ASA difficult airway algorithm: Pediatrics

ASA: American Society of Anesthesiologists; CO₂: carbon dioxide; ECMO: extracorporeal membrane oxygenation.
* The airway manager's assessment and choice of techniques should be based on their previous experience; available resources, including equipment, availability, and competency of help; and the context in which airway management will occur.
¶ Low- or high-flow nasal cannula, head elevated position throughout procedure. Noninvasive ventilation during preoxygenation.
Δ Awake intubation techniques include flexible bronchoscope, videolaryngoscopy, direct laryngoscopy, combined techniques, and retrograde wire-aided intubation.
◊ Invasive airway techniques include surgical cricothyroidotomy, needle cricothyroidotomy if age-appropriate with a pressure-regulated device, large-bore cannula cricothyroidotomy, or surgical tracheostomy. Elective invasive airway techniques include the above and retrograde wire-guided intubation and percutaneous tracheostomy. Also consider rigid bronchoscopy and ECMO.
§ Other options include, but are not limited to, alternative awake technique, awake elective invasive airway, alternative anesthetic techniques, induction of anesthesia (if unstable or cannot be postponed) with preparations for emergency invasive airway, or postponing the case without attempting the above options.
¥ Includes postponing the case or postponing the intubation and returning with appropriate resources (eg, personnel, equipment, patient preparation, awake intubation).
‡ Alternative difficult intubation approaches include, but are not limited to, video-assisted laryngoscopy, alternative laryngoscope blades, combined techniques, intubating supraglottic airway (with or without flexible bronchoscopic guidance), flexible bronchoscopy, introducer, and lighted stylet. Adjuncts that may be employed during intubation attempts include tracheal tube introducers, rigid stylets, intubating stylets, or tube changers and external laryngeal manipulation.
† Other options include, but are not limited to, proceeding with procedure utilizing face mask or supraglottic airway ventilation. Pursuit of these options usually implies that ventilation will not be problematic.