Pediatric airway: What is new in approaches and treatments?

  • Daniel Rivera-Tocancipá a. Anesthesia Graduate Program, Universidad Surcolombiana. Neiva, Colombia. b. Anesthesia Service, Hospital Universitario Hernando Moncaleano Perdomo. Neiva, Colombia. c. Anesthesia Service, Clínica Emcosalud. Neiva, Colombia.
Keywords: Airway management, Pediatrics, Algorithms, Pediatric anesthesia, Complications, Devices


Perioperative morbidity and mortality are high among patients in the extremes of life undergoing anesthesia. Complications in children occur mainly as a result of airway management-related events such as difficult approach, laryngospasm, bronchospasm and severe hypoxemia, which may result in cardiac arrest, neurological deficit or death. Reports and new considerations that have changed clinical practice in pediatric airway management have emerged in recent years. This narrative literature review seeks to summarize and detail the findings on the primary cause of morbidity and mortality in pediatric anesthesia and to highlight those things that anesthetists need to be aware of, according to the scientific reports that have been changing practice in pediatric anesthesia.

This review focuses on the identification of “new” and specific practices that have emerged over the past 10 years and have helped reduce complications associated with pediatric airway management. At least 9 practices grouped into 4 groups are described: assessment, approach techniques, devices, and algorithms. The same devices used in adults are essentially all available for the management of the pediatric airway, and anesthesia-related morbidity and mortality can be reduced through improved quality of care in pediatrics.


Apricot group of the european Society of Annaesthesiology Clinical Trial network. Incidence of severe critical events in paedicatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitales in Europe. Lancet Respir Med. 2017;5(5):412-25. doi:

Cheon E, Longhini A, Lee J, Hansen J, Jagannathan N, De Oliveira G, Suresh S. Predictive factors for adverse outcomes in pediatric patients undergoing low‐risk skin and soft tissue surgery: A database analysis of 6730 patients. Pediatric Anesthesia. 2019(29):44-50. doi:

Uffman J, Tumin D, Beltran R and Tobias J. Severe outcomes of pediatric perioperative adverse events occurring in operating rooms compared to off‐site anesthetizing locations in the Wake Up Safe Database. Pediatric Anesthesia. 2019;(29):38-43. doi:

Jagannathan N, Sohn L, Fiadjo J. Paediatric difficult airway management: what every anaesthetist should know! Br J Anaesthesia. 2016;117(S1):i3-5. doi:

Weiss M, Engelhardt T. A child with a difficult airway: Wat do i do next? Curr Opin Anaesthesiol. 2012(25):326-32.

Hagberg C. Current concepts in the management of the difficult airway. Anesthesiology Newz. Supplement special edition. 2018;15(2):105-36.

Engelhard T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, et al. A framework for the management of the pediatric airway. This article has been accepted for publication and undergone full peer review. doi:

Raghavan K, Ying Moo DX, Tan Z. Severe obesity in children as an independent risk factor for perioperative respiratory adverse events during anaesthesia for minor non-airway surgery, a retrospective observational study. Proceeding Singapore Healthcare. 2019;28(2):83-9. doi:

Eckenhoff JE. Some anatomic considerations of the infant larynx influencing endotracheal anesthesia. Anesthesiol. 1951;12(1951):401-10.

Bayeux. Tubage de larynx dans le Croup. Presse Med. 1987;20:1.

Litman RS, Weissend EE, Shibata D, Westesson PL. Developmental changes of laryngeal dimensions in unparalyzed, sedated children. Anesthesiology. 2003;98(1):41-5.

Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg. 2009;108(5):1475-9.

Wania T, Bissonnette B, Engelhardtd T, Buchhe B, Arnousb H, AlGhamdib F, Tobias J. The pediatric airway: Historical concepts, new findings, and what matters. Int J Pediatric Otorhinolaryngol. 2019(121):29-33. doi:

Wani T, Rafiq M, Akhter N, Saeed F, AlGhamdi, Tobias J. Upper airway in infants—a computed tomography-based analysis. Pediatric Anaesthesia. 2017;27(5):501-5. doi:

Holzki J, Brown K, Carroll R, Cot Ch. The anatomy of the pediatric airway: ¿Has our knowledge changed in 120 years? A review of historic and recent investigations of the anatomy of the pediatric larynx. Pediatric Anesthesia. 2018;(28):13-22. doi:

Schmidt A, Weiss M, Engelhardt T. The paediatric airway: Basic principles and current developments. Review Article. Eur J Anaesthesiol. 2014(31):293-9. doi:

Dave M, Kemper M, Schmidt A, Both C, Weiss M. Pediatric airway dimensions-A summary and presentation of existing data. Pediactric Anesthesia. 2019; 00:1-8. doi:

Sathyamoorthy M, lerman J, Okhomina VI and penman AD. Use of cuffed trcheal tubes in neonates, infants and children: A practice survey of members of the Society of Pediatric Anesthesia. J Clin Anesth. 2016;33:266-72.

De Orange FA, Andrade RGAC, Lemos A, Borges PSGN, Figueiroa JN, Kovatsis PG. Cuffed versus uncuffed endotracheal tubes for general anaesthesia in children aged eight years and under. Cochrane Data base of Systematic Reviews. 2017;11:CD011954. doi:

Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011;55(19):1155-73.

Engelhardt T, Teoh W, Stafrace S, Kristensen M. Review Article: Essential ultrasound techniques of the pediatric airway. Pediatric Anesthesia. 2016;(26):122-31. doi:

Orhan-Sungur M, Altun D, Ozkan-Seyhan T, Aygun E, Koltka K, Camci E. Learning curve of ultrasound measurement of subglottic diameter for endotracheal tuve selection in pediatric patients. Pediatric Anesthesia. 2019;00:1-7. doi:

Lyons C, Callaghan M. Uses and mechanisms of apnoeic oxygenation: a narrative review. Anaesthesia. 2019;74:497-507. doi:

Napolitano N, Laverriere EK, Craig N, et al. National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Apneic oxygenation as a quality improvement intervention in an academic PICU. Pediatr Crit Care Med. 2019;20(2):e531-7. doi:

Holyoak R, Melhuishb T, Vlok R, Binks M, White L. Intubation using apnoeic oxygenation to prevent desaturation: A systematic review and meta-analysis. J Crit Care. 2017(41):42-8. doi:

Hegde S, Prodhan P. Serious air leak syndrome complicating high-flow nasal cannula therapy: a report of 3 cases. Pediatrics. 2013;131(3):e939-44.

Díaz R, Fajardo Ch, Rufs J. Historia del ECMO. Med Clin Condes. 2017;28(5):796-802. doi:

Zapata R, Naranjo C, Méndez M, Montoya C, Jaramillo J, Cruz G, Posada L. Reconstrucción traqueal bajo oxigenación con membrana para circulación extracorpórea para el manejo de una lesión traumática: reporte de caso y revisión bibliográfica. romb Cir. 2018;(33):211-9. doi:

Malpas G, Hung O, Gilchrist A, Wong C, Kent B, Hirsch G, Hart R. The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review. Can J Anesth. 2018;(65):685-97. doi:

Chen R. Concern regarding the use of extracorporeal membrane oxygenation in the anticipated difficult airway. Can J Anesth. 2019;66:1115-6. doi:

Sancho-Hernández R, Solorio-Rodríguez L, Durán-Colín A, Cuevas-Schacht F. Procedimiento EXIT (ex utero intrapartum) en las malformaciones congénitas broncopulmonares de alto riesgo. Descripción de la técnica y revisión de la literatura. Neumol Cir Torax. 2016;75(4):281-90.

Mychaliska GB, Bealer JF, Graf JL, Rosen MA, et al. Operating on placental support: the ex utero intrapartum treatment procedure. J Pediatr Surg. 1997;32:227-30; discussion 230-21.

Kumar K, Miron C, Singh SI. Maternal anesthesia for EXIT procedure: A systematic review of literatura. J Anaesthesiol Clin Pharmacol. 2019;35(1):19-24. doi:

Rivera-Tocancipa D, Díaz-Sánchez E. Vía aérea pediátrica. ¿Tan difícil como dicen? Colombian Journal of Anesthesiology. 2018;46(Sup):56-62. doi:

Fiadjoe JE, Kovatsis P. Videolaryngoscopes in pediatric anesthesia: what´s new? Minerva Anestesiol. 2014;80(1):76-82.

Abdelgadir IS, Phillips RS, Singh D, Moncreiff MP, Lumsden JL. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates). Cochrane Database of Systematic Reviews 2017,5: CD011413. doi:

Lingappan K, Arnold JL, Shaw TL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database Syst Rev. 2018;2018(6):CD009975. doi:

Grunwell JR, Kamat PP, Miksa M, et al; National Emergency Airway Registry for Children (NEAR4KIDS) and the Pediatric Acute Lung Injury and Sepsis (PALISI) Network. Trend and Outcomes of Video Laryngoscope Use Across PICUs. Pediatr Crit Care Med. 2017;18(8):741-9. doi:

Pouppirt NR, Nassar R, Napolitano N, et al. Association Between Video Laryngoscopy and Adverse Tracheal Intubation-Associated Events in the Neonatal Intensive Care Unit. J Pediatr. 2018;201:281-4. doi:

Stendall C, Glaisyer H, Liversedge T. Actualización en dispositivos supraglóticos para la vía aérea pediátrica. Colombian Journal of Anesthesiology. 2017;45(S2):39-50. doi:

Koele-Schmidt L, Vásquez M. NewB for newbies: a randomized control trial training housestaff to perform neonatal intubation with direct and videolaryngoscopy. Pediatric Anesthesia. 2016;(26):392-8. doi:

Black AE, Flynn PE, Smith HL, et al. Development of a guidelines fo the management of the unanticipated difficult airway in pediatric practice. Pediatr Anesth. 2015;25:346-63.

Burjek NE, Nishisaki A, Fiadjoe JE, et al. Videolaryngoscopy versus fiber-optic intubation through a supraglottic airway in children with a difficult airway: an analysis from the multicenter pediatric difficult intubation registry. Anesthesiology. 2017;127(3):432-40.

Lee JH, Smith PB, Huey Quek MB, et al. Risk factors and in-hospital outcomes following tracheostomy in infants. J Pediatr. 2016;173:39-44. doi:

Fennessy P, Walsh B, Laffey J, McCarthy Kand McCaul C. Accuracy of peediatric cricothyroid membrane identification by digital palpation and implications for emergency front of neck Access. Pediatric Anesthesia. 2020;30:69-77. doi:

Pawar DK, Doctor JR, Raveendra US, et al. All India difficult airway association 2016 guidelines for the management of unanticipated difficult tracheal intubation in paediatrics. Indian J Anaesth. 2016;60(12):906-14. doi:

Echeverry P, Engelhard T. Algoritmo para el manejo de la vía aérea difícil en pediatría. Colombian Journal of Anesthesiology. 2014;42(4):325-34. doi: 10.1016/j.rca.2014.05.008.

Weiss M, Engelhardt T. Cannot ventilate—paralyze! Paediatr Anaesth. 2012;22(12):1147-9. doi:

Ozawa Y, Ades A, Foglia EE, et al; National Emergency Airway Registry for Neonates (NEAR4NEOS) Investigators. Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events. J Perinatol. 2019;39(6):848-56. doi:

Streiff A, Chimhundu-Sithole T, Evans F. Manejo de la vía aérea pediátrica Difícil en centros con altos y bajos recursos: Una comparación de algoritmos y carros de vía aérea difícil. Paediatric Anaesthesia Tutorial 399 [internet]. 5 de marzo de 2019. Disponible en:

Chrisme N. The Vortex: a universal “high-acuit implementation tool” for emergency airway management. Br J Anaesthesia. 2016;117(S1):i20-i27. doi:

Baquero H, Celis LA, Martínez I, Restrepo N, et al. Consenso de manejo en vía aérea y soporte ventilatorio en neonatos con sospecha o riesgo de Covid19. 1ra. ed. Bogotá: Asociación Colombiana de Neonatología (ASCON); 2020.

Matava C, Fiadoe JE, Kovatsis P, et al. Pediatric airway managemente in Covid-19 patients: consensus guidelines from the Society for Pediatric Anesthesia´s Pediatric Difficult Intubation Collaborative and the Canadian pediatric Anesthesia Society. Anesth Analg. 2020;131:61-73. doi:

How to Cite
Rivera-Tocancipá D. Pediatric airway: What is new in approaches and treatments?. Colomb. J. Anesthesiol. [Internet]. 2020 Sep. 21 [cited 2024 May 25];49(2). Available from:


Download data is not yet available.
How to Cite
Rivera-Tocancipá D. Pediatric airway: What is new in approaches and treatments?. Colomb. J. Anesthesiol. [Internet]. 2020 Sep. 21 [cited 2024 May 25];49(2). Available from:
Narrative review


Article metrics
Abstract views
Galley vies
PDF Views
HTML views
Other views
QR Code

Some similar items: