Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide, by Christine E. Whitten MD.

Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary.

Children are not miniature adults: in many ways normal pediatric anatomy and physiology make children more vulnerable to hypoxia, respiratory distress, and respiratory failure. Compared to adults, the leading cause of preventable death in pediatric emergencies – both medical and trauma – is failure to adequately manage the airway. Pediatric respiratory events carry a higher mortality than adult events (1).

I had my first introduction to just how different children are as a senior medical student on the anesthesia service — an elective that eventually proved life changing. My teacher had asked me what I wanted to do on the rotation and I had requested to take care of children. That resulted in a long pause in the conversation and a non-committal comment that we would just have see to how that went as the rotation progressed. Finally, on my last day my teacher assigned me to a room full of pediatric patients having either ear tube placement or tonsillectomies. Every child was a different age and every child seemed to have different anatomy. My teacher spent the day showing me how to adjust my newly acquired skills to each child. I left that rotation which deeper respect for the subtleties of pediatric airway management.

There is good reason why most providers are more nervous taking care of children, especially young children less than 2 years of age. From infants to toddlers to teenagers, the anatomy and physiology of the child is continuously changing. Managing the airway of a premature infant requires a slightly different technique than managing the airway of an older infant, a toddler, a child and a teenager. Not big differences, but enough to make care of the pediatric airway more challenging, especially for providers who care for children infrequently.

Fortunately, most children have easily managed airways. If you understand the differences, taking care of the typical pediatric airway is not difficult.

It’s a common trend to concentrate care of children in the hands of those who are more experienced. For example, anesthesia in young children is more frequently being done by pediatric anesthesiologists in children’s hospitals. While good in many ways, this trend deprives other providers of caring for children — making them less prepared for when they do have to care for a small child.

For those of you who rarely care for pediatric emergencies this book will teach you the anatomy, physiology and technical differences in recognizing respiratory distress, opening an airway, ventilating, and intubating infants and children. For those of you who routinely care for children, this book will share some of the tips and tricks I’ve learned for managing more challenging airways from 4 decades of practicing anesthesia.

Even if you don’t perform intubation yourself, chances are you will be assisting someone who does. Understanding how the techniques are performed will allow you to more effectively assist and improves the chance for a good outcome. Dosages, advantages and disadvantages of the different drugs for rapid sequence induction are also covered.

This book gives you step by step instructions on basic airway management guided by 267 illustrations and photos, plus over an hour of on-line video clips. These free video clips provide hours of footage of actual patients undergoing real surgical procedures, manikin demonstrations, and animations. The URL to my video page, which you’re welcome to use, is here.

The goal of Pediatric Airway Management is to give you a visual picture of airway management and intubation for each age of childhood. As you proceed through the book, use the video clips to picture yourself performing the steps. I hope my efforts make you confident in your ability to help children breathe. Anyone can learn how to to open an airway and ventilate a child.

My sincere wish is that this new book helps in the care of our littlest patients, no matter where they are.

May The Force Be With You!

Christine E. Whitten MD







Avoiding Difficult Intubation Of The Easy Airway

We’ve all done it. It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. Let’s see how to avoid this pitfall. (All illustrations by Christine Whitten MD, Anyone Can Intubate). Continue reading

Intubating The Infant or Toddler

I’ve been hard at work on writing and illustrating my upcoming book on pediatric airway management so I thought I would spend some time talking about care of our littlest patients.

Providers who infrequently care for children less than two years of age are often rightfully anxious when faced with a sick child, especially if airway management is required. This is especially true if the child is less than one. Healthy respect is certainly indicated because airway complications are one of the leading causes of pediatric cardiac arrest.

Children are not small adults. From infants to toddlers to teenagers, the anatomy and physiology of the child is continuously morphing until finally reaching the adult form and function. We all know this instinctively. When we look at a child we can often tell how old he or she is simply by looking at head size, characteristics of the face, length of neck, shape of the body, and how long the arms and legs are related to the trunk. It should not be surprising that the inside of the child is changing as well.

Even placing an oral airway and using a mask in an infant can seem more challenging because of the size and fragility of the patient.

Even placing an oral airway and using a mask in an infant can seem more challenging because of the size and fragility of the patient.

Infants and young children are small. The head of a newborn infant can fit on the palm of my hand. The palm of a premature infant’s hand may be the same size as my thumbnail. It’s challenging to open the airway of such a small infant when adult fingers dwarf the size of the baby’s mouth and all of the instruments are smaller. And babies are fragile, with little reserve.

Like adults, children can be small or tall, lean or overweight. But unlike adults, their airway anatomy is changing shape and structural relationships as they grow. A particular 2 year old may be as tall as a particular 6 year old, or as heavy as a particular 8 year old, but all have very different airways.

Intubating an infant or small child is more of a challenge than an older child or adult both because of their anatomical differences as well as their physiologic predisposition for hypoxia. One can certainly argue that faced with elective care, that only experienced providers should manage the airways of infants and children less than two. However, medical care is not always elective.

Faced with a sick child, especially in more urgent settings, anyone who can ventilate and intubate an adult can also ventilate or intubate an infant or toddler safely —if they take the differences in anatomy and physiology into account, and are gentle and methodical in their approach. Continue reading

Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation

Attaching a nasal airway to a breathing circuit as a tool to assist or control ventilation is a very helpful trick to have in challenging airway management situations.

Illustration of An alternate means of ventilation — insert an endotracheal tube connector into a nasal airway as in a. Place the nasal airway, close the opposite nostril and mouth. Ventilate as in b.

An alternate means of ventilation — insert an endotracheal tube connector into a nasal airway as in a. Place the nasal airway, close the opposite nostril and mouth. Ventilate as in b. occluding the mouth and opposite nostril. (From Anyone Can Intubate, 5th Edition, C. Whitten MD)

The Case

Many years ago I was taking care of a 40 y.o. man had Ludwig’s Angina, a serious, potentially life-threatening cellulitis infection of the tissues of the floor of the mouth, often occurring in an adult with a dental infection. Continue reading

Risks of Placing Your Endotracheal Cuff Too High

When intubating, we all know to check the depth of the endotracheal tube. Most people believe this is just to ensure that the tube is not too deep and therefore causing a mainstem intubaton: intubating just one bronchus and therefore only one lung. However, there are significant risks with having the tube too shallow as well. Continue reading

Should I Use A Cuffed or Uncuffed Endotracheal Tube In a Child?

When intubating children, the question always arises whether to use a cuffed or an uncuffed endotracheal tube (ETT). Historically uncuffed endotracheal tubes have been used when the child is less than about 8 years old. Why is it that we can get away with using an uncuffed tube in a young child, but not an adult? Are there advantages and disadvantages to each?  The answers comes from understanding some of the anatomical differences between children and adults. Continue reading