PEDIATRIC AIRWAY & RESPIRATORY PHYSIOLOGY

The respiratory mechanism of the pediatric patient varies from the adult in both
anatomy and physiology. As children grow, the airway enlarges and moves more
caudally as the c-spine elongates. The pediatric airway overall has poorly developed
cartilaginous integrity allowing for more laxity throughout the airway. Another important
distinction is the narrowest point in the airway in adults is at the cords versus below the
cords for children. Some of the important anatomic differences are listed below.
Tongue Large Normal Eiglottis Shape Floppy, omega shaped Firm, flatter Epiglottis Level
Level of C3 - C4 Level of C5 - C6 Trachea Smaller, shorter Wider, longer Larynx Shape
Funnel shaped Column Larynx Position Angles posteriorly away from glottis Straight up
and down Narrowest Point Sub-glottic region At level of Vocal cords Lung Volume 250ml
at birth 6000 ml as adult An important aspect of the narrow airway in children is that
resistance is significantly increased. The formula to consider is R ~ 8l / r4 R resistance,
l length, r radius Small changes in the airway radius will therefore increase the
resistance to the fourth power. Therefore, a small amount of post-extubation sub-glottic
edema will significantly increase the work of breathing for an infant. Children also have a
smaller forced residual capacity (FRC) defined as the residual volume plus the expiratory
reserve volume. Physiologically, FRC occurs when the outward pull of the chest wall
equals the inward collapse of the lungs. FRC essentially acts as a respiratory reserve.
When patients begin to develop respiratory distress, an increased FRC equates to a
longer period of time prior to respiratory failure. The reduced FRC is important in two
particular circumstances. First, it can be decreased by up to 30% in a supine patient as
compared to a sitting patient. As the abdominal contents push up on the diaphragm in a
supine patient, the FRC is affected. This situation is amplified in pediatric patients
because of a compliant chest wall, small thoracic cage, and large abdominal contents.
Second, while pre-oxygenating a patient prior to intubation the reduced FRC decreases
the amount of time allowed to establish an endotracheal tube prior to desaturation. There
are also many physiologic differences in respiratory mechanisms between children and
adults. Children have a more complaint trachea, larynx, and bronchi due to poor
cartilaginous integrity. This in turn allows for dynamic airway compression, i.e. a greater
negative inspiratory force sucks in the floppy airway and decreases airway diameter.
This in turn increases the work of breathing by increasing the negative inspiratory
pressure generated. A vicious cycle is created which may eventually lead to respiratory
failure: subglottic stenosis negative inspiratory force airway collapse
subglottic stenosis negative inspiratory force work of breathing respiratory
failure. Pediatric patients also have more compliant chest walls also increasing the work
of breathing i.e. the outward pull of the chest is greater. Infants are dependent on
functional diaphragms for adequate ventilation. The accessory muscles contribute less to
the overall work of breathing in infants as compared to older children and adults.
Therefore, a non-functional diaphragm often leads to respiratory failure. Diaphragmatic
fatigue is one amongst several potential causes of respiratory failure and apnea in young
patients with RSV bronchilitis. Finally, the respiratory muscles themselves have a
significant oxygen and metabolite requirement in children. In pediatric patients the work
of breathing can account for up to 40% of the cardiac output, particularly in stressed
conditions. This cursory discussion of the pediatric respiratory anatomy and physiology
allows one to appreciate the significant differences between children and adults.
Therefore, the child with respiratory distress / failure should be approached and treated
with urgency, vigilance, and caution.