
eyes of the child. A chin lift or a jaw thrust may be helpful. The mouth of the child should be opened
widely if airway obstruction is not immediately relieved. Quite often, it will be observed that the
tongue is pressed against the palate and the wide mouth opening will release the tongue from the
palate and restore the open airway. Some children continue to obstruct despite a correct technique.
This is most commonly seen in children who also obstruct during sleep. This may be caused by
hypertrophic tonsils, airway malacia, or other conditions with narrow or soft airways. In these
children, it is useful to apply assisted ventilation with CPAP, If the described techniques are used,
supraglottic airway devices are rarely needed.
Supraglottic airway devices
An oral airway prevents the tongue from pressing against the palate and creates a passage for
ventilation. It is important that the oral airway has exactly the correct length, which is estimated by
holding it against the cheek of the child. The tip of the airway should reach distal to the angle of the
jaw. If the oral airway is too short, it will displace the tongue and obstruct the airway, and if it is too
long, it may precipitate laryngospasm, as anaesthesia is often light, when the oral airway is needed.
As mentioned earlier, if the mouth is kept open during mask ventilation, the oral airway is only rarely
needed. The nasal airway is also a useful device in difficult upper airways or in the case of a difficult
face mask fit. It is possible to assist or control ventilation via the nasal airway if the mouth and the
free nostril are closed manually

Laryngeal mask airways (LMA)

LMA are widely used in children. In many situations, it is an acceptable alternative to endotracheal
intubation and its usefulness in difficult airways is well documented. The choice of the LMA is based
on the lean body weight of the child (Table 2). The LMA is usually easy to insert in children, but in
infants the long epiglottis is frequently caught and down-folded by the tip of the LMA. The amount of
air in the cuff should keep it expanded but not distended.If there is a leakage around the LMA, it is
probably misplaced or too small. It is important to make sure that the LMA does not displace from
the central position. Otherwise, the risk of air insufflation of the stomach increases during controlled
ventilation. Tracheal intubation is preferred with longer procedures. So far, it seems wise not to
connect a ventilator, when the smallest LMAs are used. When spontaneous ventilation is sufficient
the LMA is removed. If the cuff is not deflated before removal, more secretions are removed with the
mask. The timing of removal is debated, but it is recommended to remove the LMA rather early,
before the return of reflexes.

Until the age of 10–12 years, the narrowest portion of the airway is at the level of the cricoid
cartilage, which is a ring of cartilage, which is why the airway at this point is rigid and not
distendable. Therefore, an endotracheal tube that easily passes the vocal cords may still be too
large, and forcing it through the cricoid ring will compress and traumatise the mucosa. The airway in
small children is very vulnerable, and airway oedema and post-intubation stridor is easily induced.
Subsequent tracheal scarring and stenosis may follow, although this is very uncommon. Airway
trauma can be reduced by careful instrumentation and by using an endotracheal tube of an
appropriate size. The tube must not be forced into the trachea, and if a cuffed tube is used, the cuff
pressure should be monitored and kept as low as possible.
In the smallest children, airway oedema will have the most impact due to the smaller dimensions.
The estimated size of the endotracheal tube can be chosen from a table (Table 3) and compared
with the distal phalanx of the fifth finger of the child, which often correlates well with the tube size.
From the age of 2 years, the formula Tube size541(age/ 4), may be used as guidance. If cuffed
tubes are used, the formula is changed to 3.51(age/4).

During laryngoscopy, the tongue should be moved to the left by the laryngoscope and the blade
should be introduced gradually into the midline until the epiglottis is seen. The tip of the blade is then
advanced further against the vallecula at the base of the epiglottis. The best view would often be like
in Fig. 4A, where the epiglottis is covering the laryngeal aperture. Even though the Miller blade was
designed to lift up the epiglottis, this should not be done routinely, as it may precipitate bradycardia.
Instead, an external pressure may be applied over the larynx with the fifth finger, which will flip up
the epiglottis and bring the vocal cords into view.
When the vocal cords are visualised, the endotracheal tube is inserted between them, and without
use of force, it is then moved through the cricoid cartilage. In infants, the vocal cords are angled
more anteriorly, and if the tip of the tube is caught in the anterior commisure, a slightly rotating
movement of the tube will often solve the problem.

If the intubation turned out to be more difficult and traumatic than expected, it may be wise to administer
intravenous (i.v.) steroids prophylactically to reduce the risk of airway oedema and post-intubation stridor. We
suggest dexamethasone 0.6 mg/kg up to a maximum of 12 mg.

If stridor is present after extubation, adrenalin inhalation very effectively reduces the swelling. A rather high dose of
L-adrenaline or racemic adrenaline can be used without significant side effects and our protocol includes L-
adrenaline 0.5 mg/kg (maximum 6 mg). If racemic adrenaline is used the dose should be doubled. The treatment
should be repeated at increasing intervals to avoid recurrence of the stridor.

Paediatric airway management is a great challenge, especially for doctor and anaesthesiologists working
in departments with a low number of paediatric surgical procedures. The airway of the pediatric patient
has a number of significant differences when compared to the adult airway and presents some unique
challenges. Awareness of anatomical and physiological differences, important pathological conditions
affecting children, and a knowledge of the available airway techniques and tools will allow the doctor to
formulate and execute safe and effective management of the pediatric airway. Strict adherence to safe
and simple principles can definitely affect the confidence and outcome. It is essential to pay attention to
the details described in this paper, such as positioning of the head of the child, keeping the mouth of the
child open during mask ventilation, the appropriate use of supraglottic airways, and using an optimal
technique during tracheal intubation and extubation.
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