INTRODUCTION — This topic will review conditions in children that can make airway management difficult, anatomic characteristics that may identify those conditions, and management strategies.
General principles of airway management in children, including rapid sequence intubation are discussed separately. (See "Basic airway management in children" and "Emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) outside the operating room in children: Approach".)
BACKGROUND — Effective airway management includes anticipating and planning for problems. Difficulties frequently occur as the result of patient characteristics that interfere with spontaneous breathing, bag-mask ventilation, laryngoscopy, and/or intubation of the trachea. Identifying characteristics of the difficult airway and developing a plan for addressing problems are essential principles in airway management. Published guidelines exist for management of the difficult airway in anesthesia practice [1]. These principles have also been modified and effectively used to evaluate adults patients in the operating room (OR) and emergency department (ED) [2].
Children infrequently require aggressive airway management and difficulties do not often occur [3,4]. Many of the difficult airway predictors, particularly anatomic abnormalities, are more common in adults. As a result, evidence specific for children regarding identification and management of difficult airways is limited [5,6]. Nevertheless, a reasonable, systematic approach for children can be developed from experience with adult patients in the operating room and emergency department.
DEFINITION — A difficult airway is generally defined as a situation in which a clinician experiences difficulty with face mask ventilation, laryngoscopy, or intubation [1,2]. In an emergency setting, this also includes difficulty performing an emergency surgical airway, such as needle cricothyroidotomy.
These difficulties may arise whenever any of the following maneuvers cannot be successfully performed:
●Positioning to optimally align the pharyngeal and tracheal axes (picture 1 and picture 2) for direct laryngoscopy
●Achieving sufficient positive pressure with a resuscitation bag to inflate the lungs
●Opening the mouth and controlling oral structures with the laryngoscope blade
●Visualizing the larynx and intubating the trachea
●Identifying landmarks in the neck for performing a surgical airway
CAUSES OF THE DIFFICULT PEDIATRIC AIRWAY
Normal pediatric airway — Predictable differences in the pediatric airway (as compared with adult airway anatomy) may make management difficult. These differences, most evident in children less than two to three years of age, include the following (see "Emergency airway management in children: Unique pediatric considerations"):
●A large occiput affects positioning
●A large tongue and small mouth may make laryngoscopy difficult
●The larynx may be harder to locate with the laryngoscope because it is higher and more anterior than in an adult
●The epiglottis is large and floppy and may be difficult to control
Anatomic features of the normal pediatric airway are reviewed separately. (See "Basic airway management in children", section on 'Anatomic considerations' and "Emergency endotracheal intubation in children".)
Normal pediatric physiology — Young children are prone to desaturation, even when optimally preoxygenated, due to their high native metabolic rate combined with a small pulmonary functional reserve capacity. Thus, airway management in children with compromised pulmonary function, as is seen with obstructive lung disease, pneumonia, sepsis, and acute respiratory distress syndrome (ARDS), can be accompanied by rapid desaturation during intubation attempts even with meticulous attention to pre-procedure oxygenation. (See "Emergency airway management in children: Unique pediatric considerations", section on 'Physiologic considerations'.)
Congenital abnormalities — Numerous congenital conditions have features that may make airway management difficult (table 1). In addition, children with underlying airway abnormalities who acquire an acute condition (such as croup or an upper respiratory tract infection) may quickly develop respiratory compromise. Congenital features that may interfere with airway management include the following:
●Misshapen head – Positioning of the head to optimally align the pharyngeal and tracheal axes may be difficult if the head is misshapen, as can occur with craniosynostosis (such as Apert or Crouzon syndrome) or macrocephaly. (See "Craniosynostosis syndromes" and "Macrocephaly in infants and children: Etiology and evaluation".)
●Facial abnormalities – Facial asymmetry or underdevelopment may make it difficult to achieve a good seal between the face and a mask, creating difficulties with bag-mask ventilation (picture 3). As examples, maxillary hypoplasia is a feature of Apert syndrome, while Goldenhar syndrome includes unilateral hypoplasia of the mandible. (See "Syndromes with craniofacial abnormalities".)
●Abnormal neck mobility – Limited neck mobility (as occurs with Klippel-Feil syndrome) or cervical spine instability (which can occur with Down syndrome and the mucopolysaccharidoses) may interfere with positioning of the head. (See "Down syndrome: Clinical features and diagnosis", section on 'Atlantoaxial instability' and "Mucopolysaccharidoses: Complications", section on 'Anesthesia'.)
●Small oral aperture – Opening the mouth for laryngoscopy may be difficult in children with microstomia, which is a feature of Freeman-Sheldon and Hallermann-Streiff syndromes.
●Small oral cavity – Children with small mandibles or palatal abnormalities (such as high arched or cleft palates) have a smaller oral cavity. This may make laryngoscopy and control of oral structures difficult. For instance, mandibular hypoplasia is a feature of the Robin sequence and Treacher Collins syndrome (picture 4).
●Large tongue – A large tongue may obstruct the airway during bag-mask ventilation or be difficult to control during laryngoscopy. Macroglossia occurs in several conditions (such as hypothyroidism, Beckwith-Wiedeman syndrome, and Down syndrome). It is also a feature of infiltrative diseases such as the mucopolysaccharidoses.
●Masses – Masses in the neck (such as cystic hygromas) may interfere with positioning. Masses within the airway (such as teratomas or hemangiomas) may obstruct the airway and interfere with visualization of the larynx. Mediastinal masses may make tube placement difficult and interfere with ventilation after successful intubation [7]. (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx" and "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications", section on 'Airway hemangiomas'.)
●Laryngeal and subglottic abnormalities – Abnormalities of the larynx or subglottic trachea may interfere with intubation (picture 5).
Acquired conditions — Acquired conditions that can cause difficulties with airway management may develop as the result of infection, allergic reactions, trauma, or aspiration of a foreign body.
Infection — The specific difficulties in airway management that arise because of infection depend upon where the infection is located within the airway.
●Retropharyngeal and peritonsillar abscesses may interfere with laryngoscopy and visualization of the larynx. These conditions do not typically require emergency airway management. (See "Retropharyngeal infections in children".)
●Epiglottitis is characterized by rapidly progressive inflammation and edema of the supraglottic structures. Airway management is difficult because laryngeal anatomy is distorted and the glottic opening may be small and difficult to identify. Since the introduction of conjugate Haemophilus influenza type B vaccines, the incidence of epiglottitis in children has declined dramatically. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis".)
●Croup and tracheitis cause subglottic airway obstruction. As a result, it may be difficult to deliver effective bag-mask ventilation or to pass an endotracheal tube through the subglottic trachea. Fortunately, both conditions generally respond to medical management. (See "Croup: Clinical features, evaluation, and diagnosis", section on 'Pathogenesis' and "Management of croup".)
Anaphylaxis — Edema involving the tongue, retropharynx, and/or larynx, that can interfere with laryngoscopy and visualization of the larynx, may develop as the result of anaphylaxis. Symptoms typically respond to aggressive medical management (table 2).
Trauma — Injury to the face or airway (as the result of blunt or penetrating trauma, thermal burns, or caustic ingestions) may complicate airway management:
●Facial burns may make it difficult to deliver bag-mask ventilation because an adequate seal between the mask and face cannot be achieved.
●An expanding hematoma in the pharynx can interfere with laryngoscopy.
●Injury to the midface (eg, LeFort fracture), larynx, or subglottic trachea may be exacerbated by intubation and make securing of the airway difficult.
●Spinal immobilization with a rigid cervical collar, regardless of the presence of injury can make direct laryngoscopy difficult because the clinician is unable to optimally position the patient in the sniffing position and adequately align the visual axis. (See 'Management' below.)
Foreign body — A foreign body in the airway may cause significant obstruction and require immediate treatment. Identification and removal of the foreign body during laryngoscopy can be challenging. In addition, normal anatomic landmarks may be distorted by the foreign body. (See "Emergency evaluation of acute upper airway obstruction in children", section on 'Causes'.)
Piercings around the mouth and tongue may interfere with or become dislodged during laryngoscopy [8].
Other causes — Other acquired conditions in children that may make airway management difficult include tumors, previous surgery, radiation treatment, or obesity [9].
COVID-19 INFECTION CONTROL PRECAUTIONS — There is a significant risk for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during laryngoscopy, endotracheal intubation, and other airway management procedures in any pediatric patient, regardless of symptoms. Techniques designed to improve patient care, minimize infectious risks to care providers, and decrease spread of the virus should be applied to all children undergoing rapid sequence intubation and are summarized in the following rapid overview (table 3) [10]. Of particular importance for children with a difficult airway:
●Oral intubation is preferred to nasal intubation
●A supraglottic airway (SGA) with a good seal is an acceptable method for securing the airway in some patients
●Video laryngoscopy
IDENTIFICATION OF THE DIFFICULT PEDIATRIC AIRWAY — The initial evaluation of any critically ill or injured child should include a brief, systematic assessment of the airway to identify characteristics that may complicate management. These characteristics must be taken into consideration when developing an airway management plan. (See "Emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) outside the operating room in children: Approach", section on 'Preparation'.)
Anesthesiologists have used bedside evaluation tools to identify patients for whom airway management may be difficult [1]. None of these indicators has been tested in emergency departments or in children. Nevertheless, a reasonable approach can be developed using evidence from the operating room and clinical experience in the emergency department to identify children who may have difficult airways [2].
Bag-mask ventilation — Bag-mask ventilation may be difficult in children with the following features:
●A misshapen head (as the result of trauma or a congenital anomaly) or limited neck mobility (such as a patient whose cervical spine is immobilized) can interfere with proper positioning (picture 1).
●Facial burns or any disruption of lower facial continuity (as can occur with facial trauma or a congenital anomaly with facial asymmetry) can make it difficult to achieve an adequate seal between the face and the mask.
●Patients who are obese or who have significant lung disease (such as severe asthma) may be difficult to ventilate with a bag and mask [11].
Laryngoscopy or intubation — Several clinical features appear to be sensitive predictors of difficult laryngoscopy or intubation for adults as described separately. (See "Airway management for induction of general anesthesia", section on 'Difficult intubation'.)
Features potentially useful in children include:
●Small mouth opening (<3 patient fingers)
●Mallampati score (figure 1)
●Thyromental distance (3 patient finger-widths); difficulty visualizing the larynx may occur when the distance is longer or shorter
●Difficult bag-mask ventilation [12]
Cricothyroidotomy — Needle cricothyroidotomy, which permits percutaneous transtracheal ventilation, should always be considered a difficult technique in children because normal landmarks are difficult to identify and the caliber of the airway is small. In addition, few if any practitioners can gain proficiency with these techniques because clinical scenarios that require them rarely occur. (See 'Surgical airway' below.)
The LEMON approach to difficult airway assessment — The mnemonic LEMON has been developed by researchers in emergency airway management as a tool for rapidly identifying adult patients in whom direct laryngoscopy may be difficult (table 4). (See "Approach to advanced emergency airway management in adults", section on 'Rsi and the difficult airway'.)
The tool has not been tested in children. Components of the mnemonic include the following:
●L: Look externally for indicators of a difficult airway (such as a misshapen head, facial abnormalities, or neck masses).
●E: Evaluate mouth opening, thyromental distance, and the distance between the mandible and the thyroid cartilage (this correlates with the distance between the base of the tongue and the larynx) (picture 6). Adequate mouth opening and thyromental distance should be the width of three of the patient's fingers. The distance between the mandible and thyroid cartilage should be the width of two fingers.
●M: Mallampati score: Assigning a Mallampati score may be difficult in young children. For the obtunded, supine patient, a crude assessment can be made using a tongue blade (figure 1) [2].
●O: Obstruction: Signs of airway obstruction (such as stridor, a muffled voice, or difficulty handling secretions) always indicate that airway management may be difficult. Upper airway obstruction can interfere with bag-mask ventilation, as well as with laryngoscopy and intubation.
●N: Neck mobility: Conditions that limit neck mobility (such as congenital anomalies or cervical spine immobilization) can usually be identified by observation.
ALTERNATIVE AIRWAY TECHNIQUES — Alternative strategies for providing oxygenation and ventilation must be considered for the child who may be difficult to intubate with direct laryngoscopy. These techniques may be temporizing (such as laryngeal mask airway or a percutaneous needle cricothyrotomy) or provide alternative approaches to tracheal intubation (eg, intubating introducers or fiberoptic intubation). Several factors impact the choice of device including the clinical situation, type of airway difficulty, and experience of the operator.
Devices for difficult intubation in children are discussed in detail separately. (See "Devices for difficult endotracheal intubation in children", section on 'Choice of device' and "Supraglottic airway devices in children with difficult airways", section on 'Choice of device'.)
Video laryngoscopy — Video laryngoscopes provide indirect laryngoscopy and display the glottic view on a video monitor during endotracheal intubation. Several devices are available in sizes appropriate for infants and children. Video laryngoscopy is becoming widely used for pediatric endotracheal intubation. Practitioners with airway training and experience, even those who are relatively early in their careers (ie, anesthesiology residents), can use these advanced laryngoscopes effectively with little additional training and orientation. Predictors of difficult video laryngoscopy include limited mouth opening and pre-intubation positioning (neutral position preferred to the "sniffing" position). (See "Devices for difficult endotracheal intubation in children", section on 'Video laryngoscope'.)
Intubating introducers (gum elastic bougie) — Intubating introducers are helpful when the epiglottis is visible but the vocal cords cannot be seen in patients without laryngeal or tracheal injury. These devices are semi-rigid solid or hollow rods with the distal tip bent at a 30 degree angle (picture 7 and picture 8). Pediatric sized introducers permit placement of endotracheal tubes as small as 4.0 mm (internal diameter). (See "Devices for difficult endotracheal intubation in children", section on 'Intubating introducers (gum elastic bougie)'.)
Supraglottic airway — We suggest that a supraglottic device (eg, laryngeal mask airway, i-gel, or AirQ) be used as the initial rescue device for a child with a failed intubation who does not have complete upper airway obstruction or an airway condition that could be worsened by injury from attempts to place a supraglottic airway.
The device is available in multiple sizes suitable for infants, children, and adults. The appropriate size is based upon the patient's weight (table 5). The Classic LMA is a scaled down version of the adult LMA while the pediatric ProSeal LMA has specific design features that may permit a better seal and greater protection against aspiration, especially in infants and young children, including a gastric channel which permits passage of a nasogastric tube and gastric decompression while the LMA is in place. In anesthesia studies in children, LMAs can be successfully inserted on the first attempt 80 to 100 percent of the time, depending upon the technique (rotational, lateral, or standard placement) and specific device (Classic LMA or ProSeal LMA) used. Although experience with the device as a rescue airway in children is limited [13], case series and reports suggest that an adequate airway can be achieved with an LMA in neonates when bag-mask ventilation and tracheal intubation have failed [14]. (See "Supraglottic airway devices in children with difficult airways", section on 'Laryngeal mask airway (LMA)'.)
The LMA should be avoided in patients with airway obstruction (eg, croup, asthma) or distorted airway anatomy (eg, laryngeal trauma, congenital anomalies of the larynx, or epiglottitis). (See "Supraglottic airway devices in children with difficult airways", section on 'Contraindications'.)
The technique for placing an LMA is discussed separately. (See "Supraglottic airway devices in children with difficult airways", section on 'Choice of technique'.)
Flexible intubating scope — In the hands of an experienced clinician, use of a flexible intubating scope is an excellent method for endotracheal intubation for a patient with a difficult airway who is breathing spontaneously. Availability of equipment and experienced personnel, time considerations, as well as inability for the pediatric patient to cooperate are usually the limiting factors for using this technique for emergency airway management.
Flexible intubating scopes have been used extensively by anesthesiologists for difficult intubations [1,15]. Experience with this approach in the emergency department is almost exclusively in adult patients [16]. Typically, an endotracheal tube is threaded onto the end of the scope. The scope is then introduced into the nose or mouth. The trachea is visualized and intubated with the scope and endotracheal tube. The scope is then withdrawn, placement of the endotracheal tube in the trachea is confirmed, and the tube is secured. (See "Devices for difficult endotracheal intubation in children", section on 'Flexible intubating scope'.)
Flexible intubation should be considered in cases where the pre-intubation assessment suggests that orotracheal intubation via rapid sequence intubation (preferred in most emergency department intubation scenarios) is unlikely to be successful. Examples include congenital airway anomalies such as micrognathia or conditions where difficulty aligning the oral, pharyngeal, and laryngeal axes is predicted (such as when neck mobility is limited). The small size of the nasal passages in very young children often precludes the nasal route for intubation; patient cooperation and compliance may limit its utility for awake intubation.
SURGICAL AIRWAY — Rarely, noninvasive rescue devices fail to provide an airway. As a result, emergency healthcare providers should be familiar with surgical airway techniques, such as needle (figure 2 and table 6) or surgical cricothyroidotomy; although in reality, few if any practitioners have enough opportunity with these approaches to gain proficiency [17]. Surgical cricothyroidotomy should be avoided in children <10 years old.
Equipment required for needle and surgical cricothyroidotomy should be organized in advance and readily available in locations where emergency airway procedures are performed. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation", section on 'Equipment'.)
Step by step instructions on how to perform needle or surgical cricothyroidotomy and on how to perform percutaneous transtracheal ventilation are discussed separately. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation" and "Emergency cricothyrotomy (cricothyroidotomy)".)
We prefer manually controlled ventilation (figure 2 and figure 3) to jet ventilation during transtracheal ventilation in children because of a lower chance of barotrauma. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation", section on 'Performing transtracheal ventilation'.)
MANAGEMENT — Anticipating and preparing for advanced airway management, including intubation, for a critically ill or injured child who may have a difficult airway should begin before the patient arrives in the emergency department. Emergency departments should have equipment and supplies available in a readily identifiable location, such as a "difficult airway box." (See 'Alternative airway techniques' above.)
Once the child with a difficult airway is identified, a specific plan for management must be developed that includes mobilizing appropriate personnel and assembling specialized equipment (algorithm 1A and algorithm 1B and algorithm 1C). The child may improve with supportive care and aggressive treatment of the underlying condition. For children who require intubation, airway management must include a rescue plan and preparation for a failed airway (algorithm 1D).
General principles — Care for all patients with respiratory difficulties who may have a difficult airway should include the following:
●Provide supportive care and careful monitoring. Children who are developing respiratory compromise must be rapidly identified. (See "Initial assessment and stabilization of children with respiratory or circulatory compromise".)
●Aggressively treat the underlying condition. As an example, a patient with a congenitally abnormal airway who develops croup should quickly receive nebulized epinephrine and corticosteroids. In most cases, the child's condition will improve, and advanced airway management will not be necessary. (See "Management of croup".)
●Avoid situations that could worsen airway compromise. As an example, a child with a retropharyngeal abscess who requires sedation for imaging studies should receive reversible agents, whenever possible. (See "Procedural sedation in children outside of the operating room".)
●Anticipate the need for advanced airway management. Children with conditions that rapidly and predictably progress to involve edema and distortion of normal airway anatomy despite aggressive medical management (such as thermal or chemical airway burns) should be intubated early, in as controlled a setting as possible.
Airway management — In the case of a predicted difficult airway, the first intervention should be to "call for help" if such help is available. The most expert physician available may be from anesthesia or otorhinolaryngology rather than emergency medicine or pediatrics, and they may provide valuable assistance in the rare case of a difficult pediatric airway. An approach to management decisions should consider the urgency of establishing an airway, and the likelihood that rapid sequence intubation will be successful. In comparison to adults, fewer interventions are available for children who have a failed airway.
Cardiac arrest airway — Children who are in extremis are considered a "cardiac arrest airway" and should receive bag-mask ventilation, followed by orotracheal intubation (algorithm 1C). Numerous studies have demonstrated that effective bag-mask ventilation, especially in the prehospital arena, is an effective means of supporting respirations [18,19]. Bag-mask ventilation may provide oxygenation and ventilation as personnel and equipment are being mobilized for endotracheal intubation, even in situations with significant soft tissue obstruction such as epiglottitis [20]. Alternative airway techniques (such as laryngeal mask airway or needle cricothyrotomy) should be employed when attempts to intubate the trachea are unsuccessful. (See 'Alternative airway techniques' above and 'Approach to the failed airway' below.)
Rapid sequence intubation — Rapid sequence intubation should be considered for children who are not in extremis when the clinician is confident that the child can be adequately ventilated with a bag and mask and that oral tracheal intubation will be successful (algorithm 1A). Preparations should always be made for alternative airway management (such as a laryngeal mask airway). (See "Rapid sequence intubation (RSI) outside the operating room in children: Approach" and 'Alternative airway techniques' above.)
Awake intubation — Awake intubation, using sedation and local anesthesia, is an approach that is frequently used for adults [21]. With this technique, the patient is sedated but not paralyzed and continues to breath spontaneously. There are no reports describing experience with this technique for children in the emergency department. It is likely that the degree of sedation required to perform awake intubation in a frightened young child would depress airway protective reflexes and spontaneous respiration, placing the patient at risk for aspiration and hypoxia.
Alternative airway techniques — Alternatives for airway management when rapid sequence intubation or awake intubation are not feasible include a laryngeal mask airway or fiberoptic intubation. (See 'Alternative airway techniques' above and 'Approach to the failed airway' below.)
Forced to act scenario — Certain circumstances (ie, anaphylaxis or thermal injury with rapidly progressive airway swelling) may fall short of a "cardiac arrest" intubation but due to the time sensitive nature of the condition, there may not be sufficient time to call additional resources to the bedside. In these patients, the clinician may elect to perform rapid sequence intubation and create conditions for the best, first attempt at airway management, understanding that if oral intubation fails, the patient would then transition to the failed airway algorithm (algorithm 1D).
Approach to the failed airway — A child with respiratory failure for whom bag-mask ventilation is not effective and the trachea cannot be intubated has a failed airway. This situation is often referred to as a "can't ventilate, can't intubate" scenario [2]. Prompt intervention to improve oxygenation and ventilation is essential (algorithm 1D). The most expert clinician available should be managing the airway.
There is no evidence to guide recommendations for management of these rare, but life-threatening, situations. Therefore, any intervention that could be possibly helpful and is unlikely to worsen the patient's condition, should be considered.
A supraglottic airway should be used initially for most children with failed airways who do not have complete airway obstruction. Positive pressure ventilation through a device that is sealed around the larynx may be effective for those with partial airway obstruction, even if the obstruction is subglottic (such as with croup or a subglottic foreign body). Temporary improvement in oxygenation may be lifesaving, while other interventions are implemented.
A surgical airway should be performed for a child with a complete upper airway obstruction. A surgical airway should also be considered for children with airway conditions that could be worsened by injury from attempts to place a supraglottic airway (such as expanding hematomas, significant midface trauma, or large abscesses). Needle cricothyroidotomy is recommended for children ≤10 years of age (Seldinger cricothyrotomy may be used in children >5 years old). Surgical cricothyroidotomy may be used in children >10 years old. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation" and "Emergency cricothyrotomy (cricothyroidotomy)".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Airway management in children".)
SUMMARY AND RECOMMENDATIONS
●Definition – A difficult airway is generally defined as a situation in which a clinician has trouble with face mask ventilation, laryngoscopy, or intubation. Problems with airway management can occur with positioning, positive pressure ventilation, laryngoscopy, visualizing and/or intubating the trachea, or identifying landmarks for performing a surgical airway. (See 'Definition' above.)
●Recognition – Conditions in children that may make airway management difficult include characteristics of the normal airway and congenital features (table 1) or acquired conditions such as upper airway burns; swelling due to trauma, infection, or anaphylaxis; or tumors (See 'Causes of the difficult pediatric airway' above.)
Airway characteristics that may identify a difficult airway can be rapidly assessed using the mnemonic LEMON (table 4) (see 'The LEMON approach to difficult airway assessment' above):
•L: Look externally for indicators of a difficult airway
•E: Evaluate mouth opening, thyromental distance, and the distance between the mandible and the thyroid cartilage (picture 6)
•M: Mallampati score (figure 1)
•O: Obstruction: Signs of airway obstruction
•N: Neck mobility
●Alternative airway techniques – Alternative airway techniques that are commonly used to manage a difficult pediatric airway include (see 'Alternative airway techniques' above):
•Video laryngoscopy (see 'Video laryngoscopy' above)
•Intubating introducers (gum elastic bougie) (see 'Intubating introducers (gum elastic bougie)' above)
•Supraglottic airway (eg, laryngeal mask airway [LMA] or i-gel) (see 'Supraglottic airway' above)
•In the hands of an experienced clinician, flexible intubating scope (spontaneous breathing patient or through a supraglottic airway (eg, LMA or AirQ) (see "Devices for difficult endotracheal intubation in children", section on 'Flexible intubating scope')
●Management – General management issues for all patients include providing supportive care, monitoring, treating the underlying condition, avoiding situations that could worsen airway compromise, and anticipating the need for advanced airway management. (See 'Management' above.)
Once the child with a difficult airway is identified, a specific plan for management must be developed that includes mobilizing appropriate personnel and assembling specialized equipment (algorithm 1A-D). The child may improve with supportive care and aggressive treatment of the underlying condition. For children who require intubation, airway management must include a rescue plan and preparation for a failed airway (algorithm 1D).
We suggest that a supraglottic device (eg, LMA, i-gel, AirQ) be used as the initial rescue device for a child with a failed airway who does not have complete upper airway obstruction or an airway condition that could be worsened by injury from placement attempts (Grade 2C). (See 'Supraglottic airway' above and 'Approach to the failed airway' above.)
●Surgical airway – A surgical airway is the only option for a child who has a failed airway with complete upper airway obstruction or an airway condition that could be worsened by injury from attempts to place a supraglottic airway. Children ≤10 years of age should receive a needle cricothyrotomy (figure 2 and table 6). For children who are older than 10 years, the surgical approach may be dictated by experience of the clinician. (See 'Approach to the failed airway' above and "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)
