• John Fiadjoe and Akira Nishisaki.
• Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
• Paediatr Anaesth. 2020 Mar 1; 30 (3): 257-263.

BackgroundPediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit.MethodsExpert review of the recent literature.ResultsCognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each 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 department and neonatal intensive care units, adverse tracheal intubation-associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled 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 mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration.ConclusionClinicians 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.© 2019 John Wiley & Sons Ltd.

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