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The difficult pediatric airway for emergency medicine

The difficult pediatric airway for emergency medicine
Literature review current through: May 2024.
This topic last updated: May 19, 2023.

INTRODUCTION — This topic will review conditions in children that can make airway management difficult, anatomic characteristics that may identify those conditions, and management strategies for emergency medicine. Management of the difficult airway for pediatric anesthesia is discussed separately. (See "Management of the difficult airway for pediatric anesthesia".)

General principles of airway management in children, including rapid sequence intubation for emergency medicine, are discussed separately. (See "Basic airway management in children" and "Technique of emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) in children for emergency medicine: 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 advanced 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 ED and children in the OR. (See "Management of the difficult airway for pediatric anesthesia", section on 'Incidence of difficult pediatric airway'.)

DEFINITION — A difficult airway is generally defined as a situation in which a clinician experiences difficulty with bag-mask ventilation, laryngoscopy, or tracheal intubation [1,2]. In an emergency setting, this also includes difficulty performing supraglottic airway placement or 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 ventilate 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 "Technique of 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 bag-mask ventilation, supraglottic airway placement and ventilation, and endotracheal 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, supraglottic airway placement and 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 "Croup: Management".)

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]. Normal shedding of primary teeth creates a potential airway foreign body in children ≥ six years old.

Other causes — Other acquired conditions in children that may make airway management difficult include tumors, previous surgery, radiation treatment, or obesity [9].

INFECTION CONTROL PRECAUTIONS — For children with suspected highly contagious and virulent airborne pathogens such as early COVID-19 variants prior to the availability of effective vaccines, there is a significant risk for transmission during laryngoscopy, endotracheal intubation, and other airway management procedures. Techniques designed to improve patient care, minimize infectious risks to care providers, and decrease spread of pathogens should be applied to all such children undergoing rapid sequence intubation. The following measures are adapted from consensus guidance for advanced life support [10]:

All personnel involved with the procedure should wear personal protective equipment including an N95 mask, eye protection, gown, and gloves.

Whenever possible, perform RSI in a negative pressure room or room with a portable HEPA filtration unit.

Use an inline HEPA filter during bag ventilation.

Assure appropriately experienced practitioners manage the airway to reduce unnecessary risks of exposure and transmission.

Oral intubation with a cuffed endotracheal tube is preferred to nasal intubation.

A supraglottic airway (SGA) with a good seal is an acceptable method for securing the airway as a temporizing or rescue measure.

Because of higher first-attempt success in patients with difficult airways, video laryngoscopy is preferred to direct laryngoscopy.

Use an in-line HEPA filter and adapters for suctioning/bronchoscopy during mechanical ventilation.

Health care providers can significantly reduce their risk of infection, especially severe infection and death, by receiving recommended vaccinations.

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 "Technique of emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) in children for emergency medicine: Approach", section on 'Preparation'.)

General emergency medicine specialists and anesthesiologists have used bedside evaluation tools to identify patients for whom airway management may be difficult. However, the applicability of these indicators for children is unclear. 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. (See "Approach to the difficult airway in adults for emergency medicine and critical care", section on 'Identifying the anatomically difficult airway' and "Management of the difficult airway for general anesthesia in adults", section on 'Recognition of the difficult airway'.)

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, have significant lung disease (such as severe asthma), upper airway swelling, or tracheal narrowing may be difficult to ventilate with a bag and mask [11].

Laryngoscopy and intubation — Several clinical features appear to be sensitive predictors of difficult laryngoscopy and 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 oxygenation, 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 this technique because children rarely require it. (See 'Surgical airway' below.)

Difficult airway assessment (LEMON) — 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 3). Although widely used in adults with good predictive value, evidence in children is lacking. (See "Overview of advanced airway management in adults for emergency medicine and critical care", section on 'Anticipating the difficult airway'.)

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.

TECHNIQUES — Alternative techniques for providing oxygenation and ventilation must be considered for the child who may be difficult to intubate. These techniques may be temporizing such as a supraglottic airway (eg, laryngeal mask airway, i-gel) or a percutaneous needle cricothyrotomy or provide alternative procedural approaches to endotracheal 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.

Video laryngoscopy — Video laryngoscopes (VLs) display the glottic view on a video monitor during endotracheal intubation and allow indirect or, when fitted with standard geometry blades, either indirect or direct laryngoscopy. Video laryngoscopy is becoming widely used by emergency medicine providers for pediatric endotracheal intubation. For children with difficult airways undergoing endotracheal intubation in the operating room, video laryngoscope has a higher first pass success rate than direct laryngoscopy. Practitioners with airway training and experience, including those who are early in their careers, can use these advanced laryngoscopes effectively with little additional training and orientation. Acute angle scopes may be difficult to use in young infants because of the size of the blade. A common problem is the inability to pass the endotracheal tube (ETT) through the vocal cords despite having an adequate view of the glottic opening. This is a more common problem in infants, in whom the bulky VL blade may make maneuvering the ETT into the pharynx more difficult, leading to lower rates of successful intubation with VL than in older children. (See "Management of the difficult airway for pediatric anesthesia", section on 'Anticipated difficult airway management'.)

Several devices are available in sizes appropriate for infants and children. The technique of video laryngoscopy for standard and acute angle blades is described separately. (See "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Video laryngoscope'.)

Intubating introducers (gum elastic bougie) — Intubating introducers are helpful when the epiglottis is visualized but the vocal cords cannot be seen. They are contraindicated in patients with 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 "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Intubating introducers (gum elastic bougie)'.)

Supraglottic airway — A supraglottic device (eg, laryngeal mask airway [LMA] (table 4 and figure 2), i-gel, or AirQ) should be used as the initial rescue device for a child with a failed intubation unless they have upper airway obstruction or an airway condition that would impede successful placement or could be worsened by injury.

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'.)

Supraglottic airways (eg, Laryngeal Mask Airway (LMA), i-gel, and others) are 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 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 a clinician with extensive training and experience with the device, use of a flexible intubating scope is an excellent method for endotracheal intubation for a patient with a difficult airway who is breathing spontaneously. 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 and the patient is able to tolerate a longer intubation attempt. 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) (table 1). 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. The use of a flexible intubating scope in children is discussed in greater detail separately. (See "Flexible scope intubation for anesthesia" and "Management of the difficult airway for pediatric anesthesia", section on 'Alternative intubation techniques'.)

SURGICAL AIRWAY — Rarely, the techniques and devices discussed above fail to provide an airway. As a result, emergency healthcare providers should be familiar with surgical airway techniques, such as needle (figure 3 and table 6) or surgical cricothyroidotomy; although in reality, few if any practitioners have enough opportunity with these approaches to gain proficiency [15]. 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 percutaneous transtracheal ventilation are discussed separately. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation" and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

We prefer manually controlled ventilation (figure 3 and figure 4) to jet ventilation during transtracheal ventilation in children because of familiarity with the technique and 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 '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-C). 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 2).

Initial supportive care — Care for all patients with respiratory difficulties who may have a difficult airway should include the following:

Provide supportive care and monitoring – 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".)

Treat the underlying condition – 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 "Croup: Management".)

Trial noninvasive measures, if possible – If time permits and the patient does not have contraindications to their use, try noninvasive measures (eg, high flow nasal cannula [HFNC] oxygen therapy or noninvasive ventilation [NIV]) while arranging for definitive airway management. In some cases, noninvasive support alone may avoid the need for intubation. Most children in respiratory distress can tolerate HFNC oxygen therapy. However, NIV in young children may be limited by patient compliance.

Noninvasive measures should not delay endotracheal intubation in a patient who requires it (eg, progressive upper airway edema, burns, or epiglottitis). Facial anomalies or injuries may not permit NIV mask or nasal cannula fit. Noninvasive measures should not be used in patients with impaired mental status, high aspiration risk, or an untreated pneumothorax. Other contraindications are discussed separately. (See "High-flow nasal cannula oxygen therapy in children" and "Noninvasive ventilation for acute and impending respiratory failure in children".)

Avoid iatrogenic airway compromise – Avoid situations that could worsen airway compromise (eg, actions that may cause agitation or excessive sedation). 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: Approach".)

Anticipate advanced airway management – 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, preferably the operating room with the assistance of experts in airway management (eg, an anesthesiologist with pediatric expertise and an otolaryngologist or surgeon with similar expertise standing by to provide a surgical airway).

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 otolaryngology 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 with adults, fewer interventions are available for children who have a failed airway.

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 (table 7). Preparations should always be made for alternative airway management (such as a supraglottic airway [eg, laryngeal mask airway or i-gel]). (See "Rapid sequence intubation (RSI) in children for emergency medicine: Approach" and 'Techniques' above.)

Alternative airway techniques — Alternatives for airway management when rapid sequence intubation or awake intubation are not feasible include a supraglottic airway (eg, laryngeal mask airway (table 4 and figure 2) or i-gel) or, when a trained and experienced practitioner is available, flexible scope intubation. (See "Supraglottic airway devices in children with difficult airways" and "Flexible scope intubation for anesthesia".)

Awake intubation — "Awake" intubation using sedation and local anesthesia is an approach that is frequently used for adults. Evidence is lacking regarding the performance of awake intubation in children by emergency medicine or pediatric emergency medicine specialists. However, it may be feasible in selected patients. With this technique, the patient is sedated with propofol or ketamine but not paralyzed and continues to breathe spontaneously. The technique of awake intubation is discussed in detail separately. (See "Approach to the difficult airway in adults for emergency medicine and critical care", section on 'Awake techniques'.)

Sedation only without use of a neuromuscular blocking agent has been shown to have lower intubations success rates. Therefore, intubation by an airway expert is preferred when available. Awake intubation in infants and young children undergoing elective surgical procedures is discussed separately. (See "Management of the difficult airway for pediatric anesthesia", section on 'Awake intubation'.)

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, may not permit 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 2).

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 2). 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 except as noted above. (See 'Supraglottic airway' above.)

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 – Needle cricothyroidotomy is recommended for children ≤10 years of age (figure 3 and figure 4); Seldinger cricothyrotomy may be used in children >5 years old. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation" and "Emergency cricothyrotomy (cricothyroidotomy) in adults", section on 'Seldinger technique'.)

Surgical cricothyroidotomy – Surgical cricothyroidotomy may be used in children >10 years old. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

During transtracheal ventilation in children, manually controlled ventilation rather than jet ventilation is suggested because of a lower risk of barotrauma. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation", section on 'Performing transtracheal ventilation'.)

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 bag-mask ventilation, especially in the prehospital arena, is an effective means of supporting respirations [16,17]. 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 [18]. Alternative airway techniques (such as laryngeal mask airway or needle cricothyrotomy) should be employed when endotracheal intubation attempts are unsuccessful. (See 'Techniques' above and 'Approach to the failed airway' above.)

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 describes a situation in which a clinician has trouble or, due to patient factors, anticipates having trouble performing bag-mask ventilation, laryngoscopy, or endotracheal intubation. (See 'Definition' above.)

Techniques – Techniques that are commonly used to manage a difficult pediatric airway include (see 'Techniques' above):

Video laryngoscopy (picture 9) (see "Technique of emergency endotracheal intubation in children", section on 'Laryngoscopy' and "Management of the difficult airway for pediatric anesthesia", section on 'Anticipated difficult airway management')

Intubating introducers (gum elastic bougie, (picture 7 and picture 8)) (see "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Intubating introducers (gum elastic bougie)')

Supraglottic airway (eg, laryngeal mask airway [LMA] (table 4 and figure 2) or i-gel) (see "Supraglottic airway devices in children with difficult airways")

In the hands of an experienced clinician, flexible intubating scope (spontaneous breathing patient) or through a supraglottic airway (eg, LMA or AirQ) (see "Management of the difficult airway for pediatric anesthesia", section on 'Alternative intubation techniques')

Recognition – Several factors help identify a difficult pediatric airway:

Challenging characteristics of the normal pediatric airway and physiology that make visualization difficult and decrease the time permitted during intubation attempts (see 'Normal pediatric airway' above and 'Normal pediatric physiology' above)

Congenital abnormalities (table 1) (see 'Congenital abnormalities' above)

Acquired conditions such as upper airway burns; progressive swelling due to trauma, infection, or anaphylaxis; or tumors (see 'Acquired conditions' above)

Although not validated in children, the mnemonic LEMON also provides airway findings that may predict difficulty with endotracheal intubation (see 'Difficult airway assessment (LEMON)' above):

L: Look externally for indicators of a difficult airway

E: Evaluate (picture 6):

-Limited mouth opening (in children, <3 patient fingers)

-Short thyromental distance (in children, 3 patient finger-widths)

-Short distance between the mandible and the thyroid cartilage

M: Mallampati score (figure 1)

O: Obstruction: signs of airway obstruction

N: Neck mobility

Precautions – Clinicians should utilize techniques to minimize infectious risks and decrease the spread of airborne pathogens in children with suspected highly contagious and virulent pathogens who are undergoing endotracheal intubation. (See 'Infection control precautions' above.)

Initial supportive care– All patients with respiratory distress and a potentially difficult airway should receive intensive supportive care, monitoring, timely treatment of the underlying condition, and development of an airway management plan. The clinician should avoid situations that could worsen airway compromise. (See 'Initial supportive care' above.)

If time permits and not contraindicated, the clinician may try noninvasive measures (eg, high flow nasal cannula oxygen therapy or noninvasive ventilation) while arranging for definitive airway management. In some cases, noninvasive support alone may avoid the need for intubation. However, noninvasive measures should not delay endotracheal intubation when indicated. (See "High-flow nasal cannula oxygen therapy in children" and "Noninvasive ventilation for acute and impending respiratory failure in children".)

Endotracheal intubation – Our suggested approach to managing a child with a difficult airway who requires emergency endotracheal intubation includes (see 'Initial supportive care' above and 'Airway management' above):

Get help – First, "call for help". Whenever possible, 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 undergo emergency endotracheal intubation in the operating room by the most experienced practitioner (eg, an anesthesiologist with pediatric expertise or similar airway expert and an otolaryngologist or surgeon with similar pediatric surgical airway expertise).

Cardiac arrest airway – Children who are in extremis have a "cardiac arrest airway" and require bag-mask ventilation followed by orotracheal intubation (algorithm 1C).

Forced to act – If forced to act before all preparations can be made (eg, abrupt obstruction or those with rapidly progressive airway compromise), the clinician should perform bag-mask ventilation (BMV) to maintain oxygenation and then make one best attempt at orotracheal intubation (algorithm 1B). For these patients, we suggest administering RSI medications including a paralytic (table 7) rather than performing awake intubation (Grade 2C). However, an awake intubation technique is reasonable if difficulty with BMV is anticipated. (See 'Forced to act scenario' above and 'Awake intubation' above.)

Failed airway – If BMV cannot maintain oxygenation and the trachea cannot be intubated ("failed airway"), the clinician should place a supraglottic device (table 4 and figure 2) if not contraindicated (eg, upper airway obstruction, trauma, or midface fractures) (algorithm 2). (See 'Approach to the failed airway' above.)

Surgical airway – Patients with a complete upper airway obstruction or an airway condition that could be worsened by supraglottic device placement require an immediate surgical airway instead of supraglottic device placement. The suggested technique varies by age:

-≤10 years – Needle cricothyroidotomy (figure 3 and figure 4 and table 6); Seldinger cricothyrotomy may be used in children >5 years old. (See "Needle cricothyroidotomy with percutaneous transtracheal ventilation" and "Emergency cricothyrotomy (cricothyroidotomy) in adults", section on 'Seldinger technique'.)

->10 years – Depending on clinician experience and training, needle or surgical cricothyroidotomy (see "Emergency cricothyrotomy (cricothyroidotomy) in adults")

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Topic 6391 Version 31.0

References

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