The normal airway of a pediatric patient has important anatomic differences from that of the adult. These differences are most apparent in infants and become relatively insignificant by age 8. They include the size of the occiput and the tongue in the infant, the high position of the larynx, the configuration of the larynx, and the position of the vocal cords.
The infant has a large occiput. Positioning of the head to obtain the optimum orientation for laryngoscopy, or the "sniffing position," is accomplished simply by rotating the head so that it rests on the occiput. Elevating the head with padding can lead to excessive flexion of the neck and may contribute to upper airway obstruction and difficulty during intubation. The infant's tongue is also relatively large, and this can impair laryngoscopy as well as contribute to upper airway obstruction. An infant's larynx is higher in the neck, located at the C3 level, than that of an adult, which is found at the C4 to C5 level. The larynx is also funnel-shaped in infants, with the narrowest portion at the subglottic area, rather than at the level of the vocal cords, as in an adult. Hence, in infants and small children, an endotracheal tube that passes easily through the vocal cords may encounter resistance more distally. Finally, infants' vocal cords are slanted anteriorly rather than being perpendicular to the trachea, as in an adult, and this characteristic, too, can result in more difficult visualization and intubation in the pediatric population. 1
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