Recognizing and Managing the Difficult Pediatric Airway - Revision history

WikiSysop at 14:07, 7 November 2025

2025-11-07T14:07:17Z

← Older revision		Revision as of 14:07, 7 November 2025
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	[https://bjanaesthesia.org/article/S0007-0912(21)00176-8/fulltext BJA: Difficult airway management: children are different from adults, and neonates are different from children!]		[https://bjanaesthesia.org/article/S0007-0912(21)00176-8/fulltext BJA: Difficult airway management: children are different from adults, and neonates are different from children!]

			[https://www.bjanaesthesia.org/article/S0007-0912(25)00693-2/fulltext? Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults]

	[https://onlinelibrary.wiley.com/toc/14609592/2020/30/3 Pediatric Anesthesia: Special Issue:Pediatric Airway Special Issue]		[https://onlinelibrary.wiley.com/toc/14609592/2020/30/3 Pediatric Anesthesia: Special Issue:Pediatric Airway Special Issue]

WikiSysop at 16:33, 26 July 2025

2025-07-26T16:33:11Z

← Older revision		Revision as of 16:33, 26 July 2025
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	[https://pubmed.ncbi.nlm.nih.gov/31567318/ A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching]		[https://pubmed.ncbi.nlm.nih.gov/31567318/ A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching]

	[https://pubmed.ncbi.nlm.nih.gov/33308472/ ~~https~~:~~//pubmed.ncbi.nlm.nih.gov/33308472/~~]		[https://pubmed.ncbi.nlm.nih.gov/33308472/ First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial]

	[https://pubmed.ncbi.nlm.nih.gov/36095290/ Walk a Tightrope or Burn a Bridge?: Sedation versus General Anesthesia for Intubation of a Pediatric Difficult Airway]		[https://pubmed.ncbi.nlm.nih.gov/36095290/ Walk a Tightrope or Burn a Bridge?: Sedation versus General Anesthesia for Intubation of a Pediatric Difficult Airway]

WikiSysop at 16:31, 26 July 2025

2025-07-26T16:31:44Z

← Older revision		Revision as of 16:31, 26 July 2025
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	= Example of pediatric difficult airway algorithms =		= Example of pediatric difficult airway algorithms =

			[https://das.uk.com/guidelines/paediatric-difficult-airway-guidelines/ UK: Paediatric difficult airway guidelines - Difficult Airway Society]

WikiSysop at 00:29, 17 July 2025

2025-07-17T00:29:16Z

← Older revision		Revision as of 00:29, 17 July 2025
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	Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX, Jr., Litman RS, Kovatsis PG: Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016; 4: 37–48		Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX, Jr., Litman RS, Kovatsis PG: Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016; 4: 37–48

	2. Engelhardt T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, von Ungern-Sternberg BS: A framework for the management of the pediatric airway. Paediatr Anaesth 2019; 29: 985–992		Engelhardt T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, von Ungern-Sternberg BS: A framework for the management of the pediatric airway. Paediatr Anaesth 2019; 29: 985–992

	3. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, Gonzalez A, Kanmanthreddy S, Gálvez JA, Franz AM, Peyton J, Park R, Kiss EE, Sommerfield D, Griffis H, Nishisaki A, von Ungern-Sternberg BS, Nadkarni VM, McGowan FX, Jr., Fiadjoe JE: First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet 2020; 396: 1905–1913		Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, Gonzalez A, Kanmanthreddy S, Gálvez JA, Franz AM, Peyton J, Park R, Kiss EE, Sommerfield D, Griffis H, Nishisaki A, von Ungern-Sternberg BS, Nadkarni VM, McGowan FX, Jr., Fiadjoe JE: First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet 2020; 396: 1905–1913

	4. Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A: Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41: 3–23		Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A: Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41: 3–23

	5. Sequera-Ramos L, Laverriere EK, Garcia-Marcinkiewicz AG, Zhang B, Kovatsis PG, Fiadjoe JE: Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry. Anesthesiology 2022; 137: 418–433		Sequera-Ramos L, Laverriere EK, Garcia-Marcinkiewicz AG, Zhang B, Kovatsis PG, Fiadjoe JE: Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry. Anesthesiology 2022; 137: 418–433

	6. Burjek NE, Nishisaki A, Fiadjoe JE, Adams HD, Peeples KN, Raman VT, Olomu PN, Kovatsis PG, Jagannathan N, Hunyady A, Bosenberg A, Tham S, Low D, Hopkins P, Glover C, Olutoye O, Szmuk P, McCloskey J, Dalesio N, Koka R, Greenberg R, Watkins S, Patel V, Reynolds P, Matuszczak M, Jain R, Khalil S, Polaner D, Zieg J, Szolnoki J, Sathyamoorthy K, Taicher B, Riveros Perez NR, Bhattacharya S, Bhalla T, Stricker P, Lockman J, Galvez J, Rehman M, Von Ungern-Sternberg B, Sommerfield D, Soneru C, Chiao F, Richtsfeld M, Belani K, Sarmiento L, Mireles S, Bilen Rosas G, Park R, Peyton J: Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry. Anesthesiology 2017; 127: 432–440		Burjek NE, Nishisaki A, Fiadjoe JE, Adams HD, Peeples KN, Raman VT, Olomu PN, Kovatsis PG, Jagannathan N, Hunyady A, Bosenberg A, Tham S, Low D, Hopkins P, Glover C, Olutoye O, Szmuk P, McCloskey J, Dalesio N, Koka R, Greenberg R, Watkins S, Patel V, Reynolds P, Matuszczak M, Jain R, Khalil S, Polaner D, Zieg J, Szolnoki J, Sathyamoorthy K, Taicher B, Riveros Perez NR, Bhattacharya S, Bhalla T, Stricker P, Lockman J, Galvez J, Rehman M, Von Ungern-Sternberg B, Sommerfield D, Soneru C, Chiao F, Richtsfeld M, Belani K, Sarmiento L, Mireles S, Bilen Rosas G, Park R, Peyton J: Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry. Anesthesiology 2017; 127: 432–440

	7. Stein ML, Nagle JH, Templeton TW, Staffa SJ, Flynn SG, Bordini M, Nykiel-Bailey S, Garcia-Marcinkiewicz AG, Padiyath F, Matuszczak M, Lee AC, Peyton JM, Park RS, von Ungern-Sternberg BS, Olomu PN, Hunyady AI, Matava C, Fiadjoe JE, Kovatsis PG: Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry. Anaesthesia 2025; 80: 625–635		Stein ML, Nagle JH, Templeton TW, Staffa SJ, Flynn SG, Bordini M, Nykiel-Bailey S, Garcia-Marcinkiewicz AG, Padiyath F, Matuszczak M, Lee AC, Peyton JM, Park RS, von Ungern-Sternberg BS, Olomu PN, Hunyady AI, Matava C, Fiadjoe JE, Kovatsis PG: Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry. Anaesthesia 2025; 80: 625–635

	8. Evans MA, Caruso TJ: Rescuing failed direct laryngoscopy in children: one size does not fit all. Anaesthesia 2025; 80: 621–624		Evans MA, Caruso TJ: Rescuing failed direct laryngoscopy in children: one size does not fit all. Anaesthesia 2025; 80: 621–624

WikiSysop at 00:28, 17 July 2025

2025-07-17T00:28:43Z

← Older revision		Revision as of 00:28, 17 July 2025
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	[https://pubmed.ncbi.nlm.nih.gov/40113331/ Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry]		[https://pubmed.ncbi.nlm.nih.gov/40113331/ Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry]

			Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX, Jr., Litman RS, Kovatsis PG: Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016; 4: 37–48

			2. Engelhardt T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, von Ungern-Sternberg BS: A framework for the management of the pediatric airway. Paediatr Anaesth 2019; 29: 985–992

			3. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, Gonzalez A, Kanmanthreddy S, Gálvez JA, Franz AM, Peyton J, Park R, Kiss EE, Sommerfield D, Griffis H, Nishisaki A, von Ungern-Sternberg BS, Nadkarni VM, McGowan FX, Jr., Fiadjoe JE: First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet 2020; 396: 1905–1913

			4. Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A: Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41: 3–23

			5. Sequera-Ramos L, Laverriere EK, Garcia-Marcinkiewicz AG, Zhang B, Kovatsis PG, Fiadjoe JE: Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry. Anesthesiology 2022; 137: 418–433

			6. Burjek NE, Nishisaki A, Fiadjoe JE, Adams HD, Peeples KN, Raman VT, Olomu PN, Kovatsis PG, Jagannathan N, Hunyady A, Bosenberg A, Tham S, Low D, Hopkins P, Glover C, Olutoye O, Szmuk P, McCloskey J, Dalesio N, Koka R, Greenberg R, Watkins S, Patel V, Reynolds P, Matuszczak M, Jain R, Khalil S, Polaner D, Zieg J, Szolnoki J, Sathyamoorthy K, Taicher B, Riveros Perez NR, Bhattacharya S, Bhalla T, Stricker P, Lockman J, Galvez J, Rehman M, Von Ungern-Sternberg B, Sommerfield D, Soneru C, Chiao F, Richtsfeld M, Belani K, Sarmiento L, Mireles S, Bilen Rosas G, Park R, Peyton J: Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry. Anesthesiology 2017; 127: 432–440

			7. Stein ML, Nagle JH, Templeton TW, Staffa SJ, Flynn SG, Bordini M, Nykiel-Bailey S, Garcia-Marcinkiewicz AG, Padiyath F, Matuszczak M, Lee AC, Peyton JM, Park RS, von Ungern-Sternberg BS, Olomu PN, Hunyady AI, Matava C, Fiadjoe JE, Kovatsis PG: Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry. Anaesthesia 2025; 80: 625–635

			8. Evans MA, Caruso TJ: Rescuing failed direct laryngoscopy in children: one size does not fit all. Anaesthesia 2025; 80: 621–624

WikiSysop at 00:24, 17 July 2025

2025-07-17T00:24:59Z

← Older revision		Revision as of 00:24, 17 July 2025
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	[https://pubmed.ncbi.nlm.nih.gov/12512261/ Pediatric upper airway and congenital anomalies]		[https://pubmed.ncbi.nlm.nih.gov/12512261/ Pediatric upper airway and congenital anomalies]

			[https://pubmed.ncbi.nlm.nih.gov/40113331/ Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry]

WikiSysop at 02:49, 24 December 2024

2024-12-24T02:49:38Z

← Older revision		Revision as of 02:49, 24 December 2024
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	[https://link.springer.com/article/10.1007/s12630-024-02815-0 Comparison of the modified Mallampati classification score versus the best visible Mallampati score in the prediction of difficult tracheal intubation: a single-centre prospective observational study]		[https://link.springer.com/article/10.1007/s12630-024-02815-0 Comparison of the modified Mallampati classification score versus the best visible Mallampati score in the prediction of difficult tracheal intubation: a single-centre prospective observational study]

			[https://pubmed.ncbi.nlm.nih.gov/12512261/ Pediatric upper airway and congenital anomalies]

WikiSysop at 19:32, 11 September 2024

2024-09-11T19:32:36Z

← Older revision		Revision as of 19:32, 11 September 2024
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	[https://www.sciencedirect.com/science/article/pii/S0007091224000990 Airway triage: a novel application-based method for airway assessment and risk stratification]		[https://www.sciencedirect.com/science/article/pii/S0007091224000990 Airway triage: a novel application-based method for airway assessment and risk stratification]

			[https://link.springer.com/article/10.1007/s12630-024-02815-0 Comparison of the modified Mallampati classification score versus the best visible Mallampati score in the prediction of difficult tracheal intubation: a single-centre prospective observational study]

Pedro.bertolino at 17:25, 10 August 2024

2024-08-10T17:25:19Z

← Older revision		Revision as of 17:25, 10 August 2024
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	* They have large, omega-shaped epiglottis. Sometimes, it is necessary to pinch epiglottis during laryngoscopy to visualize vocal cords;		* They have large, omega-shaped epiglottis. Sometimes, it is necessary to pinch epiglottis during laryngoscopy to visualize vocal cords;
	* They have high oxygen consumption and low functional residual capacity, causing faster desaturation during apnea periods;		* They have high oxygen consumption and low functional residual capacity, causing faster desaturation during apnea periods;
	* They are susceptible to gastric distension during face-mask ventilation. As the stomach increases its volume, the diaphragm is cephalically displaced, hampering face-mask ventilation. The harder it is tried to ventilate in this situation, more air is forced into the stomach and it becomes even harder to ventilate afterall, creating a vicious cycle. When a previously easy face-mask ventilation becomes ~~hard~~ after a long period of ventilation, ALWAYS remember of gastric distention. Place an orogastric tube to empty the stomach!		* They are susceptible to gastric distension during face-mask ventilation. As the stomach increases its volume, the diaphragm is cephalically displaced, hampering face-mask ventilation. The harder it is tried to ventilate in this situation, more air is forced into the stomach and it becomes even harder to ventilate afterall, creating a vicious cycle. When a previously easy face-mask ventilation becomes harder after a long period of ventilation, ALWAYS remember of gastric distention. Place an orogastric tube to empty the stomach!

WikiSysop at 20:44, 1 July 2024

2024-07-01T20:44:48Z

← Older revision		Revision as of 20:44, 1 July 2024
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	=== Introduction ===		= Introduction =
	Difficult pediatric airway consists of difficulty in face-mask ventilation, direct or indirect laryngoscopy, tracheal intubation, supraglottic airway device placement or front-of-neck airway. In summary, it is the impossibility to ensure adequate oxygenation after general anesthesia induction. As so, that is the priority while facing a difficult airway: to guarantee oxygenation!		Difficult pediatric airway consists of difficulty in face-mask ventilation, direct or indirect laryngoscopy, tracheal intubation, supraglottic airway device placement or front-of-neck airway. In summary, it is the impossibility to ensure adequate oxygenation after general anesthesia induction. As so, that is the priority while facing a difficult airway: to guarantee oxygenation!

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	* If possible, always maintain spontaneous ventilation.		* If possible, always maintain spontaneous ventilation.

	=== General anesthesia induction under spontaneous ventilation ===		= General anesthesia induction under spontaneous ventilation =
	Many induction techniques can be used to maintain spontaneous ventilation, both inhalational or IV.		Many induction techniques can be used to maintain spontaneous ventilation, both inhalational or IV.

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	A way to test if the patient is in adequate anesthetic plan for airway manipulation is to perform a 5-second jaw-thrust. In the absence of movement, tachycardia and tachypnea, the patients is considered to be in a small risk of airway reaction during manipulation.		A way to test if the patient is in adequate anesthetic plan for airway manipulation is to perform a 5-second jaw-thrust. In the absence of movement, tachycardia and tachypnea, the patients is considered to be in a small risk of airway reaction during manipulation.

	=== Difficult bag-mask ventilation ===		= Difficult bag-mask ventilation =
	In the scenario of difficult ventilation, the following steps can be considered:		In the scenario of difficult ventilation, the following steps can be considered:

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	If none of the measures above work, place a supraglottic airway device (SAD). If adequate ventilation is obtained and the surgery can be safely conducted with the SAD, proceed. However if tracheal intubation is needed, use the SAD as a conduit to fiberoptic intubation. Nevertheless, if SAD fails to grant adequate ventilation, proceed to CICO scenario (cannot intubate, cannot oxygenate) or awake the patient if SpO2 permits (slow decline with stable hemodynamics). In CICO scenario, front-of-neck access must be made preferably by the surgery or ENT team. In the absence of them, anesthesiologist must perform a cricothyroidotomy by his/her preferable technique.		If none of the measures above work, place a supraglottic airway device (SAD). If adequate ventilation is obtained and the surgery can be safely conducted with the SAD, proceed. However if tracheal intubation is needed, use the SAD as a conduit to fiberoptic intubation. Nevertheless, if SAD fails to grant adequate ventilation, proceed to CICO scenario (cannot intubate, cannot oxygenate) or awake the patient if SpO2 permits (slow decline with stable hemodynamics). In CICO scenario, front-of-neck access must be made preferably by the surgery or ENT team. In the absence of them, anesthesiologist must perform a cricothyroidotomy by his/her preferable technique.

	=== Easy bag-mask ventilation, difficult direct laryngoscopy ===		= Easy bag-mask ventilation, difficult direct laryngoscopy =
	In this scenario, always remember to limit the attempts of laryngoscopy and intubation! Transition to indirect technique of laryngoscopy as soon as possible and use auxiliary devices as needed (e.g. bougie). If advanced techniques also fail, place a SAD and follow the steps described before.		In this scenario, always remember to limit the attempts of laryngoscopy and intubation! Transition to indirect technique of laryngoscopy as soon as possible and use auxiliary devices as needed (e.g. bougie). If advanced techniques also fail, place a SAD and follow the steps described before.

	=== Example of pediatric difficult airway algorithms ===		= Example of pediatric difficult airway algorithms =