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return to: Pediatric Airway

 Pediatric Foreign Body Removal

Adult Airway in the Operating Room

  1. GENERAL CONSIDERATIONS
    1. When performing an airway evaluation in the pediatric population through direct laryngoscopy, it is important to test for possible stenosis of the airway.
    2. The smallest point of the pediatric airway is the subglottis.
    3. The Cotton system was created in 1984 for evaluation of stenosis with grades that include:
      1. Grade I: Up to 50% stenosis
      2. Grade II: From 51 to 70% stenosis
      3. Grade III: 71 to 99% stenosis
      4. Grade IV: No detectable lumen on examination
    4. Although there are many methods to evaluate the size of the pediatric airway, the use of endotracheal tubes is considered the gold standard.
      1. The use of endotracheal tubes is consistent, and simple.
      2. Other methods including CT scan are good for evaluation of the length of stenosis, and to evaluate for other structural abnormalities.  Due to magnification errors however, using CT scans does not provide for accurate evaluation of airway stenosis.
  2. PREOPERATIVE PREPARATIONS
    1. There are many considerations to be made prior to starting the procedure including:
      1. Age of the patient
      2. Weight of the patient - calculation of the dosage of lidocaine at (4 mg/kg) should be made.
      3. Estimation of ET tube sizes to be used should be made, starting with a conservative estimate.
  3. OPERATIVE PROCEDURE
    1. The patient is placed into suspension (Please see Pediatric Direct Laryngoscopy)
      1. The region of stenosis is evaluated, and a conservative estimation of the size of tube that will pass through the point of stenosis is made.
    2. Using the endoscope, the ET tube is advanced through the area of stenosis, and a leak test is performed.
      1. Tube placement is confirmed.  The tube should be advanced so that the second hashmark noted on the tube lies in the area of stenosis.
    3. If there is an audible leak at less than 10 cmH20, then the next larger size of ET tube is placed
    4. If there is an audible leak in the range of 10 to 25 cm H20, then this size of ET tube is compared to the expected size of ET tube for the child's age.
      1. Visualization for a leak is made with the endoscope in place.  You may also hear the cuff leak.
    5. The below chart is helpful in making this conversion
      1. The percentage of stenosis is then calculated and the grade of stenosis is noted.


This chart was replicated form (Myer CM 3rd, O'Connor DM, Cotton RT., Ann Otol Rhinol Laryngol. 1994 Apr;103(4 Pt 1):319-23.)

  1. SUGGESTED READING
    1. Cotton RT. Pediatric laryngotracheal stenosis. J Pediatr Surg. 1984 Dec;19(6):699-704.
    2. Myer CM 3rd, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes.  Ann Otol Rhinol Laryngol. 1994 Apr;103(4 Pt 1):319-23.
    3. Shott SR. Down syndrome: Analysis of airway size and a guide for appropriate intubation. Laryngoscope. 2000 Apr;110(4):585-92.