Normal and Difficult Airways in Children: "What's New"- Current Evidence.

Pediatric 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 (OR), intensive care unit, Emergency Department, and neonatal intensive care unit.Expert review of the recent literature.Cognitive factors, teamwork and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated video laryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are however, substantial differences among video laryngoscopes particularly angulated vs. non-angulated 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 ICU, ED, and neonatal ICUs, adverse tracheal intubation associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the OR 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 OR. Similarly, a multicenter Neonatal ICU 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.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 ICU, ED, and Neonatology clinicians to improve the safety of airway management in all clinical settings.