PRE TEST

ANATOMIC
DIFFERENCES
BETWEEN PEDIATRICS
AND ADULTS
Anna Michaela B Valerio, RTRP
INTRODUCTION
 INTRODUCTION
• Many of the anatomical differences seen
between children and adults are most
pronounced in infancy.
• This is seen clearly when studying the
nasopharynx,
• oropharynx, and pharynx, for example, because
they continuously evolve throughout childhood.
• These changes have implications for airway
management.
• Infants are considered obligate nose breathers.
• They are not totally dependent on nose
breathing but breathe through their noses
preferentially.
• Any obstruction, such as mucus or
inflammation, can increase resistance to
airflow and work of breathing (WOB).
• In children, the size of the tongue compared to
the oral cavity is much larger, particularly in
infancy.
• This makes the tongue a natural airway
obstructer.
• An oral airway should be a first line of defense
when beginning bag-mask ventilation on an
unconscious child to avoid tissue airway
obstruction
• Children have large tonsils and
adenoids and a large amount of
lymphoid tissue in the pharynx.
• These are potential areas for swelling,
which can cause upper airway
obstruction.
• They may also bleed significantly
during trauma or intubation,
obstructing views and risking aspiration
• An infant’s epiglottis is larger, less
flexible, and omega or U-shaped.
• It lies more horizontally than an adult’s
and is more susceptible to trauma.
• The angle between the epiglottis and
laryngeal opening is more acute in an infant
than in an adult, which makes blind nasal
intubation difficult.
• In infancy, the glottis begins at the first cervical
vertebrae (C1). As the thorax and trachea grow,
the glottis moves to C3 to C4 by age 7 and is
located at C5 to C6 in adulthood. This makes
the glottis in children higher and more anterior
than in adults.
• The cricoid ring is the smallest portion of a
child’s airway, whereas in adults the vocal
cords are the smallest portion of the airway.
• An uncuffed endotracheal tube (ETT) provides
an adequate seal in a small child because it
fits snugly at the level of the cricoid ring.
• When using an uncuffed ETT, correct tube size
is imperative because air can leak around an
ETT that is too small, and tracheal damage
can result from an ETT that is too large.
• Children have small cricothyroid
membranes, and, in children younger than 3
years, it is virtually nonexistent.
• This means emergency surgical airway
techniques such as needle cricothyrotomy
and surgical cricothyrotomy are extremely
difficult, if not impossible, in infants and small
children.
• A child’s trachea is smaller and more
malleable than an adult’s trachea, meaning
it is more susceptible to changes in shape
when under pressure.
• The newborn trachea is approximately 6 mm
in diameter, and the cartilage is not fully
developed, making it more compliant than
the adult trachea.
• This means the trachea of a newborn
collapses more easily, and in the presence of
inflammation, airway resistance will increase
exponentially.
• Increased inspiratory pressure during
respiratory distress causes increased
negative intrathoracic pressure and can lead
to collapse of the extrathoracic trachea.
• Caution should be taken when caring for
pediatric patients with increased WOB
because increased respiratory effort by
patients to alleviate airway obstruction may
instead exacerbate it
• The diameter of children’s airways
is smaller than the airways of
adults, making children more
susceptible to airway obstruction
caused by swelling.
• The shorter trachea of children
makes tube misplacement and
accidental extubation much more
frequent than in adults. Small tube
migrations due to head
movement can cause ETT
dislodgement.
• With both adults and children, an effective way of
opening the airway is to place the patient in the
sniffing position, in which the patient’s head and
chin are thrust slightly forward to keep the airway
open.
• However, the occiput (back part of the skull) is
larger in children and may cause flexion of the
neck and inadvertent obstruction of the airway.
• To align the airway in an adult, a roll can be
placed under the head.
• In children this is not needed, and infants may
need a shoulder roll to achieve sniffing position.
• In summary, infants and toddlers (younger than 2
years) have higher anterior airways.
• Children older than 8 years have airways similar
to adults.
• The age range of 2 to 8 years old marks a transition
period, when the above-mentioned anatomical
differences may have varying effects on airway
management.
• On the positive side, the anatomical differences are
consistent from one child to another, so they can be
anticipated when managing a child’s airway. This is
not true in adults, however, in whom complex airway
issues are related to body build, arthritis, and chronic
disease.
• An infant’s ribs and sternum are mostly
cartilage, and the ribs lay more
horizontally than do those of an adult.
• The thoracic cage thus offers little
stability, and the chest wall will collapse
with negative pressures.
• This makes retractions more pronounced
in infants and most obvious in preterm
infants.
• The cartilaginous ribs do, however, mean
that closed-chest compressions from
cardiopulmonary resuscitation do not
usually cause rib fractures in children
• Breathing for infants is mostly diaphragmatic, making them
abdominal or “belly breathers.”
• Instability of the thoracic cage makes it difficult to increase
minute ventilation by increasing thoracic volume.
• Infants must drop the diaphragm more to increase tidal volume,
which increases WOB.
• To avoid increased WOB, infants usually increase respiratory rate
to increase minute ventilation
• The angle of the right mainstem at the
carina is lower in children than adults,
making them more susceptible to right
mainstem intubation and foreign body
obstruction of the right lung
• At birth, the number of conducting
airways is completely developed.
• However, airway diameter increases with
lung growth.
• This explains the phenomenon of children
“outgrowing” reactive airways disease.
• It is less likely that the swelling and
smooth muscles are no longer reactive;
rather, the degree of airway obstruction is
less pronounced as a result of the
increased airway diameter.
• The alveoli in newborns also do not have Pores
of Kohn (minute openings thought to exist
between adjacent alveoli), which decreases a
newborn’s capacity for collateral circulation of
air.
• The lack of collateral air circulation means
that during lower airway obstruction,
newborns and infants will be affected more
significantly and decompensate more rapidly.
• Compared to adults, infants and children
have a lower pulmonary reserve, or functional
residual capacity (FRC), which is the amount
of air remaining in the lungs after a normal
resting expiration.
THIS IS CAUSED BY
SEVERAL FACTORS
• Infants and children have larger hearts
in proportion to the thoracic diameter,
which imposes on the lungs and
decreases lung capacity.
• An infant’s chest wall is more compliant
than an adult’s chest.
• The elastic recoil of a child’s lungs is less
than that of an adult.
• Young children have proportionally
large abdominal contents, which push
up against the diaphragm.
• This can also make gastric insufflation during bag-
mask ventilation more hazardous for children.
• Using cricoid pressure, also known as the Sellick
maneuver (pushing the cricoid cartilage against
the cervical spine, compressing the esophagus to
prevent passive regurgitation), has been shown to
decrease gastric insufflation in children, even when
peak inspiratory pressures greater than 40 cm H2O
are used.
• It can also decrease the risk of aspiration.
• This is especially important for infants, in whom
gastric distention can significantly compromise
ventilation.
• Furthermore, the basal oxygen consumption of
Children is twice that of adults: 6 mL O2/kg for
children versus 3 mL O2/kg for adults.
• The clinical implication of lower pulmonary
reserve and increased oxygen consumption is
that children will desaturate more rapidly than
will adults.
• Recommendations for airway management
suggest that clinicians should be prepared to
provide bag-mask ventilation with 1.0 FIO2 if a
child’s oxygen saturation falls below 90%
POST TEST
PRE AND POST TEST
QUIZ
ASSIGNMENT/S