| Anatomical consideration | Anesthetic impact |
| Prominent occiput | - Neck flexion results in airway obstruction when supine
- Shoulder roll may improve alignment
|
| Large tongue | - Source of upper airway obstruction
- May improve with oral airway
|
| Large tonsils and adenoids | - Source of upper airway obstruction
- May bleed during intubation attempt, or with nasal intubation
|
| Superior laryngeal position | - More acute angle between axes of oral cavity and larynx
- Visualization of glottic opening may be difficult with direct laryngoscopy
- Cricothyroidotomy difficult
|
| Weak hyoepiglottic ligament | - Curved laryngoscope blades (ie, Macintosh) may not lift epiglottis when placed in vallecula
|
| Long, floppy, omega-shaped epiglottis | - Obstructs view of glottis
- May require straight laryngoscope blade (ie, Miller) to directly lift epiglottis during laryngoscopy
|
| Short trachea | - ETT depth must be carefully checked
- Inadvertent extubation or advancement into right mainstem bronchus more likely than in adults
|
| Narrow trachea | - Small decreases in diameter due to edema or secretions result in large changes in airway resistance
- Cricothyroidotomy difficult
|
| Elliptical subglottis | - Pressure on narrow diameter may result in edema even if a leak is audible
|
| Physiologic consideration | Anesthetic impact |
| Compliant chest wall | - Loss of intrinsic muscle tone with anesthesia results in loss of functional residual capacity, atelectasis, and rapid desaturation
- Increased work of breathing may lead to chest wall collapse and decreased alveolar ventilation
|
| Increased respiratory rate | - Higher respiratory rate required for mechanical or mask-assisted ventilation than adults
|
| Increased rate of oxygen consumption | - Shorter apneic time to desaturation
|
| Decreased type 1, slow-twitch respiratory muscle fibers | - Prone to fatigue and respiratory failure in setting of increased airway resistance (ie, bronchospasm, postintubation croup)
|
| Increased vagal tone | - May experience bradycardia or cardiac arrest in response to instrumentation of the airway or hypoxemia
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