Difficult airway infographic: Pediatric patients

(A) Time out for identification of the airway management plan. A team-based approach with identification of the following is preferred: the primary airway manager and backup manager and role assignment, the primary equipment and the backup equipment, and the person(s) available to help. Contact an ECMO team/otolaryngologic surgeon if noninvasive airway management is likely to fail (eg, congenital high airway obstruction, airway tumor, etc).

(B) Color scheme. The colors represent the ability to oxygenate/ventilate: green, easy oxygenation/ventilation; yellow, difficult or marginal oxygenation/ventilation; and red, impossible oxygenation/ventilation. Reassess oxygenation/ventilation after each attempt and move to the appropriate box based on the results of the oxygenation/ventilation check.

(C) Nonemergency pathway (oxygenation/ventilation adequate for an intubation known or anticipated to be challenging): deliver oxygen throughout airway management; attempt airway management with the technique/device most familiar to the primary airway manager; select from the following devices: supraglottic airway, videolaryngoscopy, flexible bronchoscopy, or a combination of these devices (eg, flexible bronchoscopic intubation through the supraglottic airway); other techniques (eg, lighted stylets or rigid stylets may be used at the discretion of the clinician); optimize and alternate devices as needed; reassess ventilation after each attempt; limit direct laryngoscopy attempts (eg, one attempt) with consideration of standard blade videolaryngoscopy in lieu of direct laryngoscopy; limit total attempts (insertion of the intubating device until its removal) by the primary airway manager (eg, three attempts) and one additional attempt by the secondary airway manager; after four attempts, consider emerging the patient and reversing anesthetic drugs if feasible. Clinicians may make further attempts if the risks and benefits to the patient favor continued attempts.

(D) Marginal/emergency pathway (poor or no oxygenation/ventilation for an intubation known or anticipated to be challenging): treat functional (eg, airway reflexes with drugs) and anatomical (mechanical) obstruction; attempt to improve ventilation with facemask, tracheal intubation, and supraglottic airway as appropriate; and if all options fail, consider emerging the patient or using advanced invasive techniques.