Analysis of the functionally-narrowest portion of the pediatric upper airway in sedated children

Abstract

The narrowest portions of the pediatric larynx are the glottis and subglottic region. However, the pliable and paralyzed subglottic region, acting like a curtain, is no resistance when passing an endotracheal tube. Therefore, the 'functionally' portion of the pediatric upper airway, which may be the most vulnerable to damage during intubation, is the unyielding portion below the cricoid cartilage. We investigated the functionally-narrowest portion below the cricoid cartilage.Computed tomography (CT) was performed under deep sedation. CT images were used for measurement of dimensions and cross-sectional area (CSA) of the larynx at the level of the cricoid, subcricoid, and trachea. We analyzed the anteriorposterior (AP) diameter, transverse diameter, and CSA below the cricoid cartilage (at the cricoid, subcricoid, and tracheal levels).CT images of 46 children from 8 months to 96 months were reviewed from electric medical record (EMR). The mean ± SD of AP diameter was the shortest at the subcricoid level (cricoid, 105.7 ± 15.8 mm; subcricoid, 94.6 ± 15.3 mm; and trachea, 101.5 ± 15.7 mm; P < .001). The mean ± SD of transverse diameter was the shortest at the trachea level (cricoid, 99.8 ± 12.2 mm; subcricoid, 102.5 ± 13.7 mm; and trachea, 98.8 ± 10.7 mm; P = .01). The mean ± SD of CSA was the smallest at the subcricoid level (cricoid, 8781.5 ± 1963.3 mm; subcricoid, 8425.0 ± 2025.7 mm; and trachea, 8523.7 ± 1791.1 mm; P = .02). The AP diameter at the subcricoid level was narrower than the transverse diameter at trachea level (mean difference: 4.2 mm, 95% confidence interval [CI]: 0.7-7.7, P = .02).Since the most susceptible portion for airway damage is unyielding portion, our findings suggest that, functionally, the narrowest portion of the pediatric larynx is located in the subcricoid region.

Figure 1

Sagittal image of the airway of a pediatric patient showing the transition from the subglottic level to the tracheal level. Axial image of the airway showing the cricoid level (A), subcricoid level (B), and trachea level (C).

Figure 2

Correlation between the CSA at the subcricoid level and age (A), height (B), and weight (C). CSA = cross sectional area.

Figure 3

Correlation between the AP diameter at the subcricoid level and age (A), height (B), and weight (C).