Management of the difficult airway for pediatric anesthesia

INTRODUCTION — Difficulty with airway management for anesthesia has potentially serious implications, as failure to secure a patent airway can result in hypoxic brain injury or death in a matter of minutes. Early recognition that a patient's airway may be difficult to manage allows the clinician to plan the anesthetic to minimize the potential for serious airway-related morbidity.

This topic will review the incidence of difficulty with airway management in infants and children during anesthesia, and strategies for management of the anticipated and unanticipated difficult airway. Management of the difficult airway in adults and the difficult pediatric airway in the emergency setting are discussed separately. (See "Management of the difficult airway for general anesthesia in adults" and "The difficult pediatric airway for emergency medicine".)

PREDICTION OF THE PEDIATRIC DIFFICULT AIRWAY — Difficulty with airway management may be anticipated based on the preanesthesia airway assessment or may occur unexpectedly during anesthesia. The majority of children with difficult airways (ie, difficulty with mask ventilation or intubation) can be identified preoperatively, but as many as 20 percent are unanticipated. In a prospective multicenter registry including 1018 cases of difficult intubation over the course of 2.5 years, 80 percent of patients were identified preoperatively as having a high likelihood of difficult laryngoscopy, difficult mask ventilation, or both [1].

However, difficult intubation is common, and is not reliably predicted by preanesthesia evaluation in neonates and infants. In a multicenter study of 4683 intubations in children less than 60 weeks postmenstrual age, the incidence of difficult intubation (defined as two failed intubation attempts) was 5.8 percent; two-thirds of the difficult intubations were not anticipated based on preoperative examination [2].

Airway assessment for prediction of difficulty with airway management in children is discussed separately. (See "Airway management for pediatric anesthesia", section on 'Airway assessment'.)

INCIDENCE OF DIFFICULT PEDIATRIC AIRWAY — Several studies have reported the incidence of difficulty with airway management for pediatric anesthesia. In most cases, the incidence of difficulty is higher in infants compared with older children.

●The incidence of difficult bag-mask ventilation appears to be similar in children and in adults, reported at 6.6 percent for children and 5 to 7.5 percent for adults [3-5]. In a single center prospective observational study, difficult mask ventilation occurred in 6.6 percent of children aged zero to eight years without risk factors for difficult airway management, with younger age identified as a risk factor [3]. There was no association between difficult mask ventilation and difficult intubation.

●Several other studies have reported that difficult direct laryngoscopy (DL) and endotracheal intubation are more common in very young children. Reported rates of difficult intubation in infants vary from 3 to 6 percent [2,6,7]. Representative studies include the following:

•A retrospective study of 11,219 pediatric patients undergoing general anesthesia with endotracheal intubation found an overall rate of difficult DL (Cormack and Lehane grade III and IV) of 1.35 percent (figure 1) [6]. The highest rate of difficult DL was found in children younger than one year old (4.7 versus 0.7 percent in children >1 year). Additional predictors of difficult intubation included American Society of Anesthesiologists (ASA) III and IV status, higher Mallampati score (when it could be obtained), low body mass index, and presentation for oromaxillofacial or cardiac surgery.

•In a multicenter observational study of 4683 intubations for anesthesia in children <60 weeks postconceptual age, difficult intubation occurred in 5.8 percent of patients [2].

•A single center prospective study of 511 patients age 0 to 13 years old without known airway abnormalities who were intubated for anesthesia found a 3 percent rate of poor laryngoscopic views (Cormack and Lehane grade III and IV). All instances of difficult laryngoscopy occurred in patients less than three months old [7].

•A study with data collected from 13 pediatric centers found that among pediatric patients, those who weighed less than 10 kg and those with short thyromental distance by physical examination had higher rates of airway-related complications [1]. In children who were difficult to intubate by DL the most common physical findings were micrognathia and limited mouth opening (picture 1).

ANTICIPATED DIFFICULT AIRWAY MANAGEMENT — The plan for anesthesia and airway management for the patient with a predicted difficult airway may differ from the standard approach (algorithm 1 and figure 2) [8,9].

General concerns — Management of the difficult airway for anesthesia in adults is discussed separately. (See "Management of the difficult airway for general anesthesia in adults".)

Concerns specific for pediatric patients include the following:

●For patients in whom difficult laryngoscopy, face mask ventilation, or supraglottic airway (SGA) use is expected, we suggest performing airway management in a tertiary center with experience managing the pediatric difficult airway whenever possible. This may require rescheduling elective surgery or transporting patients who are stable to another institution.

●We suggest performing a Time Out prior to pediatric difficult airway management. The Time Out should include all team members involved in the patient's care, and identify the primary airway manager, backup manager, additional roles, primary technique, backup technique, equipment needed, and potential need for an otolaryngologic surgeon or extracorporeal membrane oxygenation (ECMO).

●Whenever possible, we suggest obtaining intravenous (IV) access prior to induction of anesthesia for children with predicted airway difficulty, to allow rapid administration of sedatives, anesthetics, neuromuscular blocking agents, and emergency drugs. If this is not possible, appropriate doses for intramuscular administration of succinylcholine and atropine should be prepared.

●We suggest administration of supplemental oxygen, including during apnea, throughout induction of anesthesia and attempts at airway management. (See 'Apneic oxygenation' below.)

●For patients with anticipated difficult airway management, we suggest using an advanced airway management technique (eg, videolaryngoscopy, flexible scope intubation) rather than direct laryngoscopy for the first attempt at intubation (see 'Alternative intubation techniques' below). If direct laryngoscopy is used initially, or if an unanticipated difficult airway is encountered, we suggest limiting direct laryngoscopy (DL) to one attempt before switching to an advanced airway technique. Multiple attempts at DL are associated with a high failure rate and an increased incidence of complications [1], including edema, bleeding, or laryngospasm, and may convert a stable situation (spontaneously breathing or easy mask ventilation) to an unstable, "cannot intubate, cannot ventilate" scenario.

●Bradycardia in response to hypoxemia and airway manipulation is more common in children than in adults. When difficulty is expected, we administer atropine (0.02 mg/kg) prior to airway manipulation to prevent this complication, as well as to decrease oral secretions.

Apneic oxygenation — We suggest the use of supplemental oxygen insufflation during laryngoscopy for all children thought to be at risk for prolonged or difficult intubation, or who are at risk for rapid oxygen desaturation (patients with poor pulmonary reserve, or those undergoing rapid sequence induction and intubation) [10]. This includes all neonates (<1 month of age), since neonates desaturate more quickly, have a higher incidence of difficult airways, and are more likely to have unanticipated difficult airways compared with older infants and children [2,11].

Administration of oxygen into the posterior pharynx delays oxygen desaturation during periods of apnea, as occurs during prolonged intubation attempts. In apneic patients, oxygen extraction from the alveoli results in subatmospheric alveolar pressures, and if the airway is unobstructed, oxygen will be drawn in from the glottic opening. (See "Preoxygenation and apneic oxygenation for airway management for anesthesia".)

●Devices for apneic oxygenation – When we expect relatively quick success at intubation with an advanced airway technique in patients with a difficult airway, we typically use a standard nasal cannula for apneic oxygenation due to availability and ease of application and removal. In small children, we use 1 to 2 liters/minute/kg oxygen from the auxiliary oxygen flowmeter. In larger children, we use the maximum flow rate available.

In cases where we expect a prolonged intubation attempt, we prefer either a humidified high flow nasal cannula or modified nasal trumpet.

A number of devices have been described for apneic administration of oxygen in children, including the following, which are shown in a graphic (picture 2):

•Standard nasal cannulae [12]

•Humidified high-flow nasal cannulae [13-15]

•An endotracheal tube (ETT) placed through the nose into the posterior pharynx

•A laryngoscope blade with an oxygen side port [16]

•An ETT placed in the side channel of a videolaryngoscope [17]

•Nasal trumpet modified with an ETT adaptor [18]

Studies have reported variable effectiveness of these techniques, but all would likely allow an increased margin of safety for prolonged intubation attempts. As an example, in one study, the rate of oxygen desaturation was recorded in children who were intubated with conventional DL, or with apneic oxygenation with one of two types of laryngoscope modifications [16]. All children were preoxygenated with 30 percent oxygen. The time for 25 percent of patients to reach a 1 percent decrease in oxygen saturation was 30 seconds without apneic oxygenation, 67 seconds with oxygen supplementation via a laryngoscope blade with an oxygen cannula attached to the side, and 75 seconds with oxygen administered via a videolaryngoscope with an oxygen sideport.

In another study, 48 children ≤2 years of age were randomly assigned to intubation with or without insufflation of oxygen through an ETT positioned in the side channel of an AirTraq videolaryngoscope [17]. After intubation, patients were left apneic until oxygen saturation (SpO₂) fell to 95 percent. Insufflation of oxygen prolonged the mean time to desaturation by an estimated 35 seconds (95% CI, 10 to 60 seconds), from 131±39 seconds without oxygen to 166±47 seconds with oxygen.

●High-flow nasal cannula– High flow nasal oxygen (HFNO) has been used to improve oxygenation in critically ill infants and children. (See "High-flow nasal cannula oxygen therapy in children".)

The use of heated humidified high flow nasal oxygen (HFNO) is increasing in the operating room for both children and adults [19]. Studies in infants and children have reported maintenance of normal oxygen saturation with HFNO during prolonged periods of apnea and spontaneous ventilation [13-15]. HFNO has also been used to maintain normoxia for tubeless airway surgery lasting up to one hour. The degree to which HFNO removes carbon dioxide is variable, with studies reporting conflicting results [14,20,21]. (See "Preoxygenation and apneic oxygenation for airway management for anesthesia".)

Theoretical and usually clinically inconsequential disadvantages to apneic oxygenation include the following:

●The apneic oxygenation device may have to be removed, if the intubation attempt is aborted, to allow mask ventilation.

●Intraoral devices (eg, catheter taped to the laryngoscope, side ports) may obstruct the laryngeal view during laryngoscopy.

●Oxygen may be insufflated into the stomach.

Alternative intubation techniques — Alternatives to DL for intubation in children are similar to those that may be used in adults (eg, flexible scope intubation [FSI], videolaryngoscopy [VL], intubation through an SGA).

●The appropriate advanced airway technique may depend on factors such as clinician preference and familiarity with techniques, patient size, mouth opening, neck mobility, physiologic reserve, apnea tolerance, and presence of blood or secretions in the airway. More important than the first intubation technique attempted is avoidance of repeated attempts of the same technique without adjustment. Therefore, additional equipment for secondary attempts using alternative approaches should be immediately available.

●VL increases intubation success in both adults and children with difficult airways. VL is faster to perform and easier to set up than a flexible scope. However, a common problem is the inability to pass the ETT through the vocal cords despite having an adequate view of the glottic opening. This is particularly a problem when using a hyperangulated VL blade in infants, in whom the bulky, highly curved blade may make maneuvering the ETT into the pharynx more difficult. This may explain findings of lower rates of successful intubation with hyperangulated VL blades in infants than in older children [22], and lower success rates in infants less than 5 kg with a hyperangulated VL blade compared to a standard Macintosh or Miller VL blade [23]. (See "Video laryngoscopes and optical stylets for airway management for anesthesia in adults", section on 'Intubation success and outcomes with video laryngoscopes'.)

●FSI through an SGA may provide a first pass success rate similar to VL, with the added advantage of allowing continuous ventilation and oxygenation throughout laryngoscopy. In an analysis of data from the Pediatric Difficult Intubation (PeDI) registry that included 1603 difficult pediatric intubations, first pass success was similar overall with FSI through an SGA versus VL (59 percent for FSI through an SGA, 51 percent for VL) [24]. First attempt success rate in infants less than one year of age was higher with FSI though an SGA than with VL (54 percent versus 36 percent).

Use of an SGA facilitates unobstructed passage of the flexible intubation scope (FIS) past the soft tissue of the oropharynx, and we prefer this technique over freehand FSI. However, FSI, even through an SGA, may take longer than DL or VL, and may be difficult or impossible if there are blood or secretions in the airway.

●A hybrid technique using VL and FIS is increasingly being used. With this technique, the videolaryngoscope is inserted in the normal fashion. An ETT is loaded onto an FIS, which is used as a maneuverable stylet while watching the tip on the VL screen.

Awake intubation — Intubation while awake, or with intravenous sedation and maintenance of spontaneous ventilation, should be considered if there is anticipated difficulty with endotracheal intubation and in addition, any one of the following (see "Management of the difficult airway for general anesthesia in adults", section on 'Awake intubation'):

●Both mask ventilation and SGA ventilation are likely to be difficult, or

●There is high risk of aspiration, or

●The patient will not tolerate an apneic period

Awake or sedated intubation may be impractical for young children because of lack of cooperation, and is therefore less commonly performed than in adults with difficult airways. In a multicenter observational study of 1839 pediatric patients with anticipated difficult intubations, the first intubation attempt was in awake or lightly sedated spontaneously breathing patients in only 75 cases; the rest had general anesthesia for the first attempt [25]. Twenty eight percent of the sedated patients had to be converted to general anesthesia for successful intubation. After propensity score matching, complication rates were similar in patients who had general anesthesia versus sedation. Awake intubation with sedation and airway topicalization may be possible as it would be for adults if the child is able to cooperate. (See "Management of the difficult airway for general anesthesia in adults", section on 'Awake intubation'.)

When awake intubation is required for neonates, we use the following technique for awake FSI through an SGA:

●Obtain IV access

●Pass a nasal or oral gastric tube and connect to suction to decompress the stomach

●Apply topical anesthesia to the tongue, oropharynx, and hypopharynx, using one of the following:

•Lidocaine 2% solution via atomizer

•Lidocaine 2% jelly, swabbed over the posterior pharynx with a gloved finger

•Lidocaine 2% jelly injected into a pacifier with multiple perforations made with a needle [26]

The dose of lidocaine should be limited to 4 to 5 mg/kg to avoid systemic toxicity. (See "Local anesthetic systemic toxicity", section on 'Local anesthetic dose'.)

●Administer atropine (0.02 mg/kg) or glycopyrrolate (0.01 mg/kg) IV as an anti-sialagogue and to prevent bradycardia

●Insert an intubating SGA (eg, air-Q or Ambu Aura-i), inflate the cuff

●Insert flexible scope, preloaded with a lubricated ETT, through the SGA

●Advance the flexible scope through the vocal cords to the level of the carina, and advance the ETT over it

●Remove the flexible scope and confirm ETT placement and depth

Patients who cough or gag during SGA placement or passage of the flexible scope through the SGA may be inadequately topicalized, and may be at risk for laryngospasm when the scope is passed through the vocal cords. In such patients, once the vocal cords are visualized, we administer an IV induction agent (eg, propofol 2 to 3 mg/kg IV or ketamine 1 to 2 mg/kg IV) and a neuromuscular blocking agent (eg, succinylcholine 1 mg/kg IV, unless contraindicated), just prior to passing the scope through the vocal cords to prevent laryngospasm [27].

THE UNANTICIPATED DIFFICULT AIRWAY — Difficulty with airway management may arise unexpectedly after induction of anesthesia. The American Society of Anesthesiologists (ASA) and other organizations have developed guidelines for management of adults and children with difficult airways, that include algorithms to aid in clinical decision-making (algorithm 2 and algorithm 1) [28-34]. (See "Management of the difficult airway for general anesthesia in adults", section on 'Importance of an algorithmic approach'.)

Algorithmic approach — We agree with the approach outlined in the American Society of Anesthesiologists (ASA) 2022 Practice Guidelines for Difficult Airway Management, which provides a difficult airway algorithm specifically for pediatric patients (algorithm 1 and figure 2) [34]. The algorithm in the ASA guidelines is similar to the one that appears in 2024 guidelines for airway management in neonates and infants, created jointly by the European Society of Anesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) [35]. Other guidelines and algorithms have been published, including those from the Association of Paediatric Anaesthetists of Great Britain and Ireland (APA), and the Vortex approach. These different guidelines do not represent conflicting approaches to the difficult airway; they all share the goals of maintaining adequate oxygenation and ventilation throughout airway management and avoiding irreversible deterioration in patient condition.

ASA difficult airway guidelines — Highlights of this approach, some of which are specific to the pediatric difficult airway, include the following:

●Care for patients with anticipated airway difficulty at a tertiary center experienced in pediatric airway management when feasible.

●Use an awake or sedated approach which preserves spontaneous ventilation if difficult laryngoscopy and ventilation (by mask or supraglottic device) is anticipated.

●Use continuous oxygenation throughout airway management.

●Limit the number of attempts at airway manipulation.

●Choose an advanced airway technique, such as videolaryngoscopy, flexible scope intubation, or a combination technique based on both the patient's condition and anticipated anatomy as well as the provider's experience.

●Assess oxygenation and ventilation after each airway attempt, with awareness that multiple attempts and the passage of time throughout airway management may lead to deterioration in the patient's physiologic condition, a cannot intubate/cannot ventilate scenario, and the need for emergency airway management (eg, rigid bronchoscopy, emergency invasive airway, extracorporeal membrane oxygenation [ECMO]).

●Recognize functional obstruction (such as laryngospasm) as a frequent and treatable cause of difficult ventilation in children, which may be avoided or treated by maintaining adequate anesthetic depth throughout airway manipulation.

●Reverse sedatives or muscle relaxants and emerge the patient from anesthesia if a total of four or more attempts have been made by two different providers, OR the patient is deteriorating, AND postponing of the procedure is possible.

●Perform rigid bronchoscopy or invasive airway access by a trained individual (such as an otolaryngologic surgeon) or initiate ECMO if intubation and ventilation become impossible.

ESAIC and BJA guidelines for airway management in neonates and infants — The difficult airway algorithm provided for use in neonates and infants is similar to the one provided by the ASA [35]. Additional recommendations include use of neuromuscular blocking drugs when possible and ensuring an adequate level of anesthesia during airway management to increase success and reduce laryngospasm, use of a rigid stylet when a hyperangulated video laryngoscope is used, and use of high-flow nasal oxygenation, continuous positive airway pressure, or nasal intermittent positive pressure for postextubation support. A summary of the recommendations from this guideline is shown in a table (table 1).

APA difficult airway guidelines — The guidelines from the APA are divided into algorithms for difficult mask ventilation, difficult tracheal intubation, and the cannot intubate, cannot ventilate scenarios [33].

Vortex approach — The Vortex cognitive aid is another simplified and flexible approach to the difficult airway. When difficulty is encountered, this strategy recommends a best effort attempt at intubation, SGA placement, or mask ventilation. If the first attempt is unsuccessful, the provider either makes an adjustment to the technique or rapidly transitions to a different technique. Once adequate oxygenation is achieved with any technique, the patient enters what is called the green zone in which there is no longer a risk of imminent desaturation. This allows the provider to regroup, reoxygenate the patient, assemble additional resources, and develop a strategy in light of the existing situation [36].

Invasive airway access — Invasive airway access, which may be used after other attempts at airway management have failed, is especially difficult in children, as the larynx is higher in the neck and more difficult to access, and the risk of advancing through the back wall of the trachea into the esophagus is high [37]. Needle/catheter cricothyrotomy is preferred over surgical cricothyroidotomy because it is anatomically easier to perform in children with less potential damage to surrounding structures [38,39]. Invasive airway access for cannot intubate, cannot ventilate scenarios in children is discussed elsewhere. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation" and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

EXTUBATION OF THE DIFFICULT PEDIATRIC AIRWAY — Extubation following anesthesia should be planned as carefully as initial intubation, particularly in patients with difficult airways. Here we discuss extubation of pediatric patients with difficult airways. Extubation following anesthesia in adults is discussed in detail separately. (See "Extubation following anesthesia".)

●Risk assessment – Extubation of a patient following anesthesia is considered high risk if reintubation is expected to be difficult, or if additional oxygenation or ventilation techniques are anticipated to be necessary following extubation. This may occur in the operating room immediately following surgery, or days later in the intensive care unit (ICU).

Children of all ages are at higher risk for laryngospasm than adults. Laryngospasm often occurs during light planes of anesthesia, such as occurs during extubation. Successful management of laryngospasm may require administration of neuromuscular blocking agents followed by controlled mask ventilation or reintubation. Therefore, patients with difficult airways are at particular risk from laryngospasm-related morbidity at emergence and extubation. (See "Complications of pediatric airway management for anesthesia", section on 'Laryngospasm'.)

When evaluating a patient for extubation, difficult airway risk factors should be considered. These include risk factors that were present before the anesthetic, as well as those which have developed during intubation (such as edema, airway trauma, or vocal cord paralysis). Infants <10 kg are also particularly prone to mechanical upper airway obstruction which may require intervention while recovering from anesthesia.

●Incidence of failed extubation – The incidence of failed extubation in children is unknown. One single-center study of 137 pediatric patients with difficult airways undergoing anesthesia found that while the majority were successfully extubated after anesthesia with minimal respiratory support, 5 percent failed extubation, requiring attempts at reintubation [40]. Most of these cases were infants <10 kg who experienced severe airway obstruction following extubation. One patient required tracheostomy and two died from airway complications. This study underscores the risk of morbidity and supports a thoughtful and prepared approach to high risk extubations.

●Extubation technique – The following are considerations specific to extubation of children with difficult airways [41]. Most are applicable to extubation in the operating room or in the intensive care unit.

•A clinician experienced with managing and intubating the difficult pediatric airway should be present.

•An otolaryngologist should be present if the patient’s anatomy makes airway management with common advanced airway techniques likely to fail, and/or if a need for invasive airway access is anticipated in case of failed extubation.

•Ensure that basic airway equipment (eg, supraglottic airways, appropriately sized endotracheal tubes, oral and nasal airways), video laryngoscopes, and flexible intubating scopes are present and operational.

•Ensure that equipment for respiratory support is present (eg, high flow nasal cannula, BiPAP machine)

•If the patient has been intubated for a prolonged period, plan for extubation early in the day so that staffing is optimal if the patient requires reintubation in the subsequent few hours.

•Perform a Time Out prior to attempted extubation, detailing a plan for respiratory support and reintubation should it become necessary.

•Optimize for extubation by correcting any reversible issues that could complicate extubation. Fully reverse neuromuscular blockade. For patients who have been prone for a prolonged anesthetic or who have received large volumes of IV fluid, turn supine with the patient’s head elevated until edema starts to subside. If the patient is hemodynamically unstable or requires a high fraction of inspired oxygen for adequate oxygenation, it is best to delay extubation.

•Consider the use of an airway exchange catheter, particularly in older children. Airway exchange catheters are devices inserted through the endotracheal tube prior to extubation, and left in place after extubation to provide a means of guided reintubation. The patient can breathe around the AEC, and supplemental oxygen can be provided by facemask. AECs are available for use in ETT sizes 3 mm ID or larger. There is little literature on the use of AECs in small children [42]. Concerns include the possibility of airway obstruction, laryngospasm, airway trauma, and the need for sedation to tolerate the device. Use of an AEC may be reasonable in cooperative older children and those for whom the risk of reintubation is high and access to the airway is limited (ie, a patient with a difficult airway undergoing surgery requiring the mouth to be wired shut postoperatively). Use of AECs in adults is discussed separately. (See "Extubation following anesthesia", section on 'AEC technique'.)

•For patients who are extubated in the operating room:

-Wait to extubate until the patient shows signs of complete emergence from anesthesia, including purposeful movement, facial grimace, eye opening with conjugate gaze, and consistent tidal volumes of over 5 mL/kg [43].

-Prior to discharge from the postanesthesia recovery unit, observe the patient until they reach their preoperative respiratory status, with no airway obstruction and complete recovery from sedation.

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" and "Society guideline links: COVID-19 – Index of guideline topics".)

SUMMARY AND RECOMMENDATIONS

●Prediction and incidence of the difficult airway

•Neonates have a higher incidence of difficult intubation and are more likely to have unanticipated difficult airways than older children. (See 'Prediction of the pediatric difficult airway' above.)

•Difficulty with airway management in older children can usually be predicted preoperatively based on airway assessment, though as many as 20 percent of difficult pediatric airways are unanticipated. (See 'Prediction of the pediatric difficult airway' above and "Airway management for pediatric anesthesia", section on 'Airway assessment'.)

•The incidence of difficult mask ventilation is similar in children and adults, at about six percent. (See 'Incidence of difficult pediatric airway' above.)

•Difficult laryngoscopy or intubation occurs in 1.25 to 3 percent of children, up to 4.5 percent of children <1 year of age, and in up to 6 percent of neonates. (See 'Incidence of difficult pediatric airway' above.)

●Anticipated difficult airway (algorithm 1 and figure 2)

•Patients anticipated to have difficult laryngoscopy and ventilation with facemask or supraglottic airway (SGA) should be transferred to a tertiary center with experience in managing the difficult pediatric airway if possible. (See 'General concerns' above.)

•A Time Out outlining staff roles, planned approach, and necessary equipment should be performed prior to pediatric difficult airway management. (See 'General concerns' above.)

•For children with anticipated difficult airways, we suggest obtaining intravenous access prior to induction of anesthesia whenever possible (Grade 2C). (See 'General concerns' above.)

•For all children thought to be at risk for prolonged or difficult intubation, or for rapid oxygen desaturation during apnea, we suggest the use of supplemental oxygen insufflation throughout airway management (Grade 2C). This includes all neonates (<1 month of age), since neonates desaturate more quickly, have a higher incidence of difficult airways, and are more likely to have unanticipated difficult airways compared with older infants and children. Options for apneic oxygenation include standard nasal cannula, humidified high-flow nasal oxygen, modifications of standard or video-laryngoscopes, and oxygen insufflation via nasal trumpets or endotracheal tubes (ETTs) placed in the posterior pharynx (picture 2). (See 'Apneic oxygenation' above.)

•For children with anticipated difficult airways, we suggest using an advanced airway management technique (eg, videolaryngoscopy, flexible scope intubation, intubation through an SGA) rather than direct laryngoscopy (DL) for intubation. Choice of technique should be based on both the patient's condition and anticipated anatomy as well as the provider's experience. Multiple attempts using the same technique should be avoided. Equipment for alternative techniques should be readily available. (See 'Alternative intubation techniques' above.)

•If DL is used, we suggest no more than one attempt before switching to an advanced technique (Grade 2C). Repeated attempts at DL are associated with a high failure rate, and can result in edema, bleeding, laryngospasm, and/or a "cannot intubate, cannot oxygenate," scenario.

•Awake intubation should be considered in patients with predicted difficulty with intubation in addition to one of the following (see 'Awake intubation' above):

-Predicted difficulty with both mask ventilation and SGA ventilation

-High risk of aspiration

-Predicted intolerance of an apneic period

●Unanticipated airway difficulty – For these patients, we use an approach consistent with the guidelines from the American Society of Anesthesiologists (algorithm 1 and figure 2). Important considerations include:

•Consider laryngospasm as a cause of total airway obstruction during mask ventilation

•Limit the number of attempts at direct laryngoscopy

•Use an SGA early (see 'Algorithmic approach' above)

•Reverse anesthesia and return to spontaneous ventilation if possible

•Be prepared for an invasive airway approach or extracorporeal membrane oxygenation (ECMO) in case of failure to oxygenate and ventilate

●Invasive airway access – Invasive airway access may be more difficult in children than adults. Needle/catheter cricothyrotomy is preferred over surgical cricothyroidotomy in children. (See 'Invasive airway access' above.)

●Extubation of the difficult pediatric airway

•Extubation should be planned as carefully as intubation.

•Extubation is considered high risk if reintubation would likely be difficult, or if the patient is not likely to tolerate extubation.

•Ensure that appropriate equipment and personnel are available and optimize the timing and setting for extubation.

•For high risk extubation, patients should be fully awake with full return of respiratory control. (See 'Extubation of the difficult pediatric airway' above.)