Airway management in infants and children

Airway management in children and infants, especially in those with a difficult airway, presents a major challenge for every anaesthesiologist, paediatrician, paediatric intensivist and emergency physician. The most important differences, as compared to adult airway management, result from the specific aspects of paediatric anatomy and physiology, which are more important to consider the younger the child is. A number of inherited and acquired pathological syndromes have significant impact on the airway management in this age group. During past years several new devices have been introduced into clinical practice, intended to improve airway management in this age group. Important new studies have gathered evidence about risks and benefits of certain confounding variables for airway problems and specific techniques for solving them.Several risk factors for airway-related problems during anaesthesia in children having a ‘cold’ have been identified, and the use of propofol in combination with the LMA is suggested if anaesthesia cannot be postponed in children with a recent upper airway infection. The use of cuffed endotracheal tubes appears to be advantageous in certain clinical situations, and may be safe in infants if the appropriate tube size is carefully determined and continuous monitoring of the cuff pressure is performed to avoid post-intubation tracheal stenosis. Promising novel video-assisted systems comprising appropriately sized and redesigned fibre-optic endoscopes have been introduced for the management of the difficult airway in small children, infants and even premature newborns. Today, the laryngeal mask airway is a well-accepted extra-tracheal airway device in paediatric anaesthesia, and the flexible LMA allows for its use during ENT and dental surgery procedures. However, LMA-associated partial obstruction of the airway in infants requires great caution when these devices are used in this age group. The recently introduced Proseal LMA for children may allow higher airway pressures and improved protection from gastric inflation, e.g. in paediatric ambulatory anaesthesia. The LMA may also serve well to guide the endoscope during fibre-optic intubation in children and infants.Prediction of the unexpected difficult airway in infants and children remains really difficult, as the respective screening systems have been developed in adults and are, for a variety of reasons, not applicable to young children and infants. A thorough determination of the individual risk of developing airway complications, as well as continuous attention to airway patency during the procedure, are prerequisites for reducing airway-related morbidity and mortality in children and infants during anaesthesia. Appropriate preparation of the available equipment and frequent training in management algorithms for all personnel involved appear to be very important.