Received: 15 December 2019 | Accepted: 17 December 2019

DOI: 10.1111/pan.13798

E D U C AT I O N A L R E V I E W

Normal and difficult airways in children: “What’s

New”—Current evidence

John Fiadjoe1 | Akira Nishisaki2,3

1
Critical Care Medicine, The Children's
Hospital of Philadelphia, Perelman School Abstract
of Medicine, University of Pennsylvania, Background: Pediatric difficult airway is one of the most challenging clinical situa-
Philadelphia, PA, USA
2 tions. We will review new concepts and evidence in pediatric normal and difficult air-
Critical Care Medicine, Center for
Simulation, Advanced Education, and way management in the operating room, intensive care unit, Emergency Department,
Innovation at The Children's Hospital of
and neonatal intensive care unit.
Philadelphia, Philadelphia, PA, USA
3
Critical Care Medicine, and Pediatrics,
Methods: Expert review of the recent literature.
University of Pennsylvania Perelman School Results: Cognitive factors, teamwork, and communication play a major role in man-
of Medicine, Philadelphia, PA, USA
aging pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a
Correspondence monolithic way yielding inconclusive results regarding their effectiveness. There are,
Akira Nishisaki, Department of
Anesthesiology and Critical Care Medicine,
however, substantial differences among videolaryngoscopes particularly angulated
Children’s Hospital of Philadelphia, 3401 vs. nonangulated blades which have different learning and use characteristics. Each
Civic Center Blvd, Philadelphia, PA, USA.
Email: [email protected]
airway device has strengths and weaknesses, and combining these devices to leverage
both strengths will likely yield success. In the pediatric intensive care unit, emergency
Funding information
Eunice Kennedy Shriver National Institute
department and neonatal intensive care units, adverse tracheal intubation–associated
of Child Health and Human Development, events and hypoxemia are commonly reported. Specific patient, clinician, and prac-
Grant/Award Number: R21HD089151;
Anesthesia Patient Safety Foundation;
tice factors are associated with these occurrences. In both the operating room and
Agency for Healthcare Research and Quality, other clinical areas, use of passive oxygenation will provide additional laryngoscopy
Grant/Award Number: R03HS021583, R18
HS022464, R18HS024511, R03HS026939
time. The use of neuromuscular blockade was thought to be contraindicated in dif-
ficult airway patients. Newer evidence from observational studies showed that con-
Section Editor: Britta von Ungern-Sternberg
trolled ventilation with or without neuromuscular blockade is associated with fewer
adverse events in the operating room. Similarly, a multicenter neonatal intensive
care unit study showed fewer adverse events in infants who received neuromuscular
blockade. Neuromuscular blockade should be avoided in patients with mucopolysac-
charidosis, head and neck radiation, airway masses, and external airway compression
for anticipated worsening airway collapse with neuromuscular blocker administration.
Conclusion: Clinicians caring for children with difficult airways should consider new
cognitive paradigms and concepts, leverage the strengths of multiple devices, and
consider the role of alternate anesthetic approaches such as controlled ventilation
and use of neuromuscular blocking drugs in select situations. Anesthesiologists can
partner with intensive care and emergency department and neonatology clinicians to
improve the safety of airway management in all clinical settings.

KEYWORDS

apneic oxygenation, cognitive bias, difficult airway, emergency department, neonatal intensive
care unit, neuromuscular blockade, operating room, pediatric intensive care unit, Pediatrics

Pediatric Anesthesia. 2020;30:257–263. wileyonlinelibrary.com/journal/pan© 2019 John Wiley & Sons Ltd | 257
258 | FIADJOE AND NISHISAKI

1 | I NTRO D U C TI O N
Key questions
The pediatric difficult airway is one of the most challenging clinical
situations faced by clinicians. This is because of their short apnea • What are cognitive biases observed in pediatric difficult

tolerance, propensity for airway edema, and changing anatomy dur- airway management?

ing growth. The goal of this article is to review new concepts and • What are the strengths and weaknesses of videola-

evidence in pediatric normal and difficult airway management in the ryngoscopes and flexible bronchoscopes for tracheal

OR, intensive care unit, and Emergency Department. intubation?

• What is the current evidence for spontaneous versus
controlled ventilation techniques when managing the

1.1 | Cognitive factors anticipated difficult airway?

• What is the role of passive oxygenation in difficult air-

Cognitive and human factors play an important role in airway man- way management in the OR and pediatric ICU?

agement; understanding these factors is critical for all clinicians. • What is the current evidence regarding the use of neu-

A sentinel event in aviation, the crash of United Airlines Flight romuscular blockade in neonatal tracheal intubation and

173 flying from New York to Oregon, started the movement of difficult airway in children?

crew resource management. On approach to Oregon, there was a

problem with the landing gear, and the Captain was fixated on ad-
dressing it while they flew in a holding pattern. The Engineer noted
and announced that they were low on fuel several times with little 2 | A I RWAY M A N AG E M E NT I N TH E
acknowledgment or action taken by the Captain, who was still inves- O PE R ATI N G RO O M
tigating the landing gear issue. The aircraft ran out of fuel, crashing
in a Portland suburb, killing ten people. This incident mirrors the case 2.1 | New devices & techniques
of Elaine Bromley, who presented for routine sinus surgery and was
found to be difficult to intubate and ventilate. The team fixated on Technology for airway management continues to evolve. The broad
tracheal intubation, and during their repeated attempts to intubate, categories include direct laryngoscopy, videolaryngoscopy, optical
she became severely hypoxic. Unfortunately, the team failed to per- stylets, and flexible bronchoscopes. The most popular techniques
form a surgical airway even though the nurse involved had brought for managing challenging pediatric airways utilize flexible bronchos-
in and announced the presence of a tracheostomy kit.1 Both these copy and videolaryngoscopy. Flexible bronchoscopy remains the gold
cases highlight the importance of human factors in decision making standard for managing difficult pediatric airways and remains the
during critical events. One study demonstrated that students en- technique of choice for patients with limited mouth opening. The Pedi
gaged in a challenging task underestimate the elapsed time by 40% Registry, a multicenter international quality improvement registry, re-
when compared to an easy task. We are all vulnerable to task fixa- ported an association between flexible bronchoscopy techniques and
tion, particularly when dealing with challenging clinical scenarios. It higher first-attempt success when compared to other approaches,
is essential during these critical events that clinicians are particularly particularly in infants.2 In older children with normal mouth opening,
responsive to other members of the team who may be less engaged videolaryngoscopy and flexible bronchoscopy have similar success
in the task and have a more global perspective. rates. Videolaryngoscopes can be categorized as angulated or nonan-
Another common cognitive bias is loss aversion, which refers to gulated videolaryngoscopes. Angulated videolaryngoscopes are most
the tendency to avoid a loss rather than acquire an equivalent gain. effective for patients with severe airway abnormalities. Although an-
Clinicians sometimes lack experience with an indicated airway man- gulated blades almost always provide an adequate view of the airway,
agement technique and may be reluctant to attempt the technique they are sometimes associated with difficulty with placing the breath-
or call for help for fear of loss of reputation. The loss of reputation ing tube, in contrast with standard direct laryngoscopy, where a good
is avoided against the gain of expert assistance. Anchoring refers to view almost always assures easy tube placement. Videolaryngoscopes
the tendency to rely heavily on an initial piece of information when have not been shown to be superior to direct laryngoscopy in children
making decisions. It may manifest as a tendency to continue an inef- with normal airways. A recent Cochrane review concluded that direct
fective technique such as facemask ventilation when an alternative laryngoscopy was faster than videolaryngoscopy by a few seconds (12
approach such as a laryngeal mask or surgical airway is required. trials; n = 798; mean difference (MD) 5.49 seconds, 95% confidence
Several other cognitive issues come into play in airway manage- interval (CI) 1.37 to 9.60; very low-quality evidence). 3 They also found
ment but are beyond the scope of this article. Cognitive errors may no difference in first-attempt success (11 trials; n = 749; risk ratio (RR)
not be overcome by simply being aware of them. Checklists, reduc- 0.96, 95% CI 0.91 to 1.02) and more intubation failures with videola-
ing hierarchy, and being receptive to input from all members of the ryngoscopy. However, they stated that the evidence supporting these
team regardless of their rank may help clinicians break a cognitive conclusions was of very low quality due to their heterogeneity.3,4
error cycle. One of the major reasons was pooling of studies that evaluated both
FIADJOE AND NISHISAKI | 259

angulated and nonangulated videolaryngoscopes. Standardizing out- tracheal intubation to reoxygenate. High-flow nasal oxygen should
comes and terminology would allow meaningful comparisons across be applied judiciously as pneumothorax has been reported with flow
studies in the future. rates as low as 6 liters per minute.9 Dedicated humidified high-flow
Combining techniques leverage the strengths of the devices systems such as transnasal humidified rapid-insufflation ventilatory
combined, particularly videolaryngoscopy and flexible bronchos- exchange (THRIVE) are useful in small children, doubling the apnea
copy. Combined techniques require two clinicians—one to expose time when compared to no passive oxygen.10
the larynx with videolaryngoscopy and the second to guide the flex- Neuromuscular blockade agents have traditionally been avoided
ible bronchoscope into the airway. The videolaryngoscope displaces in patients with difficult airways. An observational study from the
soft tissue (weakness of the flexible bronchoscope), and the fiber- aforementioned Pedi Registry found an association between spon-
optic bronchoscope is used to maneuver the tube into the glottis taneous ventilation technique (versus controlled ventilation with or
(weakness of angulated videolaryngoscopy). An additional limitation without neuromuscular blockade) and increased nonsevere com-
of fiberoptic intubation is the inability to visualize the insertion of plications.11 Light anesthesia was the likely cause of these compli-
the tube into the glottis. Combining videolaryngoscopy with fiber- cations as patients in the spontaneous group had more reported
optic bronchoscopy allows visualization throughout the intubation. airway reactivity. When using spontaneous ventilation, clinicians
should continually assess the anesthetic depth. A five-second Larson
maneuver is suggested to determine patient readiness for airway in-
2.2 | Invasive airway access strumentation.12 We have found that when this technique is applied,
a lack of physical movement, an increase in heart rate (>10bpm), or
Invasive airway access is particularly challenging in children. Needle respiratory rate indicates optimal conditions for tracheal intubation.
cricothyroidotomy may not be feasible in small children (<8yrs) be- Neuromuscular blockade agent should be administered if airway
cause the cricothyroid membrane is difficult to locate and too small to reactivity occurs, especially if associated with complete ventilation
accommodate an appropriately sized tube. Tracheal access may be pre- failure. Neuromuscular blockade should be avoided in patients with
ferred in these patients.5 Ventrain (Ventinova Medical, BV, Eindhoven, mucopolysaccharidosis, head and neck radiation, and airway masses
The Netherlands) is a new device that allows effective ventilation as worsening of their ventilation may occur.
through a small-bore cannula. It not only delivers an adequate volume Traditionally sedated approaches have not been considered
but also evacuates the gas using suction, theoretically reducing the feasible in children with difficult airways. Newer drugs such as dex-
risk of barotrauma.6 Surgical airway should not be delayed when indi- medetomidine may facilitate sedated approaches in children partic-
cated; clinicians should act when complete ventilation failure occurs, ularly in combination with midazolam or ketamine.13
that is, inability to ventilate with a facemask or laryngeal mask even if
oxygen saturation is normal. Waiting for the onset of hypoxemia to act
will likely be too late and result in severe consequences. 3 | A I RWAY M A N AG E M E NT I N
Laryngeal masks remain a useful tool for managing children TH E PE D I ATR I C I CU, E M E RG E N C Y
with challenging airways. They are excellent tools for rescuing dif- D E PA RTM E NT, A N D N EO N ATA L I CU
ficult ventilation and are excellent conduits for fiberoptic intuba-
tion when properly placed. Using a laryngeal mask may prevent the Nonanesthesiology trained clinicians commonly handle airway man-
need for tracheal intubation in children with difficult airways; how- agement for pediatric or neonatal patients. These children are at much
ever, equipment for tracheal intubation should be readily available higher risk for adverse events during airway management. These ad-
and prepared in the event tracheal intubation is needed. Second- verse events can be defined as adverse tracheal intubation–associated
generation laryngeal masks have a gastric access port that provides events (TIAEs) [Table 1].14 While the definition of adverse TIAEs does
a way for the clinician to empty the stomach. They also allow assess- not include hypoxemia, these are often reported together. Current evi-
ment of the laryngeal mask position using simple tests such as the dence suggests 1. adverse TIAEs and hypoxemia are common in air-
7,8
suprasternal notch and positive pressure tests. way management in the pediatric ICUs, Emergency Department, and
neonatal ICUs,14-16 2. patient, clinician, and practice factors are associ-
ated with the occurrence of these adverse events,17-21 and 3. inter-
2.3 | Conduct of anesthesia disciplinary quality improvement has helped reduce these events.22-24
Pediatric anesthesiologists can partner with nonanesthesiologists to
Supplemental oxygen has traditionally not been used during tracheal improve the safety of airway management in these clinical locations.
intubation. Accumulating evidence suggests that passive delivery of
oxygen may be beneficial during difficult airway management, pro-
vided the airway is kept open. Flow rates of 1-2 liters kg−1 min−1 have 3.1 | Airway management outcomes
been used in small children, and using passive oxygen via a nasal can-
nula, modified nasal trumpet, or oral RAE tube will increase the time The majority of airway management in the pediatric ICU and ED are
available for intubation and potentially reduce the need to interrupt successful. In a large cohort study, the first-attempt success (defined
260 | FIADJOE AND NISHISAKI

TA B L E 1 Tracheal intubation–associated events (TIAEs) and In neonatal ICUs (NICU) and the delivery room (DR), first-at-
severe TIAEs tempt success was 49% in NICU, 46% in the DR, and the course
Nonsevere TIAE Severe TIAE success was 96% in NICU and 95% in DR.16 Tracheal intubation
was associated with adverse TIAEs in 18% (NICU) and 17% (DR).
Esophageal intubation with Cardiac arrest (with or without
immediate recognition return of spontaneous Hypoxemia, defined as ≥ 20% SpO2 decrease, is more common
circulation) in the NICU (48%) and DR (31%) among neonates who had SpO2
Mainstem bronchial intubation Esophageal intubation with monitor at the time of airway management. This reflects the pa-
delayed recognition tients underlying disease processes and smaller functional residual
Cardiac dysrhythmia Emesis with aspiration capacities. The most common severe adverse TIAEs were esoph-
Emesis without aspiration Hypotension requiring fluid ageal intubation with delayed recognition, cardiac compression
and/or vasoactive agent (<1 min), and laryngospasm (each reported in 1% of all tracheal
Lip trauma Laryngospasm intubations in the NICU). The most common nonsevere TIAEs
Airway trauma Dental trauma were esophageal intubation with immediate recognition (9%), dys-
Epistaxis Pneumothorax or rhythmia including bradycardia (4%), and mainstem bronchial in-
pneumomediastinum tubation (2%). The effect of these immediate airway management
Pain or agitation requiring Malignant hyperthermia outcomes on NICU outcomes or neurodevelopmental impact has
additional medication not been reported on a large scale. One small single-center ret-
Hypertension requiring rospective study (n = 88) reports a strong association between
additional medication
first laryngoscopy attempt success within 10 minutes of life and
Medication error better neurodevelopmental outcomes among extremely very low
birthweight infants (ie, birthweight ≤ 1000g): death or neurode-
as secure airway establishment) was 62%, first clinician success was velopmental impairment 29% in infants with first-attempt success
79%, and the first course success (the success of first method) was versus 53% in infants with multiple laryngoscopy attempts, unad-
98% in pediatric ICUs.14 Recent analysis suggests that these outcomes justed odds ratio 0.4, 95% CI 0.1-1.0, P < .05. 26
were also similar in EDs (unpublished data, personal communication,
Capone, Nishisaki, December 2019). Multiple attempts (3 or more at-
tempts) were reported in 14% of all airway management in the PICUs. 3.2 | Patient factors
14

There is robust evidence that the adverse events during airway In both ICUs and EDs, patients often require airway management be-
management (TIAEs) are frequent, occurring at 15%-20% in many cause of ventilation failure, hemodynamic instability, and neurological
pediatric ICUs (in both general and cardiac ICUs) and in the EDs.14 failure [1]. Tracheal intubation for procedures is also common in ICUs,
Severe TIAEs (eg, cardiac arrests, emesis with aspiration, hypoten- reported in approximately 15% of all tracheal intubations. This practice
sion) also reported in 3%-5% of all airway management. Hypoxemia varies across the ICUs, since it depends on the anesthesiology service
(defined as SpO2 < 80% for children with initial SpO2 > 90%) model for their ICU patients. In one study evaluating risk factors for
during airway management is also common, reported in 20% of tracheal intubation–associated cardiac arrests, the patient hemody-
all airway management in the pediatric ICUs. Not surprisingly, the namics (shock state) and respiratory failure had more weights (adjusted
occurrence of adverse TIAEs and oxygen desaturations is closely OR 6.6 for shock state, adjusted OR 4.3 for respiratory failure) than
associated: In pediatric ICUs, 33% of TIs with adverse TIAEs expe- difficult airway features (adjusted OR 2.1).27 This highlights that the
rience oxygen desaturation < 80% (unpublished data). Conversely, risk of airway management in the ICU and ED is often dictated by the
the TIs with hypoxemia SpO2 < 80% experienced hemodynamic patient's systemic condition. Graciano et al reported the predictive
TIAEs (ie, cardiac arrest, hypo/hypertension, dysrhythmia) more values of clinical features for difficult tracheal intubations.17 Difficult
often (9.8% vs. 4.4% of TIs without oxygen desaturation). After tracheal intubation was defined as three or more attempts or course
adjusting for patient conditions and clinician levels, the odds ratio failure by nonresident clinicians. After adjusting for multiple compari-
(OR) for these hemodynamic TIAEs was 1.83 (95% CI 1.34-2.51) sons, a history of difficult airway, limited neck extension, limited mouth
in tracheal intubations with hypoxemia (SpO2 < 80%) and 2.16 opening, small thyromental space, and upper airway obstruction were
(95% CI 1.54-3.04) in tracheal intubations with severe hypoxemia all associated with difficult tracheal intubations. Multivariable analy-
(SpO2 < 70%).15 The occurrence of adverse TIAEs or oxygen de- ses for intubations with advanced first clinicians (fellows or attending)
saturation was independently associated with a longer duration of showed that a history of difficult airway (adjusted OR 2.11), limited
mechanical ventilation in the ICU (+12%, 95% CI 4%-21%), and the mouth opening (adjusted OR 1.63), and signs of upper airway obstruc-
occurrence of severe TIAEs was independently associated with tion (adjusted OR 1.91) were independently associated with difficult
increased pediatric ICU mortality (OR 1.80, 95% CI 1.24-2.60). 25 tracheal intubations. Sensitivity and positive predictive value for each
These data highlight the clinical significance of adverse TIAEs and clinical feature were suboptimal. Reed et al originally described the
hypoxemia during airway management. LEMON method and its predictive value.28 Their LEMON method
FIADJOE AND NISHISAKI | 261

included 1. look externally, 2. evaluate using 3-3-2 rule, 3. Mallampati, 24%, neonatology fellows 52%, and attending clinicians 64%; and
4. obstruction, and 5. neck mobility. They used Cormack-Lehane grade success within 2 attempts for pediatric residents 56%, neonatol-
2-4 as the difficult airway definition. While there was a significant ogy fellows 78%, and attending clinicians 88%.16 In neonatal ICUs
association between the airway assessment scores and outcome, its and DRs, pediatric resident participation in tracheal intubation has
clinical value was not fully established. substantially decreased over time, and it is difficult for graduat-
In the neonatal ICUs, airway management is most often required ing pediatric residents to become competent in neonatal tracheal
for respiratory failure: oxygenation or ventilation failure, frequent intubations.33-35
16
apnea and bradycardia, and surfactant administration. In the mul- Anesthesiologists should be aware of their institution's norms
tivariable analysis, unstable hemodynamics for airway management and expectations for each trainee and frontline clinician. Given
(adjusted OR 3.85, 95% CI 1.59-9.35) and increased number of at- the importance of first laryngoscopy attempt success in high-risk
tempts (adjusted OR 1.87 95% CI 1.63-2.14) were independently patients, matching patient risk level with the clinicians’ skill level is
associated with the occurrence of TIAEs. essential.
Sawyer et al evaluated the association between difficult airway
features and actual difficult intubations (defined as ≥ three attempts
by nonresident clinicians or course failure). 29 Difficult airway fea- 3.4 | Practice factors
tures included symptoms of upper airway obstruction, history of
difficult airway, limited mouth opening, limited neck extension, cleft In the pediatric ICUs and EDs, intravenous induction with neuro-
palate, midline hypoplasia, and short thyromental distance. While muscular blockade agent is a standard of care, unless there is strong
the presence of difficult intubation was strongly associated with ad- concern for difficult mask ventilation after neuromuscular blockade
verse outcomes, each of these clinical features often used for airway administration as discussed above.36 A standard induction (adminis-
assessment lacked sensitivity, positive predictive value, and discrim- tration of sedative/induction agent) with mask ventilation followed by
ination ability using receiver operating characteristic (ROC) curve. neuromuscular blocker administration is practiced commonly in the
The limitation of this study was that both the laryngoscopists and airway management in the ICUs.20 While some clinicians believe the
clinicians evaluating the airway features were not anesthesiologists. establishment of mask ventilation after induction assures continued
Regardless, the commonly used features for difficult airway assess- mask ventilation after neuromuscular blockade administration, there is
ment in adult and pediatric practice seem less useful in the neonatal no clear published evidence to back up this theory. Careful risk assess-
population. ment for suspected difficult airway patients is warranted, especially
for anticipated worsening airway collapse with sedative or neuromus-
cular blocker administration (eg, external airway compression).37
3.3 | Clinician level In the NICU, a recent publication from a multicenter registry
(11 NICUs) confirmed that the use of sedation and neuromuscular
In both ICUs and EDs, the overwhelming majority of pediatric air- blockade is independently associated with lower adverse TIAEs
ways are managed by nonanesthesiologists in North America.14 This (adjusted OR 0.47, 95% CI 0.34-0.65, P < .001). 38 Interestingly,
is different from the practice in the United Kingdom, where anes- the occurrence of severe hypoxemia was unchanged. There was
thesiologists perform > 80% of tracheal intubations in the pediatric substantial site variance in the use of sedative and neuromuscu-
ICU.30 A series of observational studies document the difference in lar blockade in the NICU intubations, suggesting room for quality
TI first-attempt success, overall success, and the occurrence of TIAEs improvement.
14,16
and severe TIAEs across the spectrum of clinician experience. The use of videolaryngoscopy was associated with a lower
An early study reported the pediatric resident first laryngoscopy at- occurrence of TIAEs in pediatric ICU intubations.19 This is simi-
tempt success rate at approximately half that of critical care fellows lar to results from a single academic neonatal ICU study. 39 These
(residents 37%, fellows 70%, attendings 72%).18 Adverse TIAEs by studies differ from adult randomized control data from French
residents had 30% of TIAEs while TIs by fellows had 16% and TIs medical ICUs, where the first-attempt success and adverse event
by attendings had 22%. Interestingly, severe TIAE rates were the rates were not different between videolaryngoscopy (McGrath
highest in TIs performed by attending clinicians (9%) as compared Macintosh laryngoscope) and direct laryngoscopy.40 As discussed
to TIs by residents (6%) and fellows (6%), suggesting clinician selec- earlier, the advantage of videolaryngoscopy in the standard intu-
tion based on anticipated patient risk of severe adverse events. In bation in the OR is not clearly demonstrated.41 Videolaryngoscopy
North America, there is a consistent declining trend of pediatric provides additional visual information to laryngoscopy coaches (ie,
resident participation in ICU airway management as laryngoscopists, senior supervising clinicians), and two neonatal studies showed
especially in large teaching programs with pediatric critical care fel- that supervisor coaching with laryngoscopy views was signifi-
31
lowships. Non-neonatal intubation is no longer a required skill cantly associated with first-attempt success.42,43 The value of
32
competency for pediatric residency curriculum. videolaryngoscope on clinician coaching is currently under investi-
In NICUs and DRs, the clinician training level was strongly asso- gation as a NICU multicenter prospective trial and in the pediatric
ciated with outcomes: first-attempt success for pediatric residents OR in a randomized fashion.
262 | FIADJOE AND NISHISAKI

The use of apneic oxygenation has been explored in the adult 8. O'Connor CJ Jr, Borromeo CJ, Stix MS. Assessing proseal laryn-
44-47 geal mask positioning: the suprasternal notch test. Anest Analg.
EDs and ICUs. Napolitano et al recently published a single-cen-
2002;94(5):1374-1375; author reply 1375.
ter experience to implement apneic oxygenation as a quality im- 9. Hegde S, Prodhan P. Serious air leak syndrome complicating
provement interventions in a single pediatric ICU. 24 Among 1,373 high-flow nasal cannula therapy: a report of 3 cases. Pediatrics.
tracheal intubations, the implementation of apneic oxygenation was 2013;131(3):e939-944.
10. Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler
associated with lower oxygen desaturation (SpO2 < 80%): apneic
A. Transnasal humidified rapid-insufflation ventilatory exchange
oxygenation 15.4% vs. without apneic oxygenation 11.8%, P = .049. (THRIVE) in children: a randomized controlled trial. Br J Anaesth.
The adjusted OR after adjusting for patient level confounders was 2017;118(2):232-238.
0.55 (0.34-0.88, P = .013). The findings were similar when they 11. Garcia-Marcinkiewicz AG, Adams HD, Gurnaney H, et al. A ret-
performed per-protocol analysis among intubations during post- rospective analysis of neuromuscular blocking drug use and
ventilation technique on complications in the pediatric difficult
implementation phase. They utilized a regular nasal cannula, with
intubation registry using propensity score matching. Anesth
relatively low flow oxygen for feasibility (infants 5L/min, 1-7 year Analg. 2019.
old 10L/min, 8 year or older 15L/min). It is likely that the effect of 12. Abelson D. Laryngospasm notch pressure ('Larson's maneuver')
apneic oxygenation varies based on patient physiology: more effec- may have a role in laryngospasm management in children: high-
lighting a so far unproven technique. Pediatr Anesth. 2015;25(11):
tive in children without respiratory disease. This finding is similar
1175-1176.
to the preoxygenation practice in the adult ICU, where prolonged 13. Buck ML. Dexmedetomidine use in pediatric intensive care and pro-
(>3 minutes) preoxygenation does not translate into higher oxygen cedural sedation. J Pediatr Pharmacol Ther. 2010;15(1):17-29.
reserve.48 14. Nishisaki A, Turner DA, Brown CA III, Walls RM, Nadkarni VM, For
the National Emergency Airway Registry for Children (NEAR4KIDS)
In summary, while the majority of airway management in pe-
and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI)
diatric ICUs, EDs, and neonatal ICUs are performed by nonan- Network. A national emergency airway registry for children
esthesiologists in many places, their risks for adverse tracheal (NEAR4KIDS) landscape of tracheal intubation in 15 pediatric in-
intubation–associated events and hypoxemia are higher than intuba- tensive care units. Crit Care Med. 2013;41(3):874-885.
15. Li S, Hsieh TC, Rehder KJ, et al. Frequency of desaturation and as-
tions in the OR. Quality improvement interventions are ongoing to
sociation with hemodynamic adverse events during tracheal intu-
mitigate identified patient, clinician, and practice factors that facili- bations in PICUs. Pediatr Crit Care Med. 2018;19(1):e41-e50.
tate or minimize the occurrence of adverse tracheal intubation–as- 16. Foglia EE, Ades A, Sawyer T, et al. Neonatal Intubation Practice
sociated events and hypoxemia. Anesthesiologists can partner with and Outcomes: An International Registry Study. Pediatrics.
2019;143(1):e20180902.
ICU, ED, and neonatology clinicians to improve the safety of airway
17. Graciano AL, Tamburro R, Thompson AE, for the National
management in all clinical settings. Emergency Airway Registry for Children (NEAR4KIDS) and
Pediatric Acute Lung Injury and Sepsis Investigators (PALISI)
ORCID Network. Incidence and associated factors of difficult tracheal
Akira Nishisaki https://orcid.org/0000-0002-7590-0156 intubations in pediatric ICUs: A Report from National Emergency
Airway Registry for Children: NEAR4KIDS. Intensive Care Med.
2014;40(11):1659-1669.
REFERENCES 18. Sanders R, Giuliano J, Sullivan J, et al. Level of trainee and tracheal
1. Syed M.Black box thinking: why most people never learn from Their intubation outcomes. Pediatrics. 2013;131(3):e821-e828.
mistakes--But some Do. Portfolio. 2015;ISBN:9781591848226. 19. Grunwell JR, Kamat PP, Miksa M, et al. Trend and outcomes of
2. Burjek NE, Nishisaki A, Fiadjoe JE, et al. Videolaryngoscopy versus video laryngoscope use across PICUs. Pediatr Crit Care Med.
fiber-optic Intubation through a supraglottic airway in children with 2017;18(8):741-749.
a difficult airway: an analysis from the multicenter pediatric difficult 20. Kojima T, Harwayne-Gidansky I, Shenoi AN, et al. Cricoid pressure
intubation registry. Anesthesiology. 2017;127(3):432-440. during induction for tracheal intubation in critically Ill children: a
3. Abdelgadir IS, Phillips RS, Singh D, Moncreiff MP, Lumsden JL. report from national emergency airway registry for children. Pediatr
Videolaryngoscopy versus direct laryngoscopy for tracheal intuba- Crit Care Med. 2018;19(6):528-537.
tion in children (excluding neonates). Cochrane Database Syst Rev. 21. Kojima T, Laverriere EK, Owen EB, et al. Clinical impact of exter-
2017;5:CD011413. nal laryngeal manipulation during laryngoscopy on tracheal in-
4. Lingappan K, Arnold JL, Shaw TL, Fernandes CJ, Pammi M. tubation success in critically Ill children. Pediatr Crit Care Med.
Videolaryngoscopy versus direct laryngoscopy for tra- 2018;19(2):106-114.
cheal intubation in neonates. Cochrane Database Syst Rev. 22. Simon LI, Rehder K, Giuliano J, et al. Development of a quality im-
2015;2:CD009975.12. provement bundle to reduce tracheal intubation-associated event
5. Pawar DK, Doctor JR, Raveendra US, et al. All India Difficult Airway in pediatric ICUs. Am J Med Qual. 2016;31(1):47-55.
Association 2016 guidelines for the management of unantici- 23. Davis KF, Napolitano N, Li S, et al. Promoters and Barriers to
pated difficult tracheal intubation in Paediatrics. Indian J Anaesth. implementation of tracheal intubation airway safety bundle:
2016;60(12):906-914. a mixed-method analysis. Pediatr Crit Care Med. 2017;18(10):
6. Escriba Alepuz FJ, Alonso Garcia J, Cuchillo Sastriques JV, Alcala 965-972.
E, Argente NP. Emergency ventilation of infant subglottic stenosis 24. Napolitano N, Laverriere EK, Craig N, et al. Apneic oxygenation As a
through small-gauge lumen using the ventrain: a case report. A A quality improvement intervention in an academic PICU. Pediatr Crit
Pract. 2018;10(6):136-138. Care Med. 2019;20(12):e531-e537.
7. Sharma B, Sood J, Sahai C, Kumra VP. Troubleshooting ProSeal 25. Parker MM, Nuthall G, Brown C 3rd, et al. Pediatric acute lung injury
LMA. Indian J Anaesth. 2009;53(4):414-424. and sepsis investigators (PALISI) network. Relationship between
FIADJOE AND NISHISAKI | 263

adverse tracheal intubation associated events and PICU outcomes. 38. Ozawa Y, Ades A, Foglia EE, et al. National Emergency Airway
Pediatr Crit Care Med. 2017;18(4):310-318. Registry for Neonates (NEAR4NEOS) Investigators. Premedication
26. Wallenstein MB, Birnie KL, Arain YH, et al. Failed endotracheal in- with neuromuscular blockade and sedation during neonatal in-
tubation and adverse outcomes among extremely low birth weight tubation is associated with fewer adverse events. J Perinatol.
infants. J Perinatol. 2016;36(2):112-115. 2019;39(6):848-856.
27. Shiima Y, Berg RA, Bogner HR, et al. Cardiac arrests associated with 39. Pouppirt NR, Nassar R, Napolitano N, et al. Association be-
tracheal intubations in PICUs: a multicenter cohort study. Crit Care tween video laryngoscopy and adverse tracheal intubation-as-
Med. 2016;44(9):1675-1682. sociated events in the neonatal intensive care unit. J Pediatr.
28. Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score 2018;201:281-284.
predict intubation success in the emergency department? Emerg 40. Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Clinical research
Med Australas. 2005;17(1):94-96. in intensive care and sepsis (CRICS) Group. Video laryngoscopy
29. Sawyer T, Foglia EE, Ades A, et al. National Emergency Airway vs Direct laryngoscopy on successful first-pass orotracheal in-
Registry for Neonates (NEAR4NEOS) investigators. Incidence, im- tubation among ICU patients: a randomized clinical trial. JAMA.
pact and indicators of difficult intubations in the neonatal intensive 2017;317(5):483-493.
care unit: a report from the National Emergency Airway Registry 41. Sun Y, Lu Y, Huang Y, Jiang H. Pediatric video laryngoscope versus
for Neonates. Arch Dis Child Fetal Neonatal Ed. 2019;104(5):F461 direct laryngoscope: a meta-analysis of randomized control trials.
-F466. Pediatric Anesth. 2014;24:1056-1065.
30. Matettore A, Ramnarayan P, Jones A, et al. Adverse tracheal in- 42. Volz S, Stevens TP, Dadiz R. A randomized controlled trial: does
tubation-associated events in pediatric patients at nonspecialist coaching using video during direct laryngoscopy improve residents'
centers: a multicenter prospective observational study. Pediatr Crit success in neonatal intubations? J Perinatol. 2018;38(8):1074-1080.
Care Med. 2019;20(6):518-526. 43. O'Shea JE, Thio M, Kamlin CO, et al. Videolaryngoscopy
31. Gabrani A, Kojima T, Sanders RC Jr, et al. National emergency air- to teach neonatal intubation: a randomized trial. Pediatrics.
way registry for children (NEAR4KIDS) collaborators and pediatric 2015;136(5):912-919.
acute lung injury and sepsis investigators (PALISI). Downward trend 44. Binks MJ, Holyoak RS, Melhuish TM, et al. Apnoeic oxygenation
in pediatric resident laryngoscopy participation in PICUs. Pediatr during intubation in the intensive care unit: a systematic review and
Crit Care Med. 2018;19(5):e242-e250 meta-analysis. Heart Lung. 2017;46:452-457.
32. ACGME Program Requirement for Graduate Medical Education in 45. Oliveira LJ, Cabrera D, Barrionuevo P, et al. Effectiveness of apneic
Pediatrics. Editorial revision, effective, July 1, 2019. https​://www. oxygenation during intubation: a systematic review and meta-anal-
acgme.org/Porta​ls/0/PFAss​ets/Progr​amReq​uirem​ents/320_Pedia​ ysis. Ann Emerg Med. 2017;70:483-494.
trics_2019.pdf?ver=2019-06-18-155134-967. Accessed December 46. Semler MW, Janz DR, Lentz RJ, et al. Randomized trial of apneic
15, 2019 oxygenation during endotracheal intubation of the critically ill. Am J
33. Falck AJ, Escobedo MB, Baillargeon JG, et al. Proficiency of pe- Resp Crit Care Med. 2016;193(3):273-280.
diatric residents in performing neonatal endotracheal intubation. 47. Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygen-
Pediatrics. 2003;112(6 Pt 1):1242-1247. ation was associated with decreased desaturation rates during
34. Bismilla Z, Finan E, McNamara PJ, et al. Failure of pediatric and neo- rapid sequence intubation by an Australian helicopter emergency
natal trainees to meet Canadian Neonatal Resuscitation Program medicine service. Ann Emerg Med. 2015;65(4):371-376.
standards for neonatal intubation. J Perinatol. 2010;30:182-187. 48. Mort TC, Waberski BH, Clive J. Extending the preoxygenation pe-
35. Downes KJ, Narendran V, Meinzen-Derr J, McClanahan S, Akinbi riod from 4 to 8 mins in critically ill patients undergoing emergency
HT. The lost art of intubation: assessing opportunities for residents intubation. Crit Care Med. 2009;37(1):68-71.
to perform neonatal intubation. J Perinatol. 2012;32(12):927-932.
36. Tarquinio KM, Howell JD, Montgomery V, et al. Current medication
practice and tracheal intubation safety outcomes from a prospec-
How to cite this article: Fiadjoe J, Nishisaki A. Normal and
tive multicenter observational cohort study. Pediatr Crit Care Med.
2015;16(3):210-218.
difficult airways in children: “What’s New”—Current evidence.
37. Stricker PA, Gurnaney HG, Litman RS. Anesthetic manage- Pediatr Anesth. 2020;30:257–263. https​://doi.org/10.1111/
ment of children with an anterior mediastinal mass. J Clin Anesth. pan.13798​
2010;22(3):159-163.