The pediatric airway: Historical concepts, new findings, and what matters

Wani, Tariq; Bissonnette, Bruno; Engelhardt, Thomas; Buchh, Basharat; Arnous, Hassan; AlGhamdi, Faris; Tobias, Joseph D.

doi:10.1016/j.ijporl.2019.02.041

Cited by 18 publications

(17 citation statements)

References 35 publications

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“…This "dogma" in pediatric anesthesia emerged more than half a century ago from the studies by Eckenhoff (9), based on prior studies by Bayeux (10) and experiments with mummified pediatric anatomical models. In vivo studies (11,12) with computed tomography, magnetic resonance and fiber-optic bronchoscopy with spontaneous breathing suggest that the pediatric larynx has the same cylindrical shape of the adult larynx -even somewhat elliptical -with the anteroposterior diameter being longer than the lateral diameter and having two sites of maximum narrowness at the level of the cricoid ring, as described in old studies, and at the level of the vocal cords as a new finding (13,14). The controversy is still open with some experts challenging these findings (15) partly on the grounds that these measurements -comparisons not only between cadaver models and live children but also between spontaneous and controlled breathing, or even between inspiratory and expiratory phasesmake consensus difficult (16,17).…”

Section: Pediatric Airway Anatomymentioning

confidence: 59%

Pediatric airway: What is new in approaches and treatments?

Rivera-Tocancipá

2020

Colomb. J. Anesthesiol.

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Perioperative morbidity and mortality are high among patients in the extremes of life undergoing anesthesia. Complications in children occur mainly as a result of airway management-related events such as difficult approach, laryngospasm, bronchospasm and severe hypoxemia, which may result in cardiac arrest, neurological deficit or death. Reports and new considerations that have changed clinical practice in pediatric airway management have emerged in recent years. This narrative literature review seeks to summarize and detail the findings on the primary cause of morbidity and mortality in pediatric anesthesia and to highlight those things that anesthetists need to be aware of, according to the scientific reports that have been changing practice in pediatric anesthesia. This review focuses on the identification of “new” and specific practices that have emerged over the past 10 years and have helped reduce complications associated with pediatric airway management. At least 9 practices grouped into 4 groups are described: assessment, approach techniques, devices, and algorithms. The same devices used in adults are essentially all available for the management of the pediatric airway, and anesthesia-related morbidity and mortality can be reduced through improved quality of care in pediatrics.

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Section: Pediatric Airway Anatomymentioning

confidence: 59%

Pediatric airway: What is new in approaches and treatments?

Rivera-Tocancipá

2020

Colomb. J. Anesthesiol.

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“…The description of the shape and diameters of the developing larynx is one of the most debated subjects in the literature 18,19 : the pediatric larynx has been considered funnel‐shaped for a long time, with the narrowest point being at the cricoid ring until 6–8 years of age, as opposed to the adult larynx, which is cylindrical and has the narrowest point localized at the glottis opening. However, it should be emphasized that this description came from anatomical measurements of the glottic and subglottic areas in cadaveric studies, particularly from the work by Bayeux 20 and Eckenhoff, 11 so the data might have been biased due to postmortem tissue muscle tonicity loss in the portions of the larynx not supported by full circumferential cartilage.…”

Section: The Pediatric Larynx: Cylindrical or Funnel‐shaped?mentioning

confidence: 99%

“…As a matter of fact, this hypothesis has recently been reconsidered in some in vivo studies: Littman and Dalal, using MR and video-bronchoscopic imaging, respectively, have shown that the pediatric larynx is conical in the transverse dimension (with the apex of the cone at the vocal cords, which is the narrowest point) and cylindrical in the anteroposterior dimension. 21,22 However, since CT is considered the gold standard for measuring the inner portions of the larynx and trachea due to its spatial resolution and discrimination of the air/tissue interface, 23,24 this technique has been used in subsequent studies by Wani et al, 19 which specified that the narrowest part of the pediatric larynx is located in the subglottic area. Specifically, these studies have clarified that the narrowest portion of the larynx in the transverse dimension is localized at the subglottic level, and in the anteroposterior dimension, it is localized at the cricoid level.…”

Section: The Pediatric Larynx: Cylindrical or Funnel-shaped?mentioning

confidence: 99%

Structural and functional development in airways throughout childhood: Children are not small adults

Cicco

Kantar

Masini

et al. 2020

Pediatric Pulmonology

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Children are not small adults and this fact is particularly true when we consider the respiratory tract. The anatomic peculiarities of the upper airway make infants preferential nasal breathers between 2 and 6 months of life. The pediatric larynx has a more complex shape than previously believed, with the narrowest point located anatomically at the subglottic level and functionally at the cricoid cartilage. Alveolarization of the distal airways starts conventionally at 36-37 weeks of gestation, but occurs mainly after birth, continuing until adolescence. The pediatric chest wall has unique features that are particularly pronounced in infants. Neonates, infants, and toddlers have a higher metabolic rate, and consequently, their oxygen consumption at rest is more than double that of adults. The main anatomical and functional differences between pediatric and adult airways contribute to the understanding of various respiratory symptoms and disease conditions in childhood. Knowing the peculiarities of pediatric airways is helpful in the prevention, management, and treatment of acute and chronic diseases of the respiratory tract. Developmental modifications in the structure of the respiratory tract, in addition to immunological and neurological maturation, should be taken into consideration during childhood.

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“…Unsurprisingly, articulated speech becomes possible when the larynx starts to descend (approximately around the second year of life) (12). The description of the shape and diameters of the developing larynx is one of the most debated subjects in the literature (18,19): the paediatric larynx has been considered funnel-shaped for a long time, with the narrowest point being at the cricoid ring until 6-8 years of age, as opposed to the adult larynx, which is cylindrical and has the narrowest point localized at the glottis opening. However, it should be emphasized that this description came from anatomical measurements of the glottic and subglottic areas in cadaveric studies, particularly from the work by Bayeux (20) and Eckenhoff (11), so the data might have been biased due to post-mortem tissue muscle tonicity loss in the portions of the larynx not supported by full circumferential cartilage.…”

Section: Larynxmentioning

confidence: 99%

“…As a matter of fact, this hypothesis has recently been reconsidered in some in vivo studies: Littman and Dalal, using MR and video-bronchoscopic imaging, respectively, have shown that the paediatric larynx is conical in the transverse dimension (with the apex of the cone at the vocal cords, which is the narrowest point) and cylindrical in the anteroposterior dimension (21,22). However, since CT is considered the gold standard for measuring the inner portions of the larynx and trachea due its spatial resolution and discrimination of the air/tissue interface (23,24), this technique has been used in subsequent studies by Wani et al, which specified that the narrowest part of the paediatric larynx is located in the subglottic area (19). Specifically, these studies have clarified that the narrowest portion of the larynx in the transverse dimension is localized at the subglottic level, and in the anteroposterior dimension, it is localized at the cricoid level.…”

Section: Larynxmentioning

confidence: 99%

Structural and Functional Development in Airways Throughout Childhood: Children Are Not Small Adults

Cicco

Kantar

Masini

et al. 2020

Preprint

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Children are not small adults, and this fact is particularly true when we consider the respiratory tract. The anatomic peculiarities of the upper airway make infants preferential nasal breather between 2 and 6 months of life. The paediatric larynx has a more complex shape than previously believed, with the narrowest point located anatomically at the subglottic level and functionally at the cricoid cartilage. Alveolarization of the distal airways starts conventionally at 36-37 weeks, but occurs mainly after birth, continuing until adolescence. The paediatric chest wall has unique features that are particularly pronounced in infants. Neonates, infants and toddlers have a higher metabolic rate, and consequently, their oxygen consumption at rest is more than double that of adults. The main anatomical and functional differences between paediatric and adult airways contribute to understanding of various respiratory symptoms and disease conditions in childhood. Knowing the peculiarities of paediatric airways is helpful in the prevention, management and treatment of acute and chronic diseases of the respiratory tract. Developmental modifications in the structure of the respiratory tract, in addition to immunological and neurological maturation, should be taken into consideration during childhood. NOSE, MOUTH AND PHARYNX The nose is the main entrance of the respiratory system: its external portion is particularly showy, projecting anteriorly between the orbits, but its internal portion is notably wider, starting at the nares and ending in the nasopharynx. The inner part of the nose is divided by the nasal septum into two irregularly shaped air chambers known as the nasal cavities, which communicate with the sinuses of the ethmoid, sphenoid, frontal, and maxillary bones through small orifices called ostia and are also connected with the orbits through the lachrymal canals and with the anterior cranial fossa through the olfactory foramina. In a well-conducted study, Xi et al. described the development of the nasal cavities and larynx as well as their air-flow dynamics and aerosol deposition, employing models based on computed tomography (CT) images of 4 children aged 10 days, 7 months, 3 years, and 5 years and comparing the models to a model from a 53-year-old adult (2): the study showed that the nasal cavities rapidly increase in space over the first 5 years of life, when the volume included between the nares and the larynx reaches 40.3% of that of the adult. In this study, the turbinate region, including the 3 turbinate bones located in the lateral walls of the nose, experienced the most noticeable growth during childhood and was undeveloped in both the 10-day-old and 7-month-old models. Moreover, the nostrils were described as smaller and their shape as more circular in the newborn, becoming more oval during infancy and childhood and wedge-shaped in adulthood (2), as shown in previous studies (3). Smaller nares and nasal cavities unavoidably limit the inflow of air, so it is estimated that the nose contributes up

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The pediatric airway: Historical concepts, new findings, and what matters

Cited by 18 publications

References 35 publications

Pediatric airway: What is new in approaches and treatments?

Pediatric airway: What is new in approaches and treatments?

Structural and functional development in airways throughout childhood: Children are not small adults

Structural and Functional Development in Airways Throughout Childhood: Children Are Not Small Adults

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