Airway Management in Children

  • Britta von Ungern-SternbergEmail author
  • Craig Sims


The potential difficulties in airway management in children discourage many anesthetists from caring for children in their practice. Airway management must be adapted to anatomical changes and variation in patient size, and the anesthetist must have skills to quickly establish ventilation because children desaturate quickly during apnea. For these reasons, airway and respiratory complications are the commonest cause of morbidity and mortality in children without cardiac malformations. Facemask ventilation is the most important skill to learn during training, along with continuous positive airway pressure support (CPAP). The LMA has become very popular for use in children because it frees up the anesthetist’s hands, while avoiding intubation of the frequently irritable tracheobronchial tree. While many new supraglottic airway devices are available in pediatric sizes, none is consistently superior to the LMA. The cuffed ETT has become standard practice, but there are important differences in design between manufacturers. The videolaryngoscope is useful for routine intubation of infants, and is a better choice than the direct laryngoscope in children with an expected difficult airway. Laryngospasm occurs from time to time in pediatric anesthesia, and needs to be managed quickly and effectively. Although deepening anesthesia with propofol is a useful early strategy, suxamethonium remains the best treatment once hypoxia has developed. Children can have difficult airways for many reasons. Difficult ventilation and intubation are managed following similar paths to adults. Infants with difficult airways are at high risk from complications and need care in a specialist center.


Upper airway, child Upper airway obstruction in pediatric anesthesia Pediatric endotracheal tube Supraglottic airways in children Pediatric difficult airway Laryngospasm, management Cuffed tracheal tubes for children 

Further Rewading

Anatomy and General Management

  1. Holzki J, et al. 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. Pediatr Anesth. 2018;28:13–22. An advanced description discussing recent debate about the shape of the cricoid cartilage and narrowest point of a child’s airway.CrossRefGoogle Scholar
  2. Karsli C. Managing the challenging pediatric airway. Can J Anesth. 2015;62:1000–16.CrossRefGoogle Scholar
  3. Schmidt AR, Weiss M, Engelhardt T. The paediatric airway: basic principles and current development. Eur J Anaesthesiol. 2014;31:293–9.CrossRefGoogle Scholar
  4. Sims C, von Ungern-Sternberg BS. The normal and challenging pediatric airway. Pediatr Anesth. 2012;22:521–6.CrossRefGoogle Scholar

Airway Obstruction

  1. Pfleger A, Eber E. Management of acute severe upper airway obstruction in children. Paediatr Respir Rev. 2013;14:70–7.CrossRefGoogle Scholar

Airway Equipment

  1. Bailey CR. Time to stop using uncuffed tracheal tubes in children? Anaesthesia. 2018;73:147–50.CrossRefGoogle Scholar
  2. Drake-Brockman TFE, et al. The effect of endotracheal tubes versus laryngeal mask airways on perioperative respiratory adverse events in infants: a randomised controlled trial. Lancet. 2017;389(10070):701–8.CrossRefGoogle Scholar
  3. Jagannathan N, et al. An update on newer pediatric supraglottic airways with recommendations for clinical use. Pediatr Anesth. 2015;25:334–45.CrossRefGoogle Scholar
  4. Kemper M, et al. Tracheal tube tip and cuff position using different strategies for placement of currently available tubes. Br J Anaesth. 2018;121:490–5.CrossRefGoogle Scholar
  5. Mihara T, et al. A network meta-analysis of the clinical properties of various types of supraglottic airway device in children. Anaesthesia. 2017;72:1251–62.CrossRefGoogle Scholar
  6. Norskov AK, et al. Closing in on the best supraglottic airway for paediatric anaesthesia? Anaesthesia. 2017;72:1167–84.CrossRefGoogle Scholar
  7. Shmidt AR, Weiss M, Engelhardt T. The paediatric airway. Basic principles and current developments. Eur J Anaesthesiol. 2014;31:293–9.CrossRefGoogle Scholar
  8. Thomas-Kattappurathu G, et al. Best position and depth of anaesthesia for LMA removal in children. Eur J Anaesthesiol. 2015;32:624–30. An RCT that gives a good way in to the literature about removal of LMAs.CrossRefGoogle Scholar
  9. Xue F, et al. Paediatric video laryngoscopy and airway management: what’s the clinical evidence? Anaesth Crit Care Pain Med. 2018;37:459–66.CrossRefGoogle Scholar

Intubation Without Relaxants

  1. Julien-Marsollier F, et al. Muscle relaxation for tracheal intubation during paediatric intubation: a meta-analysis and trial sequential analysis. Eur J Anaesthesiol. 2017;34:550–61.CrossRefGoogle Scholar
  2. Morton NS. Tracheal intubation without neuromuscular blocking drugs in children. Pediatr Anesth. 2009;19:199–201. Editorial for:; and against: Scholar


  1. Orliaguet GA, et al. Case scenario: perianesthetic management of laryngospasm in children. Anesth Analg. 2012;116:458–71. A well written description of management options of laryngospasm in a 10 month old.CrossRefGoogle Scholar

Difficult Airway

  1. Aziz M. Big data, small airways, big problems. Br J Anaesth. 2017;119:864–6. Editorial nicely summarising information in article from PediRegistry of difficult airways.CrossRefGoogle Scholar
  2. Black AE, et al. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Pediatr Anesth. 2015;25:346–62.CrossRefGoogle Scholar
  3. Doherty C, et al. Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia. 2018;73:1400–17.CrossRefGoogle Scholar
  4. Jagannathan N, Sohn L, Fiadjoe JE. Paediatric difficult airway management: what every anaesthetist should know! Br J Anaesth. 2016;117(S1):i3–5.CrossRefGoogle Scholar
  5. Long E, et al. Implementation of the NAP4 emergency airway management recommendations in a quaternary-level pediatric hospital. Pediatr Anesth. 2017;27:451–60. Describes the Melbourne Children’s difficult airway algorithm, including their Plan ABCD approach to CICO.CrossRefGoogle Scholar
  6. Park R, et al. The efficacy of GlideScope videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. Br J Anaesth. 2017;119:984–93. An important, multicenter data registry showing direct laryngoscopy is a poor choice for children with known difficult airways.CrossRefGoogle Scholar


  1. APAGBI Paediatric Airway Guidelines. Accessed July 2019.
  2. Sabato SC, Long E. An institutional approach to the management of the ‘can’t intubate, can’t oxygenate’ emergency in children. Pediatr Anesth. 2016;26:784–96. A well written, comprehensive review of techniques with recommendations for children.CrossRefGoogle Scholar

High Flow Nasal Oxygen

  1. Humphreys S, et al. Transnasal humidified rapid-insufflation ventilator exchange (THRIVE) in children: a randomized controlled trial. Br J Anaesth. 2017;118:232–8.CrossRefGoogle Scholar
  2. Riva T, et al. Transnasal humidified rapid insufflation ventilatory exchange for oxygenation of children during apnoea: a prospective randomised controlled trial. Br J Anaesth. 2018;120:592–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Anaesthesia and Pain ManagementPerth Children’s HospitalNedlandsAustralia
  2. 2.Medical School, The University of Western AustraliaPerthAustralia

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