Difficult Airway Management in Paediatrics

The aim of this algorithm is to offer 2 difficult intubation situations in a paediatric patient. In the first case  it is possible to try a protocol for the unexpected difficult intubation. The second one in an expected difficult intubation. Step by step and you can go throught the procedure for these clinicaly truly important situations.

airway management
predicted difficult airway
Published at: 22.5.2019


Pavel Herda, MD
Dept. of Anaesthesiology & Intensive Care, 1st Faculty of Medicine, Charles University in Prague; General University Hospital, Prague, Czech Republic

It is a well known medical fact, that the child should not be approached the same way as a shrunken adult would be. This is also true when speaking about the airway management. Specifics of paediatric airway securement are most noticeable in newborns and toddlers and they remain remarkable until the age of 6 to 7 years. Anatomical differences play the most important role. This applies, for example, to the difficulties with identification of the ligamentum conicum. The precise location of the thyroid cartilage is not easy to determine due the it’s shape and the morphology of children´s neck (that may be short and often impalpable). Other important distinction from adults is the size of the area, where the physician should perform BACT or coniotomy and the likelihood of traumatization of the wall of trachea and possibly of oesophagus. Apart from the structural dissimilarities, physiological and pathophysiological consequences, e.g. better tolerance of hypercapnia in children, should also be taken into account.1
This algorithm is well arranged in two branches of a predicted and an unpredicted difficult airway management situation based on everyday clinical practice.. To successfully go through this algorithm, it is absolutely essential to be familiar with the basics of the airway securement based in the VORTEX2 from the New Zeeland. Situations presented are rationally based and reflect the real-life medical practice. The physiological findings help to gain the overall understanding of the situations and the answers- both correct and incorrect- aim to familiarize the solver with the given issue. It is well understandable, that there are variations in preferred practices between different hospitals, based on the equipment available. For example, the paediatric ENT specialist with fibrooptics is not available in every hospital. It is important to note, that a catheter installation using the Seldinger technique and a connection to the mechanical ventilation, represents the best technique for surgical airway securement in newborns and toddlers. By using this approach we can avoid tracheal or oesophageal injury, which can happen during BACT or coniotomy. Characteristics of a given situation and specific needs of a patient should always be carefully considered.
It is surely an advantage to have the opportunity of working with a standardized procedure guidelines. Especially for the junior doctors this represents a recipe on how to act in stressful situation. The more experienced physicians can take these instructions as a basis and then adjust their actions according to specific patient´s needs.

  1. CHARLES J. COTÉ. Pediatric transtracheal and cricothyrotomyairway devices for emergency use: which are appropriate for infants and children?  ( Pediatric Anesthesia 2009 )
  2.  http://vortexapproach.org


BLACK, Ann, Paul FLYNN, Mansukh POPAT, Helen SMITH, Mark THOMAS and Kathy WILKINSON. Paediatric Difficult Airway Guidelines. In: Difficult Airway Society [online]. [cit. 2019-04-14]. Available at: https://das.uk.com/guidelines/paediatric-difficult-airway-guidelines


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