Expertise in airway management in infants and young children requires a comprehensive knowledge and understanding of the developmental anatomy of the human upper airway from birth through adolescence. This chapter will review these topics as well as the anatomical and developmental causes for common syndromes that are associated with difficult mask ventilation or difficult tracheal intubation.

The technique of laryngoscopy is essential in the daily delivery of many anesthetics. Direct and indirect methods of laryngoscopy are quite commonly utilized. This chapter will address considerations as they relate to direct laryngoscopy.

In the territory between the Amazon and Orinoco rivers in the late sixteenth century, Sir Walter Raleigh observed natives use arrows with a “poison” so strong that its victims died, not by direct physical injury, but rather by the perishing effect of its poison. Curiosity in this substance by European explorers helped transform curare from an arrow poison to a surgical relaxant. The introduction of muscle relaxants revolutionized anesthetic practice as it allowed for improved surgical conditions, lower levels of volatile anesthetics, and improved tracheal intubation conditions.

There are some unique considerations when caring for the airway in infants and small children. They have relatively larger oropharyngeal structures (tongue, tonsils, and adenoids), and a large and floppy epiglottis, which can predispose to upper airway obstruction. A larger occiput may increase the neck flexion observed while in supine position as compared with adults, which can also lead to airway obstruction. The shorter and narrower trachea may increase the risk for tracheal tube malposition after intubation, and has a greater risk for secretions, edema, or foreign body to produce disproportionate negative effects in airflow resistance. Children run the highest risk of problems from stridor and glottic edema because of their smaller diameter airways. Post-extubation stridor incidence ranges from 2% in children having elective surgical procedures to 40% in pediatric trauma and burn victims. Additionally, infants have less physical space in the oropharynx and within the tracheal tube for an advanced bridging technique such as SGA devices and/or airway exchange catheter.