The Pediatric Difficult Intubation Registry (PeDI-R) is an international registry for pediatric difficult airways maintained under the auspices of the Society for Pediatric Anesthesia. Analysis of cases from this registry have made significant contributions to our understanding of the pediatric airway. One of the early and landmark findings from this registry was the higher failure rate and increased complication rate associated with more than two DL attempts (Lancet Respir Med 2016;4:37-48). This finding has led to two suggestions: that the first attempt at a pediatric airway should be the best attempt, and encouragement for the use of VL.
In a recent multicenter, randomized controlled trial comparing VL with standard blade to DL, the VL group demonstrated better first-pass intubation success and was associated with fewer complications (Lancet 2020;396:1905-13). The difference in success rates between the VL group and the DL group was markedly different for children weighing less than 6.5kg. The time to intubation was longer in the VL group than the DL group, although it was not statistically significant. The increased time required to perform VL may be a function of equipment set-up/familiarity and procedural skill, thus emphasizing the importance of honing VL skills through routine use for normal intubations.
The physiological differences in oxygen consumption between adults and children are well known to all anesthesiologists, so it will come as no surprise that the most common complication involving pediatric airway management is desaturation or hypoxemia. A number of studies have investigated the role of passive oxygenation during pediatric airway management (Anesth Analg 2020;130:831-40). In summary, the use of passive oxygenation by nasal cannula with flows as low as 0.2 liters/kg/min significantly increases the time to desaturation during airway management (Figure). This benefit is found with little to no discernible downside, suggesting that passive oxygenation via nasal cannula should be considered anytime a potentially difficult pediatric airway is encountered.
The above tips may not relieve the anxiety felt when faced with a difficult pediatric airway, but they may improve the overall safety and success of the clinician’s airway management.