Pediatric endotracheal intubation is an uncommon procedure in the Emergency Department (ED); even in high volume tertiary pediatric centres the incidence has been reported at 8-10/10,000 patients. While infrequent, pediatric airway management is an essential and life-saving skill that all ER physicians must be prepared for.  Much of the knowledge and skill set from the adult world is applicable here, however there are several important differences that are unique to the pediatric population.


  • Provide a basic review of pediatric airway physiology + anatomy
  • Discuss predictors of the pediatric difficult airway
  • Review the literature on pediatric ER intubation practices and associated complications
  • Review Delayed Sequence Intubation (DSI) and the pediatric surgical airway
Pediatric Airway Anatomy and Physiology Review
1. Anatomic differences in the pediatric airway are more pronounced in younger children, especially under 1 year, and have important implications for airway management
These include: 
  • Large occiput + head à Add a shoulder roll to align the airway axes
  • Large Tongue à obstruction more common, maneuvers to open the airway may be necessary (eg jaw thrust)
  • Superior larynx and anterior vocal cords + floppy epiglottis à visualization can be more challenging, consider a straight blade in younger children to lift the large epiglottis
  • Large stomach with relatively small lungs à consider early NG tube

Walls, R. 2012. Manual of Emergency Airway Management, 4th Edition


 2. Physiologically, kids have a considerably shorter time to desaturation than adults and their relatively larger extracellular fluid compartment means a quicker onset and shorter duration of RSI drugs16

  • There are many different equations out there to figure out sizing of tubes, blades, masks, etc., but the bottom line is that it’s too much to memorize for something you won’t need to use often, so to reduce error in critical situations use memory aids such as the Broselow tape or your favourite medical app

PediStat — a commonly used pediatric reference application

3. Difficult intubation seems to be rare in children, but increases in incidence in the <1 yo population. 
This retrospective analysis of 11,219 pediatric anesthesia procedures found that the overall incidence of difficult laryngoscopy to be only 1.35%. The paper highlighted some predictors of a difficult pediatric airway, which included:
  • < 1 year old
  • Mallampati score (if attainable) III + IV
  • Low BMI
  • Children undergoing cardiac and oromaxillofacial surgery patients – likely due to higher proportion craniofacial dysmorphisms eg. Cleft palate, micrognathia

ER Pediatric Intubation Practices and Complications
1. Pediatric endotracheal intubation is an uncommon procedure, but resulting desaturation and hypotension are frequent complications
This prospective observational study reviews pediatric intubations in a tertiary pediatric ED. Their primary and secondary outcomes were, respectively, the rate of adverse effects during intubation and the incidence of difficult laryngoscopy and first pass success rate without desaturation and hypotension.
  • The incidence of pediatric intubations was found to be 9/10,000
  • 79% of intubations were for medical conditions (seizure most commonly), 21% were for trauma
  • Median age was 3, with 25% of intubations being in the <1 population
  • First pass success rate was 78%
  • First pass rate without hypotension or hypoxia was only 49%
  • Difficult intubation was seen in 7% of cases, but all intubations were ultimately successful
  • Ketamine was the most commonly used mono-agent and was the induction agent of choice in patients with CVS compromise
2. Desaturation and hypotension peri-intubation matter, as they are linked to poor neurologic outcomes and are predictors of airway mortality 12 
A review of 1081 difficult airways found that 1% were associated with cardiac arrest, all preceded by hypoxemia.  Occurrence of complications in the difficult airway was associated with: 
  • More than two intubation attempts
  • Weight < 10kg
  • Short thyromental distance
  • 3 direct laryngoscopy attempts before switching to indirect technique
3. Direct Laryngoscopy is a reasonable first line choice, but the Pediatric Difficult Intubation (PeDI) registry data suggests we should be thinking about switching to an indirect method much sooner if we run into trouble.  
In fact, first attempt success rates in the pediatric difficult airway population were found to be substantially higher in Video than in Direct Laryngoscopy (55 % vs 3 %)4. This begs the question as to whether community and ERs that see primarily adults should be stocking pediatric video laryngoscopes?
Keep in mind, though, that this is the difficult airway population, which we know is quite rare.  A systematic review of 14 prospective RCTs comparing video vs direct in the pediatric population concluded that although video improved glottis visualization, it was associated with prolonged time to intubation — something to consider given the considerably reduced safe apnea time in children.

Delayed Sequence Intubation and The Pediatric Surgical Airway
Scott Weingart’s group has paved the way for future studies on Delayed Sequence Intubation (DSI)1; keep an eye out for this in the pediatric population as it’s easy to see how it might be useful in the agitated hypoxic child that needs to be intubated
The concept is to use ketamine as an induction agent to facilitate pre-oxygenation while keeping the patient spontaneously breathing in situations where RSI would likely lead to  hypoxia. While the evidence is still in it’s infancy, case reports 2,3 are surfacing of DSI being successfully used to secure the airway in agitated hypoxic and critically ill patients.


Pediatric Airway algorithm

ASA 2013 Difficult Airway Algorithm

Finally, if you find yourself in the exceedingly rare but completely terrifying can’t intubate, can’t ventilate scenario with a pediatric patient, remember that needle cricothyrotomy is indicated in younger children14
  • The literature in this area is sparse and there is no consensus on a definite age cut off for needle vs open cricothyrotomy, it will depend on how difficult landmarking is and the size of the cricothyroid membrane (CTM). 
  • Consider using a Seldinger technique to transition to open once needle is secured if needle ventilation continues to be inadequate and help has not yet arrived
  • Anatomical differences making the traditional surgical airway challenging in this population include a smaller CTM, more compliant larynx and the thyroid cartilage riding under the hyoid bone.


Dr. Rebecca Brown, MD, CCFP – is a third year resident in the CCFP-EM Program at the University of Ottawa.

Edited and Formatted by Dr. Rob Suttie, PGY2 at the University of Ottawa





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3. Löllgen RM, Webster P, Lei E, Weatherall A. Delayed sequence intubation for management of respiratory failure in a 6-year-old child in a paediatric emergency department. EMA – Emerg Med Australas. 2014.
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