Received: 26 April 2019 | Revised: 30 July 2019 | Accepted: 6 August 2019

DOI: 10.1111/pan.13716

SPECIAL INTEREST ARTICLE

A framework for the management of the pediatric airway

Thomas Engelhardt1,2 | John E. Fiadjoe3 | Markus Weiss4 | Paul Baker5,6 |

Stephanie Bew7 | Piedad Echeverry Marín8 | Britta S von Ungern‐Sternberg9,10,11

1
Department of Anaesthesia, Royal
Children's Hospital Aberdeen and School Summary
of Medicine, University of Aberdeen, Critical airway incidents in children are a frequent problem in pediatric anesthesia
Aberdeen, UK
2 and remain a significant cause of morbidity and mortality. Young children are at
Department of Anesthesia, McGill
University Health Center, Montreal particular risk in the perioperative period. Delayed management of airway obstruc‐
Children's Hospital, Montreal, QC, CA
tion can quickly lead to serious complications due to the short apnea tolerance in
3
Department of Anesthesiology and
Critical Care Medicine, Children's Hospital
children. A simple, time critical, and pediatric‐specific airway management approach
of Philadelphia, Perelman School of combined with dedicated teaching, training, and frequent practice will help to reduce
Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
airway‐related pediatric morbidity and mortality. There is currently no pediatric‐spe‐
4
Department of Anaesthesia, University cific universal framework available to guide practice. Current algorithms are modifi‐
Children's Hospital, Zurich, Switzerland cations of adult approaches which are often inappropriate because of differences in
5
Consultant Anaesthetist, Starship
age‐related anatomy, physiology, and neurodevelopment. A universal and pragmatic
Children’s Hospital, Auckland, New Zealand
6
Department of Anaesthesiology, University approach is required to achieve acceptance across diverse pediatric clinicians, socie‐
of Auckland, Auckland, New Zealand ties, and groups. Such a framework will also help to establish minimum standards for
7
Department of Anaesthesia, Leeds
pediatric airway equipment, personnel, and medications whenever pediatric airway
Teaching Hospitals NHS Trust, Leeds, UK
8
Anestesióloga pediátrica, Miembro
management is required.
del comité de Anestesia Pediátrica,
Sociedad Colombiana de Anestesiología y KEYWORDS
Reanimación, Anestesióloga del Instituto airway, children, framework
Rooselvelt, Bogotá, DC, Colombia
9
Medical School, The University of Western
Australia, Perth, WA, Australia
10
Department of Anaesthesia and Pain
Management, Perth Children's Hospital,
Perth, WA, Australia
11
Telethon Kid's Institute, Perth, WA,
Australia

Correspondence
Thomas Engelhardt, Department of
Anaesthesia, Royal Children's Hospital
Aberdeen and School of Medicine,
University of Aberdeen, Aberdeen, UK.
Email: t.engelhardt@nhs.net

Funding information
Departmental Resources. BvUS is partly
funded by the Perth Children's Hospital
Foundation, the Stan Perron Charitable
Trust, and the Frank Callahan Estate

Editor: Mark Thomas

Pediatric Anesthesia. 2019;29:985–992. wileyonlinelibrary.com/journal/pan

© 2019 John Wiley & Sons Ltd | 985
986 | ENGELHARDT et al.
1 | I NTRO D U C TI O N
Critical airway incidents in children are a frequent problem in pedi‐
atric anesthesia1 and remain a significant cause of morbidity and
mortality. 2 Young children are at particular risk in the perioperative
period.3 Delayed management of airway obstruction can quickly
lead to serious complications due to the short apnea tolerance in
children. A simple, time critical, and pediatric‐specific airway man‐
agement approach combined with dedicated teaching, training,
and frequent practice will help to reduce airway‐related pediatric
morbidity and mortality.4 There is currently no pediatric‐specific
universal framework available to guide practice. Current algorithms
are modifications of adult approaches which are often inappropri‐
ate because of differences in age‐related anatomy, physiology, and
neurodevelopment. A universal and pragmatic approach is required
to achieve acceptance across diverse pediatric clinicians, societies,
and groups. Such a framework will also help to establish minimum
standards for pediatric airway equipment, personnel, and medica‐
tions whenever pediatric airway management is required.
2 | BAC KG RO U N D
Airway obstruction leads rapidly to profound hypoxemia, respira‐
tory acidosis, bradycardia, and ultimately cardiac arrest in children.
This is because children have a decreased oxygen reserve and in‐
creased oxygen consumption as well as higher carbon dioxide pro‐
duction when compared with adults.5,6 In general, neonates and
infants at particularly high risk7,8 as are children with significant
cardiopulmonary comorbidities and those undergoing emergency
procedures.9,10 Transient perioperative hypoxemia usually does not
result in immediate overt postoperative morbidity; however, long‐
term consequences remain largely unknown. Prolonged hypoxemia
and bradycardia increases the risk of cognitive and motor impair‐
ment in later life in preterm neonates.11
Reducing the incidence of hypoxia and bradycardia using “opti‐
mal” preoxygenation is difficult and on occasion impossible to per‐
form in awake children (particularly infants) without causing distress.
Even when successfully performed, preoxygenation may not result
in a sufficiently long period of normoxia to allow the airway to be
secured.12 Intermittent ventilation and oxygenation including “rapid
sequence inductions” is commonly required. Techniques to contin‐
uously oxygenate during airway management (such as high‐flow
humidified O2 via nasal cannula) should be considered in small chil‐
dren.13,14 “Modified” awake intubations with ORL/ENT support may
be required in appropriate situations.15,16
Timely, goal‐directed approaches are required to reestablish an
open airway and oxygenate and ventilate. Numerous published diffi‐
cult airway algorithms are available in various formats and languages
to guide practice. These are mostly coopted from adult algorithms
which are modified for children; their relevance is controversial, par‐
ticularly in younger children. Several pediatric anesthesia societies
and groups have published expert opinion‐based algorithms that are
often discordant. Nonanesthesiology specialties have also published
their own recommendations making it difficult for individual practi‐
tioners to identify the optimal approach.
A simple, universal, intuitive, and clear framework to manage
the pediatric airway that is easily adaptable to diverse clinical sit‐
uations and personnel may help guide clinical practice and reduce
complications.
3 | PR I N C I PLE A PPROAC H TO TH E
PE D I ATR I C A I RWAY
3.1 | Prevention of pediatric airway difficulties
Routine (daily best practice) pediatric airway management in healthy
(ASA‐PS 1 or 2) patients is easy for the trained and experienced
clinician.
Careful preanesthetic evaluation and clinical assessment and
recognition of possible signs and symptoms of airway obstruction
including apnea, stridor, wheeze, cyanosis, dyspnea, suprasternal
retractions, and use of accessory respiratory muscles will reduce
airway management‐related complications. Acute upper respiratory
tract infections may contribute to perioperative respiratory adverse
events.
A clear airway management plan including the knowledge of all
possible complications and their management is essential before
administering sedatives or inducing general anesthesia. This is best
achieved through regular practice, continuing medical education,
and simulation team training including human factors in an airway
crisis.
All equipment as well as resuscitation drugs should be prepared in
appropriate sizes or dosages and in working condition. Equipment in‐
cludes tracheal tubes and supraglottic airway devices, laryngoscope
blades, stylets, forceps, facemasks, nasopharyngeal and oropharyn‐
geal airways, self‐inflating ventilation bag permitting continuous pos‐
itive airway pressure (CPAP) and positive end‐expiratory pressure
(PEEP), suction devices, reliable oxygen source, and vascular access
equipment. All tools to establish a safe pediatric airway and to man‐
age possible complications must be ready for immediate use.
3.2 | General approach to the pediatric airway
A pragmatic classification of pediatric airway problems into 3 cat‐
egories determines the anesthetic approach:17
These categories are as follows:
• Normal airway (the child without history, sign, and symptoms for
a difficult airway)
• Impaired normal airway
• Abnormal or difficult airway.
The urgency of the clinical situation then dictates the necessary steps:
• Immediate intervention
ENGELHARDT et al.
• Mobilizing of best existing local expertise (which includes ORL/
ENT specialists or general surgeons)
• Careful planning and referral to a specialist pediatric center.
Children who present with an acutely impaired otherwise normal air‐
way or known difficult airway should be treated by an experienced cli‐
nician in an appropriately staffed and equipped pediatric setting unless
there is an immediate threat to life.18
Figure 1 outlines the general approach to a child that requires
anesthesia or sedation for surgery, interventional or diagnostic pro‐
cedures. It considers the child's airway, the facilities and expertise
of the department, and the urgency of the underlying clinical condi‐
tion. While it is impossible and beyond the scope of this framework
document to address all potential scenarios, the general underlying
principles of pediatric airway management are discussed below.
4 | FR A M E WO R K FO R TH E A PPROAC H TO
TH E PE D I ATR I C A I RWAY
4.1 | Principles
Pediatric airway management can be stressful for the inexperienced
clinician and may lead to poor decision‐making. 20 Good outcomes in
critical situations require a structured approach that is:
• Simple, intuitive, and forward only
• Easy to memorize and practice
• Open Box, that is, generally applicable and adaptable to all situa‐
tions including local resources and expertise.
A forward only, “step‐by‐step”, easy to memorize algorithm signifi‐
cantly reduces the cognitive load in a clinical crisis. It allows the clinician
to focus on the essential steps without distraction. The “Open‐Box”
approach allows the incorporation of local expertise and unique local
experiences. A solution incorporating these principles will be easily
adoptable across diverse pediatric specialists, specialties and societies.
F I G U R E 1 Flowchart for approaching the pediatric airway in a
child undergoing sedation or anesthesia for surgery, interventional
or diagnostic procedures [adopted from 19] [Colour figure can be
viewed at wileyonlinelibrary.com]
| 987
4.2 | Clear separation of airway problems
The ability to oxygenate and (facemask) ventilate saves lives and must
be prioritized over tracheal intubation. 21 Good basic airway manage‐
ment skills are essential. Fortunately, facemask ventilation is easy to
perform in experienced hands in the child with a normal airway. A
large cohort study reported successful oxygenation and ventilation
in all patients using either a facemask or a laryngeal mask airway. 2
Pediatric tracheal intubation is generally easy in healthy (ASA‐
PS 1 or 2) children but can be more challenging in infants (partic‐
ularly syndromic patients).4,18,22 There is no best equipment or
technique for all tracheal intubations. Continuing education, train‐
ing, and use of simulation scenarios with direct/videolaryngoscopic
techniques reduces associated complications. Repeated tracheal
intubation attempts may traumatize the pediatric airway and can
render a difficult tracheal intubation impossible or result in the in‐
ability to oxygenate and ventilate the patient. An alternative airway
technique should be used early. 2,4
4.3 | Recognize and treat airway obstruction
Airway obstruction is a common cause of anesthesia‐related perioper‐
ative hypoxemia and may occur at any time in the perioperative period.
To manage such a situation successfully, it is important to distinguish
between anatomical (mechanical) and functional causes of airway ob‐
structions which require different strategies of treatment17,21,22:
Call for help: It is essential that help and suitable assis‐
tance is sought at an early stage. This must be clearly
identified on a locally adapted algorithm including
emergency contact details and/or easy to access
technical alarm/call devices.
Anatomical/mechanical airway obstruction and functional airway
obstruction can occur at the same time. An anatomical/mechanical
airway obstruction is a physical obstruction of the airway and requires
the intervention of the clinician using basic and advanced airway
skills. Functional airway obstruction is generally treated with drugs as
mechanical interventions are mostly ineffective. Structured teaching
and training for managing functional airway obstruction is essential
since this is responsible for the majority of perioperative respiratory
complications.3,24
4.3.1 | Anatomical/mechanical airway obstructions
Anatomical and mechanical airway obstructions occur frequently
after induction of anesthesia in the unconscious patient and are usu‐
ally easy to resolve (Table 1).
Anatomical/mechanical airway obstructions: Must be recog‐
nized and treated by the clinician.
A combination of head‐tilt, chin‐lift, and/or jaw‐thrust while main‐
taining an open mouth are simple treatments employed in daily practice.
Alternatively, an appropriately sized oro‐ or nasopharyngeal airway will
988 | ENGELHARDT et al.

TA B L E 1 Airway obstruction during

Causes Treatment
anesthesia can generally be divided into
Anatomical/mechanical airway obstructions an anatomical (mechanical) or functional
Inadequate head position Repositioning, reopening obstruction

Large adenoids/ tonsils/ obesity Oropharyngeal/ nasopharyngeal airway

Difficult facemask technique
a
Blood, foreign body, secretions
Alveolar collapse (closing capacity)
Gastric hyperinflation/ distension
Functional airway obstructions
Inadequate depth of anesthesia
Laryngospasmb
Opioid‐induced muscle rigidity and/or vocal
cord closure
Bronchospasmc
Two hand/ two person technique
Suction, removal
Alveolar recruitment maneuvers
Decompression by an orogastric tube
Deepen anesthesia
Propofol, muscle relaxation
Muscle relaxation
Epinephrine, bronchodilators (sevoflurane)

Note: This distinction is important because treatments generally differ: Airway maneuvers and
adjuncts for the treatment of anatomical/ mechanical airway obstructions. Pharmacological inter‐
ventions for functional airway obstructions.
a
Preexisting copious secretions (upper respiratory tract infection) may benefit from a preinduction
anti‐sialagogue.
b
Minimal laryngospasm can initially be treated with jaw‐thrust and positive airway pressure.
c
Use epinephrine (titrate) in the periarrest situation.

relieve most upper anatomical airway obstructions. Forceful bag‐mask
ventilation may result in gastric distension (commonly not recognized by
inexperienced practitioners) which can impede ventilation/oxygenation
and requires prompt decompression using an orogastric tube. Effective
bag‐mask ventilation can be monitored using waveform capnography.
4.3.2 | Functional airway obstruction
Functional airway obstruction can occur in the upper and lower
airway.
Functional upper airway obstruction is common and usually
caused by insufficient depth of anesthesia (closure of pharynx), la‐
25
ryngospasm, or opioid‐induced glottic closure.
Functional lower airway obstruction is induced by broncho‐
spasm in children with recent respiratory tract infections, bron‐
chial hyperreactivity, or thoracic wall rigidity as a consequence of
rapid and/or high‐dose opioid administration. While minimal la‐
ryngospasm and loss of pharyngeal tone may initially be treated
using continuous positive airway pressure (good routine basic air‐
way management);
Severe Functional Airway Obstructions are treated with drugs.
Hypnotics such as propofol may be used early in otherwise
healthy, noncompromised children to overcome these acute func‐
tional airway problems such as insufficient depth of anesthesia and
severe laryngospasm. Careful hemodynamic monitoring is essential
as severe hypotension may ensue. Muscle relaxants can be used
early as an effective alternative to effectively overcome functional
airway obstruction in children with a normal airway with the ex‐
ception of bronchospasm. Care must be excercised in patients with
known distal airway obstruction.
Intravenous epinephrine starting with low doses (1 mcg/kg)
is highly effective to treat severe bronchospasm (“silent chest”).
Appropriately diluted intravenous epinephrine should be readily
available at all times.23
The early use of hypnotics and relaxants to overcome functional
airway obstruction instead of attempts to awaken the child is based
on the rational that the apnea tolerance in young children is too
small to safely overcome a “cannot oxygenate‐cannot ventilate” situ‐
ation.6,26-28 In addition, muscle relaxants should be used in the “can‐
not oxygenate‐cannot ventilate” situation before any attempts of
surgical airway such as emergency cricothyroidotomy, needle inser‐
tion or tracheostomy are to be considered as endorsed in adults. 29
Muscle relaxants overcome most functional airway obstruction per‐
mitting facemask/ laryngeal mask ventilation and improve tracheal
intubation conditions. 27,28,30
Patients with an expected or suspected difficult airway must
be treated by practitioners experienced in difficult pediatric airway
management and adequeate help sought before starting a procedure
(Figure 1).
4.4 | Universal approach
A universally accepted and implemented framework for the difficult
pediatric airway requires the recognition and use of local expertise,
resources, and facilities. The following simple, “Open‐Box” algorithms
can be adapted according to local expertise and facilities.
The algorithms are separated into:
• Oxygenation and ventilation
• Tracheal intubation.
ENGELHARDT et al.
While this suggested framework specifically applies to the normal pe‐
diatric airway, the main underlying principles can also be considered
for the expected abnormal and acutely impaired but otherwise normal
pediatric airway.
The rare but frequently discussed need for front of neck airway
(FONA) in children can be attempted as a last resort in a “cannot
oxygenate‐cannot intubate” situation. FONA is likely to be futile in
a child in an emergency. 31,32 It is not possible to sufficiently practice
or gain experience for this situation to be useful and relied upon in
an emergency due to age and size range from neonates to adoles‐
cents.33 Emergency FONA has been attempted in approximately 2%
of anticipated and unexpected difficult airways of the PeDI registry
with considerable subsequent morbidity and mortality. 2 This is in
stark contrast to the ability to almost always overcome difficult or
impossible facemask ventilation in this large cohort of difficult pedi‐
atric airways by the recognition and treatment of anatomical airway
obstructions such as the use of supraglottic devices or functional
airway obstructions through muscle paralysis.2
There is rarely a need for an emergency FONA in the otherwise
healthy child without history and findings for a difficult airway. It
may occur following airway trauma, swelling, or anaphylaxis in the
otherwise healthy child or rapid respiratory deterioration in a child
with a known difficult airway.
Preventing the need for emergency FONA by identifying high
risk patients (preexisting concerns about the ability to oxygenate/
ventilate) is essential for optimal pediatric airway management.
Early anticipation of a difficult pediatric airway allows organization
and preparation of best and appropriate ORL/ENT or surgical sup‐
port. The most experienced anesthetic and surgical (ideally ORL/
ENT) help should be available before induction of anesthesia ex‐
cept in the situation of immediate threat to life. Options available
are needle or surgical cricoidotomy. Rigid bronchoscopy may also
be successful in specific circumstances if facilities and expertise
are immediately available. There is insufficient evidence and clin‐
ical experience to support any specific device or technique over
another.33-35
If a tracheostomy is considered as a final option after compli‐
cated and failed intubation attempts and before airway trauma
makes mask ventilation impossible an emergency FONA should be
declared in the paralyzed patient. An unplanned (emergency) FONA
should only be considered as an option in a desperate scenario
rather than a recognized effective treatment of failed airway man‐
agement in children. However, elective FONA contingency planning
in children with a known difficult airway may be considered before
the start of a procedure.
4.4.1 | Oxygenation and ventilation
Saliva, blood, regurgitation, or supraglottic foreign bodies can also
lead to mechanical obstruction and necessitate suction and removal
under direct vision using either direct laryngoscopy or videolaryn‐
goscopy (PLAN A). A tracheal tube can be inserted if the larynx is
visualized (Figure 2).
| 989
Rarely, an unexpected subglottic or tracheal obstruction needs
to be bypassed with a small tracheal tube or a Frova bougie and ven‐
tilation achieved using the VentrainR device.36 Careful lung recruit‐
ment maneuvres are required to prevent atelectasis and to restore
optimal oxygenation and ventilation following prolonged tracheal
intubation attempts.
If no anatomical or mechanical obstruction is apparent during
direct laryngoscopy and the trachea cannot be intubated, a supra‐
glottic airway device or a nasopharyngeal tube should be used to
overcome any potentially unrecognized anatomical upper airway
problems (Plan B). 21
A supraglottic airway device (SAD) may be inserted before direct
laryngoscopy; however, this may be unsuccessful in the presence of
an intraoral mechanical obstruction or limited mouth opening.
4.4.2 | Tracheal intubation
Tracheal intubation in children is usually easy in experienced hands
but may be more difficult in infants and neonates (Figure 3). There
is no consensus as to which technique or device is best suited for
various clinical situations. There is continuing development of new
devices, techniques, and technologies requiring frequent updates
to recommendations by various groups involved in pediatric airway
management.
It is, therefore, impossible to develop and dictate a detailed algo‐
rithm that will be accepted by clinicians involved in pediatric airway
management.
Therefore, an “open‐box algorithm” based on local expertise and
available resources is the most practical.
It is essential to recognize that oxygenation and ventilation as
suggested above saves lives and prevents avoidable harm. Simple,
effective mask ventilation and placement of supraglottic airway de‐
vices can be learned by all specialists involved in pediatric airway
management.
Multiple tracheal intubation attempts lead to preventable harm
and must be avoided. 2,4
An initial tracheal intubation plan should be the daily local
routine, taught, and practiced. This can be in the form of direct
laryngoscopy or videolaryngoscopy. 37,38 Failure to successfully
intubate should necessitate a call for assistance. Consider using
a supraglottic airway device (SAD) for the procedure if tracheal
intubation fails.
The anesthetic should be continued and oxygenation and
ventilation maintained while Plan A is implemented. This should
be an alternative laryngoscopy technique (videolaryngoscopy),
that is, locally agreed upon and regularly practiced. Failure to
secure tracheal intubation via this method should necessitate
reconsidering the indication for tracheal intubation, potential
use of a supraglottic airway or if necessary abandoning the
procedure.
If local expertise and resources are available, flexible endoscopic
(fibrebronchoscope) intubation (nasal, oral, or via supraglottic airway
device) represents Plan B.
990 | ENGELHARDT et al.
Pediatric Oxygenation and Ventilation
(Please adapt according to local expertise and facilities)
Prevention, Teaching, Training, Facilities
Careful assessment and planning
Recognize and treat
ANATOMICAL/ MECHANICAL Airway Obstructions
TREATMENT (specify)
Positioning, mouth-opening, oral or nasal airway, two-hand two person facemask ventilation
CALL FOR HELP
(insert contact details)
Recognize and treat
FUNCTIONAL Airway Obstructions
TREATMENT (specify)
Hypnotic, muscle relaxant, epinephrine
Plan A
Direct/ Video Laryngoscopy
(specify local choice)
Plan B
Supraglottic Airway Device (SAD)
Emergency Front Of Neck Airway (eFONA) or (ORL/ENT) Rigid Bronchoscopy
An emergency FONA should only be considered as an option in a desperate situation and
if oxygenation and ventilation are impossible
F I G U R E 2 Pediatric Oxygenation and Ventilation. Adapt
according to local expertise and facilities. If appropriate, consider
abandoning the attempted procedure (see Figure 1) [Colour figure
can be viewed at wileyonlinelibrary.com]
4.4.3 | Pediatric Airway Equipment
Safe management of the pediatric airway requires a minimum avail‐
ability of suitable equipment according to national standards or rec‐
ommendations. The equipment must also meet a minimum standard
of performance and quality. Principles of standardization, redun‐
dancy, and safety cultures need to apply. Make and manufacturer
are less relevant, but the equipment must be suitable for children
and acceptable to the clinician in charge.39-41
Individual departments need to decide on the best options based
on their needs and affordability. It is essential that pediatric airway
equipment is well maintained and that staff are trained regularly.
A separate difficult/emergency airway trolley should be available
where children's airways are managed. This should be adapted to
locally accepted difficult airway algorithms. A one‐stop “airway trol‐
ley” may be the best option for some departments, with equipment
separated according to age/weight. Other departments who have
a dedicated “difficult airway” trolley for elective procedures may
choose an additional simplified “airway rescue” trolley equipped ac‐
cording to departmental rescue algorithms. Simplicity is the key to
success and overstocking must be avoided at all costs. An example
Pediatric Tracheal Intubation Approach
(Please adapt according to local expertise and facilities)
Ensure Oxygenation and ventilation at all times
Consider using a SAD if Tracheal Intubation fails at any stage
Prevention, Teaching, Training, Facilities
Initial Local Tracheal Intubation Protocol
Direct/Video Laryngoscopy (VL)
(specify local choice)
Limit to 2 attempts
CALL FOR HELP
(insert contact details)
Plan A
Alternative Approach
VL/fiberoptic
(specify local choice)
Limit to 2 attempts
Plan B
Insert Supraglottic Airway Device (SAD)
(oxygenate/anesthetize)
Fibreoptic intubation via SAD
(specify)
Surgical Tracheostomy or (ORL/ENT) Rigid Bronchoscopy
An emergency FONA should only be considered as an option in a desperate situation and
if oxygenation and ventilation are impossible
F I G U R E 3 Pediatric Tracheal Intubation Approach. Adapt
according to local expertise and facilities. If appropriate, consider
abandoning the attempted procedure (see Figure 1). A failure to
intubate should not result in an attempt at an emergency Front Of
Neck Airway (eFONA) if oxygenation and ventilation is possible
[Colour figure can be viewed at wileyonlinelibrary.com]
of a difficult/ emergency trolley setup is offered in the File S1 and
can be arranged according to the locally adapted airway algorithm
and available facilities.
5 | S U M M A RY
The overarching goal of an universal, consensus approach to the
pediatric airway is the prevention of perioperative hypoxia in chil‐
dren. Prevention of intubation‐related complications through regu‐
lar practice, teaching, and training with dedicated pediatric staffing
and equipment is a priority. The first crucial step after encounter‐
ing difficulties is to prevent, recognize, and treat ANATOMICAL/
MECHANICAL and FUNCTIONAL airway obstructions with skills and
drugs, respectively.
A locally accepted algorithm based on simple and common prin‐
ciples using local expertise with existing suitable equipment should
be established. Such an approach to the pediatric airway may find
acceptance across specialist pediatric specialties and pediatric anes‐
thesia societies and groups.
ENGELHARDT et al.
D I S C LO S U R E S
TE and BVUS are Section Editors and PB is an Associate Editor of
Pediatric Anesthesia.
ORCID
Thomas Engelhardt https://orcid.org/0000-0002-3954-5820
Markus Weiss https://orcid.org/0000-0002-5822-9591
Britta S von Ungern‐Sternberg
https://orcid.org/0000-0002-8043-8541
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