Seminars in Fetal and Neonatal Medicine 28 (2023) 101483

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Seminars in Fetal and Neonatal Medicine

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The neonatal airway

Toby Kane a, David G. Tingay b, c, d, *, Anastasia Pellicano d, e, Stefano Sabato a, f
a
Department of Anaesthesia and Pain Management, Royal Children’s Hospital, Parkville, Australia
b
Neonatal Research, Murdoch Children’s Research Institute, Parkville, Australia
c
Department of Paediatrics, University of Melbourne, Melbourne, Australia
d
Department of Neonatology, Royal Children’s Hospital, Parkville, Australia
e
Paediatric Infant Perinatal Emergency Retrieval, Royal Children’s Hospital, Parkville, Australia
f
Anaesthetics, Murdoch Children’s Research Institute, Parkville, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Safe and effective management of the neonatal airway requires knowledge, teamwork, preparation and expe­
Infant rience. At baseline, the neonatal airway can present significant challenges to experienced neonatologists and
Newborn paediatric anaesthesiologists, and increased difficulty can be due to anatomical abnormalities, physiological
Airway obstruction
instability or increased situational stress. Neonatal airway obstruction is under recognised, and should be
Airway management
considered an emergency until the diagnosis and physiological implications are understood. When multiple types
Supraglottis
Glottis of difficulties are present or there are multiple levels of anatomical obstruction, the challenge increases expo­
Subglottis nentially. In these situations, preparation, multi-disciplinary teamwork and a consistent hospital-wide approach
Trachea will help to reduce errors and morbidity.

1. Introduction 2.2. Head

Airway management in the neonate is a high-risk procedure. It is often
performed in challenging and stressful clinical situations. Even airway
management for elective surgery is associated with a higher risk of com­
plications compared with the older paediatric population [1–4]. This
chapter introduces core concepts in neonatal airway management, first
looking at the anatomical and physiological considerations of the neonatal
airway followed by a framework that outlines different types of airway
difficulties that may be encountered. The focus then shifts to the varying
presentations of neonatal airway obstruction and an approach to investi­
gation and diagnosis. Finally, this paper highlights the measures that can
be taken by a hospital to minimise risks and optimise the performance of
the airway management team. A more detailed discussion of the man­
agement of the neonatal difficult airway can be found in Chapter 8.
The neonate has a proportionally larger head, relative to body size, and
a larger occiput-to-face ratio [5]. This causes relative neck flexion and
predisposes the supine neonate to airway obstruction. In addition, posi­
tioning of the neonate for airway management is often suboptimal. This
may be due to the urgency of airway management in a setting such as the
delivery room, or due to the physical surroundings of the incubator and
other equipment in a neonatal intensive care unit (NICU) . If difficulty is
encountered, the position of the neonate must be checked and optimised
before further attempts are made. Options include raising the shoulders by
providing posterior support so that the head is in a neutral or mildly
extended position. Positioning also refers to the neonate’s position relative
to the person managing the airway. The bed should be at approximately
elbow height with the neonate positioned close to the edge of the bed.

2. Neonatal airway assessment

2.3. Upper airway
2.1. Airway anatomy
(i) Nasopharynx.
The airway should be considered as starting at the nares, ending at
the alveolus, and including all the anatomy in between. Neonates are preferential nose breathers and are therefore largely
reliant on patent nasal passages for adequate ventilation [6]. Any

* Corresponding author. Neonatal Research, Murdoch Children’s Research Institute, 50 Flemington Rd, Parkville Victoria 3052, Australia.
E-mail address: david.tingay@mcri.edu.au (D.G. Tingay).

https://doi.org/10.1016/j.siny.2023.101483

Available online 18 November 2023

1744-165X/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
T. Kane et al. Seminars in Fetal and Neonatal Medicine 28 (2023) 101483

reduction in diameter of the nares due to secretions or inflammation can
lead to a dramatic increase in work of breathing [6]. This is largely an
issue that affects the neonate whilst feeding although it can cause dif­
ficulties during mask ventilation, and care should be taken to ensure an
open mouth and unobstructed oral airway.
recently, new studies suggest that the neonatal larynx maybe more cy­
lindrical in shape and that the narrowest point of the airway is more
proximal than the cricoid cartilage [5].
2.4. Lower airway

(ii) Oropharynx. (i) Neck

The oropharynx consists of the tongue and palatal structures. The
neonatal tongue is large relative to the oral cavity and occupies more of the
posterior hypopharynx [5]. It is therefore a common source of airway
obstruction in the neonate. This is exacerbated by genetic conditions
featuring macroglossia such as Trisomy 21, Beckwith-Weidemann syn­
drome or conditions that cause abnormal positioning of the tongue in the
oropharynx (such as Pierre Robin sequence).
The neck of the neonate is proportionally short and composed of
mostly subcutaneous fat. This means the tissues can be externally
manipulated to try and enhance the proceduralist’s view of the larynx.
Care needs to be taken when using external manipulation and when
holding a mask on the neonate’s face to not obstruct the airway.
(ii) Trachea

(iii) Mandible The neonatal trachea is shorter, narrower and is positioned higher in
the neck compared with the adult trachea. This increases the risk of
Retrognathia (recessed position of the mandible) and micrognathia endobronchial intubation.
(reduced size of the mandible) can lead to airway obstruction, particularly
at the base of tongue as the tongue is pushed more posteriorly in the
2.5. Physiological differences
oropharynx [6,7]. Micrognathia is a key feature of Pierre Robin sequence
and Treacher Collins syndrome, both of which present significant chal­
Neonates have significant physiological differences compared with
lenges in airway management [8]. Evaluation of the size and position of the
older children and adults which impact airway management. Neonates
mandible is crucial in the preoperative assessment of the neonatal airway.
have a lower functional residual capacity (FRC) due primarily to an
imbalance between the inward and outward forces acting on the chest
(iv) Larynx
wall. The outward recoil of the chest wall is decreased due to a compliant
rib cage, whilst the inward recoil of the lung is only mildly reduced [5,7].
The larynx is made up of the hypopharynx, glottis and subglottis. The
Neonates attempt to preserve FRC by using “laryngeal braking”, whereby
hypopharynx encompasses structures seen during intubation including
laryngeal adductor muscles restrict exhalation [9,12]. Lung volumes and
the epiglottis, arytenoids, aryepiglottic folds and the false vocal folds.
FRC are further affected by the relatively larger size of the abdominal
The glottis refers to the true vocal folds and the subglottis refers to the
organs leading to an elevated diaphragm position compared with older
area immediately below the glottis to the edge of the cricoid cartilage.
children [7]. Perhaps most relevant to airway management is the higher
The neonatal epiglottis is proportionally longer, narrower and less
oxygen consumption of the neonate (6–8 vs 4–6 ml/kg/min) compared
flexible than that of older children and adults, and is often described as
with adults, and a higher minute ventilation to FRC ratio [6]. This leads to
omega shaped [6]. Management of the epiglottis during intubation will
rapid desaturation if airway patency and oxygenation are not maintained.
differ based on choice of laryngoscope blade. A straight Miller laryngo­
Neonates are also different to older children in their response to laryngeal
scope is designed to directly lift the epiglottis whereas a curved Macintosh
stimulation. Protective mechanisms such as coughing and swallowing are
laryngoscope is designed to be placed anteriorly to the epiglottis in the
immature and inconsistent. Laryngeal irritation can lead to central apnoea,
valleculae and indirectly lift the epiglottis. The arytenoid cartilages and
laryngospasm and bradycardia [5,9,10].
aryepiglottic folds are proportionally larger than the glottis and this can
make visualising the glottis more difficult. The neonatal larynx is located
higher in the neck relative to the cervical vertebrae [6] and the laryngeal 2.6. Assessment of the neonatal airway
inlet is angled more anteriorly toward the base of tongue [5]. The more
cephalad position of the larynx means that a straight laryngoscope blade Each neonate should be thoroughly examined prior to embarking on
may provide a better view than curved blade [9,10]. airway management. A history and examination of each patient should
A systematic review by Holzki et al. in 2018 concluded from autopsy aim to highlight any concerning anatomical or physiological features that
studies that the infant larynx is cone or funnel shaped with the narrowest may impact choice of equipment or methods used. Often airway assess­
point being the circumferential cricoid cartilage [11]. However, more ment focuses solely on markers of difficult intubation but care should be
taken to also assess potential problems with bag mask ventilation and

Fig. 1. Graphical representation of the direct laryngoscopy views of the four airway grades using the Cormack-Lehane grading system (including Grade 2a and 2b)
[18]. Images reproduced with permission from Dilon Technologies, Newport News, VA, USA
The grades are defined by the structures seen as follows:
● Grade 1 - The entirety of the vocal cords.
● Grade 2a - Only a partial view of the vocal cords.
● Grade 2b - Only the arytenoid cartilages or posterior origins of vocal cords.
● Grade 3 - Only the epiglottis.
● Grade 4 - Only the soft palate.

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T. Kane et al.
rescue techniques such as a supraglottic airway. A history should focus on
relevant comorbidities, syndromes or congenital anomalies and a review
of previous intubations in the medical record. Having a thorough under­
standing of how a particular syndrome or congenital anomaly affects
airway management is an essential part of planning [13].
Recently published consensus guidelines from the European Society
of Anaesthesiology and Intensive Care and The British Journal of
Anaesthesia on airway management in neonates and infants state that
there is “no evidence supporting or refuting the use of physical assess­
ment to predict difficult airway management in neonates and infants”
[14]. Moreover, there are no validated tools or summative assessments
for use in neonates and infants as there are in adults. However, clinician
experience and retrospective studies have identified some physical risk
factors for a difficult airway in neonates and infants. These include ab­
normalities of the mandible, limited mouth opening, facial asymmetry,
reduced neck movement, cleft lip/palate, masses of the mouth and neck
and weight <1500g [15–17]. Examination should therefore include an
assessment of mouth and tongue size, the position and size of the
mandible, any dysmorphic facial features, and neck position. Examina­
tion should also include an assessment of cardiovascular and respiratory
reserve as this may impact choice of drugs and adjuncts to airway
management such as nasal high-flow therapy. If airway management is
time critical, an assessment of mandible size and position is crucial as it
may impact choice of operator, laryngoscope and intubation technique.
2.7. Grade of airway
The Cormack-Lehane grading system describes the best view of the
larynx that is obtained with direct laryngoscopy and external laryngeal
manipulation (Fig. 1) [18]. The grading system allows for accurate
documentation of the difficulty of laryngoscopy to facilitate communica­
tion and handover between staff, and to inform future laryngoscopy and
intubation. In neonatal and paediatric practice in particular, this docu­
mentation should include the laryngoscope blade used to obtain the view.
The Cormack-Lehane system should not be applied when using a
video laryngoscope. Instead, the view obtained should be documented
as the percentage of glottic opening (POGO) seen. As with direct
laryngoscopy, the type and size of blade type used should be docu­
mented as well as any adjuncts to intubation such as a bougie or stylet.
3. Preparation for airway management
3.1. Types of difficult airways
The term “difficult airway” is commonly used but not specific. Better use
of language will focus the team on the airway problems of the individual
patient, and facilitate appropriate diagnosis and management (Table 1).
Difficult laryngoscopy is defined as an experienced intubator achieving at
best a Grade 3 or 4 view of the larynx despite optimal positioning of the
patient, and the application of external laryngeal manipulation. Difficult
laryngoscopy can have many causes including limited mouth opening,
micrognathia, and anatomical distortion due to infection and masses. In
paediatric and neonatal practice, when difficult laryngoscopy is encoun­
tered, ventilation and oxygenation are usually still possible via facemask, or
a supraglottic airway, combined with the application of positive airway
pressure [19]. However, patients at risk of difficult ventilation and
oxygenation must be identified prior to initiating airway management as
these are the patients that are most at risk of death. Difficult ventilation due
to a functional problem such as laryngospasm or bronchospasm usually
resolves with appropriate and timely management. Difficult ventilation
caused by abnormal anatomy is an emergency. Risk factors for difficult
face-mask ventilation include weight <5th percentile for age,
Treacher-Collins syndrome, glossoptosis, and limited mouth opening [9].
The hardest airways to manage occur when multiple different diffi­
cult airway types are present at the same time, and when airway
obstruction occurs concurrently at multiple anatomical locations. For
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Seminars in Fetal and Neonatal Medicine 28 (2023) 101483
example, a retrieval of neonate with respiratory distress syndrome from
a regional centre represents a situationally difficult airway, and physi­
ologically difficult airway. A neonate with micrognathia and a subglottic
stenosis is an example of multi-level airway obstruction.
4. Approach to airway management of a Neonate
A detailed approach to equipment and management of a difficult
neonatal airway is provided in Chapter 8. A consistent approach to
airway management reduces errors and morbidity. Appropriate prepa­
ration, planning, and establishment of escalation pathways to obtain
expert assistance are essential. Preparation involves a holistic assess­
ment of the situation and is the most important aspect of airway man­
agement. In many situations, temporising measures to stabilise the
airway such as a nasopharyngeal airway, CPAP and positioning may
allow more time for preparation and to assemble a team.
Video laryngoscopy is rapidly becoming the standard of care for all
Table 1
Examples of difficult airway types.
● Functional difficult airway: Airway obstruction that can manifest quickly
and resolve with management:
○ Laryngospasm
○ Upper airway obstruction from nasal secretions, the base of tongue, palate,
and pharyngeal soft tissues
○ Tracheobronchomalacia
● Neonatal “difficult” airway: Compared with children, neonates have a higher
morbidity during airway management, especially if premature or <1500g
[1–4,17].
● Physiologically difficult airway: The literature on difficult airways has
traditionally focused on anatomical difficulties, and to a lesser extent on
functional difficulties. More recently the concept of the physiologically
difficult airway has emerged [20]. Patients at risk of imminent cardiovas­
cular or respiratory collapse have a higher incidence of airway problems,
major organ failure, and arrest during the intubation procedure due to the
effect of the anaesthetic or sedative agents, the effect of positive pressure
ventilation [24,25], or a delay in securing the airway resulting in worsening
hypoxaemia [21]. If a physiologically difficult airway is identified, then
thorough resuscitation prior to intubation should be undertaken, the airway
should be managed by the most experienced available staff.
● Situationally difficult airway: Crisis management in an unfamiliar environ­
ment can contribute to a reduced performance by the staff involved due to
human factor errors. A staff member who is new to a hospital can easily
experience stress due to the cognitive overload that the unfamiliar location
presents. Also, many different teams working together can create a chaotic
environment despite the best intentions of all involved. An example of this
type of situation could be neonatal airway management during an EXIT
procedure. When operators are stressed by excess noise, unfamiliar faces,
and chaotic environments, the resultant increase in sympathetic nervous
system tone adversely affects concentration, decision making, and fine
motor skills [22,23].
● Anatomically difficult airway: Difficult laryngoscopy and or difficult venti­
lation due to congenital airway abnormality or acquired airway pathology.
Anatomically difficult airways are certainly the hardest airways to manage
and therefore dominate the airway literature. However, they are in fact
relatively rare compared with the other types of airways listed above.
Airway obstruction can occur at any level of the airway (Fig. 1). Difficult
airway anatomy at one level of the airway presents a significant challenge,
but when airway obstruction occurs at multiple levels the challenge in­
creases exponentially.
Difficult Airway Type Example
Functional Difficult Laryngospasm
Airway
Neonatal Difficult airway Extremely preterm infant
Physiologically Difficult Septic shock with indirect neonatal acute respiratory
airway distress syndrome
Situationally Difficult EXIT procedure
airway
Anatomically Difficult Micrognathia
airway
T. Kane et al.
intubations, and is recommended when difficulty is anticipated [14].
Video laryngoscopy is discussed in more detail in Chapter 4.
Plans should include the next steps if the initial intubation attempt is
unsuccessful. Each successive attempt must involve a change, rather than
simply repeating what has not worked previously [26]. Examples of man­
agement change include: changing the position of the patient, changing the
person performing the intubation, and changing the equipment used.
Particularly difficult cases benefit from a multi-disciplinary team involving
neonatology, otolaryngology, anaesthesiology and retrieval services. Chal­
lenging anatomy warrants the availability of, and the expertise to use,
advanced intubating equipment such as hyperangulated blade video­
laryngoscopy and flexible fibreoptic/video intubating bronchoscopes.
Before any neonatal airway management is undertaken, the team
should be familiar with the hospital’s intubation algorithm. The roles of
each team member should be specified before commencement. An indi­
vidual should be designated to ensure that the team adheres to the
Fig. 2. Neonatal airway obstruction by anatomical location and associated causes. *Indicates most common cause of obstruction at that anatomical location. Italics
represents acquired causes. Image courtesy of Creative Studios, Royal Children’s Hospital, Melbourne, Australia.
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Seminars in Fetal and Neonatal Medicine 28 (2023) 101483
algorithm, and does not succumb to fixation error. Fixation error is a
human factor that can manifest itself during stressful situations [27].
During airway management, common fixation errors include persisting
with an unsuccessful intubation attempt, resulting in prolonged desatura­
tion and hypoxaemia. Fixation error can also lead to the intubator believing
they have successfully placed the endotracheal tube despite the lack of
chest rise and fall with the administration of positive pressure ventilation,
and the lack of capnography or colorimetric carbon dioxide confirmation.
5. Presentation of neonatal airway obstruction
Due to the unique anatomical and physiological aspects of the
neonatal airway, obstruction is relatively common [28–30]. Airway
obstruction presents in different ways depending on the location and
cause (Fig. 2). There is no standardised approach to defining the
anatomical airway levels, and terminology varies in the literature [7,11,
T. Kane et al. Seminars in Fetal and Neonatal Medicine 28 (2023) 101483

28,30,31]. For the purpose of this review, the anatomical level of
obstruction is classified as either: supraglottic (nasopharyngeal,
oropharyngeal and hypopharyngeal), glottic, subglottic, tracheal or
within the distal respiratory tree. A structured approach to history, ex­
amination and investigation is critical in assessing the neonatal airway,
and in most cases the level of suspected obstruction can be localised
prior to imaging [32].
Neonatal airway obstruction should be considered an emergency
until the diagnosis and physiological implications are understood. This
is because for many types of neonatal airway obstruction, intubation
may be difficult and require an experienced operator (including anaes­
thesiology and/or otolaryngology staff) [32]. Temporising measures to
maintain airway patency without intubation, such as nasopharyngeal
airways, laryngeal masks, continuous positive airway pressure (CPAP)
and positioning, are often possible and usually preferable when appro­
priate staff and equipment are not available.
Assessment of neonatal airway obstruction includes evaluating.
1) The timing of onset of obstruction
2) The presence, pattern and characteristics of abnormal breathing
noises
3) The nature of the infant’s cry and any respiratory symptoms
4) The presence of associated feeding difficulties
5) Anomalies of other systems, especially cardiovascular, neurological
and gastrointestinal.
Table 2 describes the clinical features of different causes of neonatal
airway obstruction by location.
5.1. Onset of obstructive features
Onset of signs of obstruction at birth usually indicates a congenital
pathology, such as laryngeal web, tracheal or subglottic stenosis, or
vocal cord palsy related to birth trauma [7,30,33,34]. History should
focus on perinatal factors that may indicate a cause, including reduced
fetal movements, fetal distress, polyhydramnios, mode and difficulty of
delivery and any delivery interventions [6,30]. Congenital anomalies
may be identified on antenatal ultrasound, including cleft palate,
mid-face hypoplasia, craniosynostosis and cardiac abnormalities.
Onset from birth with a history of birth trauma usually indicates
vocal cord palsy secondary to injury to the recurrent laryngeal nerve
[30,31]. Following birth trauma, unilateral vocal cord palsy is more
common than bilateral [35]. Left vocal cord palsy is more common than
right due to the more tortuous and longer path of the left recurrent
laryngeal nerve. Idiopathic unilateral vocal cord palsy may also be due
to cardiovocal syndrome [29,30]. Bilateral vocal cord palsy may be
idiopathic or related to a central nervous system cause such as asphyxia,
hydrocephalus, cerebral migration disorders, or Arnold Chiari malfor­
mation. Aspiration, swallowing difficulties and respiratory distress are
common with bilateral vocal cord palsy and many infants will require
early CPAP support [30].
Onset of airway obstruction after birth is more likely to be related to
an acquired cause (such as infection) or an evolving aetiology including
laryngomalacia, haemangioma or other mass, macroglossia (including
Beckwith-Wiedemann Syndrome or Trisomy 21) and base of tongue
obstruction secondary to retrognathia and/or micrognathia (including
Pierre Robin sequence) [29,30,34,36].
5.2. Presence, pattern and characteristics of abnormal breathing noises
Abnormal breathing noises should be assessed based upon the type of
noise, pattern and timing within the respiratory cycle and association
with activities [31]. Assessment of symptoms during both active and
settled behaviour, crying and normal tidal ventilation, and in different
positions is essential. Asking the parents to record a video of the
breathing noises can be helpful. Abnormal breathing noises can be
classified as stertor, stridor and wheeze.
Stertor is a low-pitched snoring-like noise caused by coarse turbulent
gas flow that is usually present in inspiration and associated with partial
nasopharyngeal or oropharyngeal obstruction [30].
Stridor is a high-pitched vibratory noise, often having a musical
quality, that can occur in any phase of the respiratory cycle. It is the most
common abnormal breathing noise in neonates [29,33] and is caused by
the turbulent flow of gas through a narrow airway. In the neonate,
stridor most commonly has a congenital origin [34]. Stridor indicates an
airway abnormality at the hypopharyngeal level or lower [31]. As
resistance of gas flow is inversely related to the fourth power of the
radius, minor changes in the calibre of small airways of the neonate will
have a greater impact on the quality of gas flow, compared with children
and adults. Further, in a narrow airway, the forward pressure of gas flow
creates a relatively large compressive lateral pressure. This results in
lateral airway collapse when airway support (such as cartilage) is
limited, especially in inspiration. Hypopharyngeal obstruction is most
susceptible to lateral airway collapse, explaining the classical

Table 2
Clinical features of neonatal airway obstruction.
Level of airway Pattern of Respiratory Noises Cry Cough Dysphagia Example
obstruction
Type Phase Worse With?

Crying Position Activity or

Feeding

Nasopharyngeal Stertor Inspiratory No, may Supine Yes Normal Rare Variable Choanal atresia
improve
Oropharyngeal Stertor or Inspiratory Yes Supine Yes Muffled Nil Variable ± choking Pierre Robin
nil or Normal sequence
Hypopharyngeal Stridor Inspiratory Yes Supine Yes Normal Occasionally Variable ± choking Laryngomalacia
Glottic Stridor Inspiratory or Yes Supine Yes Hoarse/ Weak/absent Yes ± aspiration Vocal cord palsy
Biphasic (improved absent
sleeping)
Subglottic Stridor Inspiratory or Yes Supine Yes Normal Nil Variable feeding Subglottic stenosis
Biphasic and incoordination
Prone
Tracheal Stridor Biphasic or Yes Supine Yes Normal Barking Variable depending Tracheomalacia
expiratory (respiratory and on cause (± fistula)
distress) Prone
Distal Respiratory Wheeze Expiratory Yes Supine Yes Normal Wet and Variable depending Bronchomalacia
System or Stridor (respiratory and brassy on associated infection
distress) Prone respiratory distress

The supraglottis refers to all parts of the airway above the glottis including the nasopharyngeal, oropharyngeal and hypopharyngeal.

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T. Kane et al.
inspiratory stridor. The subglottis, glottis and trachea have greater
cartilaginous support and obstruction is associated with stridor
throughout the respiratory cycle.
The most common cause of stridor in the neonate is laryngomalacia
(60–75 %) [29,34,37]. The site of obstruction is hypopharyngeal. Lar­
yngomalacia is classically worse during crying, awake activity and su­
pine positioning [37], exemplifying the importance of understanding
the relationship between abnormal airway noises and neonatal activ­
ities. Oropharyngeal obstruction is also worse in the supine position,
especially when related to micrognathia and/or glossoptosis [30]. Su­
pine position causes the tongue to fall back into the oropharynx which
leads to increased work of breathing. This in turns results in greater
negative intra-pharyngeal pressure and inferior retraction of the tongue,
creating a cycle of anatomical and physiological obstruction. Nasopha­
ryngeal obstruction is often worse with feeding and the supine position,
improving with crying when airflow occurs through the mouth.
A wheeze is a musical high-pitched adventitious sound originating
from the airways below the larynx. Although more common in expira­
tion, wheeze can occur throughout the respiratory cycle. Lower airway
obstruction is usually associated with a prolonged expiratory phase.
5.3. Nature of any associated respiratory symptoms
The characteristics of the cry are important in localising the level of
neonatal airway obstruction [29–31]. If the cry is hoarse or absent, the
obstruction is likely to be at the glottic or subglottic level. Aphonia is a
serious finding that indicates a glottic abnormality and a high risk of a
difficult airway at intubation. A weak cry may indicate oropharyngeal
obstruction, whereas a brassy cry is often tracheal or distal airway
related. Cough should be considered a serious finding as it may also
represent an impairment of central control, persistent reflux or incoor­
dination of swallowing or aspiration. Evidence of respiratory distress
should also be carefully assessed. In addition to non-specific features
such as use of accessory muscles, nasal flaring, head bobbing, grunting,
chest wall recession and tachypnoea, neck extension at rest is often a
subtle but important sign of severe upper airway obstruction.
Auscultation should include assessment of nasal airflow, with
patency of both nasal passages also evaluated by passing a nasogastric
tube. Careful, prolonged auscultation may be required to detect absent
air entry despite respiratory muscle effort, which is a key finding in
Fig. 3. Representative fibre-optic nasal endoscopic (FNE), microlaryngoscopic, or videolaryngoscopic views of supraglottic, glottic and subglottic causes of neonatal
airway obstruction. A. Normal anatomy, B. Laryngomalacia demonstrating tight aryepiglottic folds (arrow), C. Laryngomalacia, post release of aryepiglottic folds and
removal of excess arytenoid tissue, demonstrating the omega-shaped epiglottis, D. Laryngeal cleft (arrow), E. Vallecular cyst (arrow), F. Congenital glottic web, G.
Congenital subglottic stenosis, H. Foreign body. Images reproduced with permission of Dr Karen Davies (images A-G) and Dr Stefano Sabato (image H), Royal
Children’s Hospital, Melbourne, Australia.
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Seminars in Fetal and Neonatal Medicine 28 (2023) 101483
oropharyngeal obstruction (e.g. Pierre Robin sequence).
5.4. Associated feeding difficulties
Feeding difficulties can either present with acute features associated
with aspiration and reflux such as choking (vocal cord palsy, trache­
omalacia), impaired ability to feed due to increased work of breathing
(tracheomalacia, subglottic stenosis) or failure to thrive (oropharyngeal
obstruction) [30,31,36,38]. Failure to thrive is an underappreciated
feature of subacute neonatal airway obstruction, especially due to
oropharyngeal obstruction [8,39,40]. Obstruction-related failure to
thrive may be masked during enteral tube feeding.
5.5. Others
Many syndromic causes of neonatal airway obstruction have asso­
ciated congenital cardiac disease. Vascular rings may also be the direct
cause of tracheal or distal respiratory tree obstruction. 50% of subglottic
and/or tracheal haemangiomas will have associated skin haemangiomas
[41].
6. Investigations of a suspected neonatal airway obstruction
Investigations for suspected neonatal airway obstruction should be
guided by the clinical assessment of level of obstruction. The yield from
specific imaging and other investigations without a structural approach
is low.
Point of care ultrasound and fibre-optic nasal endoscopy (FNE) have
revolutionised the assessment of suspected neonatal airway obstruction.
Both allow assessment in the NICU during spontaneous breathing
without anaesthesia or sedation [33,42–45]. Oropharyngeal, hypo­
pharyngeal, glottic and, often, subglottic obstruction can be confirmed
with FNE (Fig. 3) [33,42–45] and/or ultrasound of the oropharynx,
vocal cords or neck [46,47]. These should be considered the first line
airway investigations of the neonate, if appropriately skilled staff are
available.
Some types of nasopharyngeal obstruction (such as pyriform aper­
ture stenosis and neonatal rhinitis) can also be diagnosed by FNE, but
often additional investigations are required based upon whether the
obstruction is believed to be bony (Computerised Tomography; CT) or
T. Kane et al. Seminars in Fetal and Neonatal Medicine 28 (2023) 101483

Fig. 4. An example of a hospital wide integrated emergency intubation algorithm for neonates and infants developed via a collaborative approach designed to be
applicable in all settings within a quaternary regional referral children’s hospital. Reproduced with permission The Royal Children’s Hospital, Melbourne, Australia.

7
T. Kane et al.
soft tissue (Magnetic Resonance Imaging). The need for additional
diagnostic information, such as inner ear development (CHARGE syn­
drome), may alter the choice of imaging. Oropharyngeal obstruction can
often be diagnosed clinically and may not require any further imaging
unless a tumour, abscess or lingual thyroid is suspected.
Subglottic, tracheal and distal respiratory system obstruction may
require a rigid bronchoscopy, CT bronchogram or, rarely, functional
contrast bronchogram. Chest radiography is rarely informative unless a
primary chest abnormality is present however persistent overdistension
may indicate subglottic or tracheal obstruction. Echocardiography is
indicated in any suspected obstruction below the glottis, or when a
higher airway level obstructive haemangioma is detected.
Once the level of obstruction is confirmed, a targeted approach to
investigating the cause with additional biochemical, endocrine, echo­
cardiography, other organ ultrasound and magnetic resonance imaging
can be undertaken. Many congenital causes of neonatal airway
obstruction have an underlying genetic diagnosis. Specific genetic in­
vestigations may be warranted as not all potential genetic conditions are
identified on standard genetic tests.
7. Approach to hospital wide collaborative integrated airway
management
A consistent uniform approach throughout a hospital creates a
shared mental model that encompasses all aspects of airway manage­
ment. A multidisciplinary team comprising neonatologists, intensive
care physicians, emergency physicians, anaesthesiologists, and otolar­
yngologists are the best group to develop a universal intubation algo­
rithm that is the foundation for the shared mental model (Fig. 4) [48,
49]. The algorithm can be used during education sessions, and to
orientate new staff. Cognitive aids used during emergent airway man­
agement should remind staff of the key aspects of the algorithm, and the
use of checklists can mitigate against errors of omission. The airway
group reviews equipment available for neonatal/paediatric airway
management, and identifies the best equipment for their hospital.
Standardisation of airway equipment throughout a hospital streamlines
the teaching and ensures staff are familiar with the available devices and
trained in their use. Standardisation of equipment between different
medical specialties, and different intubating locations throughout the
hospital, also adds valuable capacity in the event that a piece of
equipment is not immediately available due to recent use or malfunction
[50]. Interdepartmental and interdisciplinary team training involving
doctors and nurses from different departments reinforces the common
approach and facilitates healthy working relationships that allow staff to
perform at their best during a crisis. Training ideally consists of
pre-reading for courses, workshops with hands on mannikin practice
and simulation, and then supervised intubation of healthy neonates for
elective surgery before finally managing difficult or emergency neonatal
airways. These hospital-wide approaches are shown to reduce morbidity
in emergency paediatric intubations [51].
8. Conclusion
Airway management in the neonate is a high-risk procedure. It is
often performed under time pressure and significant stress. When mul­
tiple factors are present that increase the difficulty of the airway it is
imperative to ask for help. This situation is best managed by a multi­
disciplinary team including neonatology, anaesthesiology and otolar­
yngology. The neonatal airway is unique and more susceptible to
obstruction than that of older patients. Neonatal airway obstruction can
present at any level from the nose to the distal airways, may be acute or
chronic in presentation, and may involve more than one level. A struc­
tured clinical approach can diagnose the level in most infants. A hospital
wide approach to training, equipment, planning and management will
help to reduce errors, morbidity and stress for those involved.
8
Seminars in Fetal and Neonatal Medicine 28 (2023) 101483
9. Practice points
● Airway obstruction is more common in neonates than older children
and adults.
● A structured clinical approach to assessing neonatal airway
obstruction can usually determine the type and anatomical level.
● A difficult neonatal airway can be caused by functional, physiolog­
ical, situational and anatomical factors.
● When a difficult airway is present, seek multi-disciplinary help
(neonatology, anaesthesiology and otolaryngology).
● A hospital wide approach to training, equipment, planning and
management will help to reduce errors, morbidity and stress for all
those involved.
Author contributions
All authors contributed to the manuscript. TK and SS wrote the first
draft of all Sections except ‘Presentation of neonatal airway obstruction’,
‘Investigations of a suspected neonatal airway obstruction’ and ‘Con­
clusions’ (DGT). All authors contributed to redrafting the manuscript.
Funding
DGT is supported by a National Health and Medical Research Council
Leadership (Australia) Level 1 Investigator Grant (Grant ID 2008212).
The authors are supported by the Victorian Government Operational
Infrastructure Support Program (Melbourne, Australia).
Declaration of competing interest
The authors have no other competing interests to declare.
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