Methods of Identifying and Managing the
Difficult Airway in the Pediatric Population
Joshua Belanger, CRNA
Mark Kossick, CRNA, DNSc
The goal of this literature review is to provide the
anesthesia practitioner with the skill set to detect and
prepare for a difficult pediatric airway. The authors
have reviewed and compiled information on some
of the most common conditions that can predis-
pose pediatric patients to a difficulty airway, such as
macroglossia, mandibular hypoplasia, micrognathia,
cervical instability, limited cervical movement, maxil-
lary and midfacial hypoplasia, and cleft palate. This
article provides an overview of preoperative assess-
A
irway management is a mainstay of anes-
thesia practice. Practitioners are required
to have a firm grasp on airway physiology,
assessment, and management, and regular
exposure to this aspect of anesthesia is vital
to maintaining these skills. Unfortunately, for many anes-
thesia practitioners, only limited opportunities to manage
the pediatric airway exist.
Statistics compiled in 1993 from the American Society
of Anesthesiologists Closed Claims Database have dem-
onstrated that respiratory events were more common
in the pediatric population (ie, 5 years of age and
younger) than in the adult population. Specific respira-
tory events relative to this review (eg, airway obstruc-
tion, difficult intubation, inadequate ventilation) were
also shown to occur at a greater frequency in children
(34%) vs adults (23%).1 The database also revealed that
of 238 pediatric claims reviewed, 67 (28%) occurred in
children under the age of 1 year.1 Since then, the rate of
these specific respiratory events for all pediatric patients
has decreased to approximately 7%.2 This decline in
adverse respiratory events may be attributed to many
factors, including better monitoring equipment, such as
pulse oximetry and end-tidal gas analysis,1,2 as well as
safer medication profiles.2
Although most pediatric airways may be easily secured
by the experienced practitioner, the potential still exists
for discovering a difficult airway (DA) after induction,
possibly leading to a cannot-intubate-cannot-ventilate sit-
uation. One retrospective study involving 8,434 patients
under the age of 18 years demonstrated the overall inci-
dence of a difficult laryngoscopy to be 1.35%.3 This study
also noted that those under the age of 1 year (n = 1,759)
had the greatest risk of presenting with a DA (4.7%).3
www.aana.com/aanajournalonline AANA Journal
ment techniques, normal pediatric airway anatomy,
and respiratory physiology. An emphasis is placed on
some common syndromes and their related anatomi-
cal abnormalities that can compromise the airway, as
well as anesthetic approaches recommended to suc-
cessfully secure a potentially difficult airway.
Keywords: Congenital, difficult airway, malformation,
pediatric.
One primary objective of the authors assessment
of the pediatric airway literature was to enhance the
anesthetists ability to detect and prepare for a diffi-
cult pediatric airway, thereby improving overall airway
management skills. For the purposes of this review, the
authors have defined a DA as one in which adequate gas
exchange is not readily accomplished through mask ven-
tilation, airway adjuncts such as oral and nasal airways,
or a combination of the two. A difficult intubation is
said to occur when an experienced provider requires 3
or more attempts to place an endotracheal (ET) tube,
with or without rescue adjuncts, such as retrograde
wires, light wands, video laryngoscopes, or gum elastic
bougies.
Review of the Literature
Using multiple online resources, such as EBSCOhost.
com, ScienceDirect.com, and PubMed.gov, the authors
searched for publications relevant to pediatric airway as-
sessment and management, pediatric genetic malforma-
tions with airway management implications, and acute
or chronic injuries that may potentially alter the normal
pediatric airway, thereby making it difficult to secure.
Search words used to locate relevant articles included
airway, pediatric, malformation, Down syndrome, cleft
palate, difficult, management, and assessment.
Unfortunately, many journal articles reviewed by the
authors did not operationalize the term pediatric, making
assessment and critique of such literature difficult. For
the purposes of this article, the term pediatric is subcat-
egorized as follows: premature, born less than 37 weeks
gestation; neonate, birth to 1 month; infant, 1 month
to 1 year; toddler, 1 to 3 years; child, 3 to 12 years; and
adolescent, 13 to 18 years.
February 2015 Vol. 83, No. 1 35
Normal Pediatric Airway Anatomy and
Physiology
The pediatric patient is both anatomically and physiologi-
cally different from the adult patient in many ways. These
differences are most important under 2 years of age4,5
and decrease as the child matures, with most differences
disappearing around 6 to 8 years of age. One difference
that is readily noticeable on assessment of the infant and
toddler is the proportionately larger head, specifically
the occipital area. This difference is clinically significant
in that the pediatric patient may potentially benefit from
a pillow or roll being placed under the shoulders, as
opposed to the head, to assist with neck flexion.5,6 In
contrast, other researchers have suggested that direct
laryngoscopy is most effective when the shoulders and
head are on a flat surface and the neck is fully extended.7
The anatomy of the pediatric airway is composed
of the same anatomical components as seen in adults,
although the size and position of several structures are
noticeably different. The most notable differences can be
seen when the adult upper airway is compared with that
of the neonate and infant upper airway. Compared with
the adult, the neonate and infant nose is softer, with more
mucous and lymphoid tissues present.8 Because of the
smaller diameter of the nasal passages, it takes much less
swelling or secretions to decrease total airflow, which
can easily lead to obstruction5 since it has been suggested
that infants are obligate nasal breathers until they reach
2 to 6 months of age.5 Being obligate nasal breathers is
also important since an improperly placed face mask
can occlude the nares, creating an obstructed airway.
One airway structure that is proportionally larger in the
pediatric patient than in the adult is the tongue. The pe-
diatric tongue, especially during the neonatal and infant
stages, is located closer to the palate by a more superiorly
located larynx, which potentiates airway obstructions.
Whereas the adult larynx is located at the junction of the
fourth and fifth cervical vertebrae (C4-5), the neonate/
infant larynx is 1 level higher, typically located at C3-4,7
and may even be as high as C2-3.9 This superior position
creates a more acutely angled view of the vocal cords
during direct laryngoscopy.
Compared with the adult, the neonate and infant epi-
glottis tends to be longer, floppier, and omega shaped,
leading some authors to state that the straight laryngo-
scope blade may potentially be more effective in viewing
the glottic opening.8 The epiglottis also sits at a greater
angle to the anterior pharyngeal wall, making visualiza-
tion of the vocal cords more difficult.8 Like the epiglot-
tis, most of the cartilaginous structures of the pediatric
airway are softer (less ossified),9 and more pliable than
the adults, increasing the chances of compression and
obstruction of the airway when pressure is applied, such
as with the Sellick maneuver.
The last important anatomical difference of the upper
36 AANA Journal February 2015 Vol. 83, No. 1 www.aana.com/aanajournalonline
airway is the diameter of the cricoid ring. In the adult,
the narrowest portion of the upper airway is the vocal
cords, as opposed to the cricoid cartilage in the neonate,
infant, and young child.9 This difference makes the
larynx funnel shaped, as opposed to the cylindrical shape
of the adult and adolescent larynx.9 This feature allows
the uncuffed ET tube to create a relative subglottic seal;
the narrowing of the airway below the vocal cords presses
against the sides of the tube.10
There are several anatomical differences in the pediat-
ric patient that are important to the anesthesia provider,
although they are not part of the airway. The costae are
more horizontal and contribute less to inspiratory and
expiratory efforts, forcing the diaphragm to do most of
the work in neonates. The infants respiratory muscles
are primarily composed of type II (fast-twitch) fibers,
and have lower stores of glycogen and fat, allowing them
to become easily fatigued after short periods of exertion
or labored breathing.5,11 This physiologic characteristic
further emphasizes the importance of rapidly establish-
ing and securing the pediatric airway.
One of the most clinically significant physiologic
factors unique to neonates, infants, and toddlers is their
elevated metabolic rate, leading to a rate of oxygen con-
sumption more than double that of the adults5 (7-9 mL/
kg/min compared with 3 mL/kg/min in adults). Another
contributing factor to their more rapid rate of desatura-
tion is their lower functional residual capacity,5 22 mL/
kg on average for toddlers12 vs 34 mL/kg for the adult.13
The newborn has just half the number of alveoli and only
1/20th the surface area available for gas exchange com-
pared with the adult, limiting oxygen absorption.14 The
neonates and infants nervous system is predominantly
influenced by the parasympathetic system (because of
the incomplete maturation of the sympathetic nervous
system), causing bradycardia in response to hypoxia and
further decreasing oxygen delivery.15 Because of these
factors, when infants begin to experience an airway ob-
struction or become relatively tachypneic, they decom-
pensate more rapidly than do adults.
Preoperative Assessment
Adult airway assessment systems are not always appli-
cable to children. For example, the Mallampati classifi-
cation system and various measurements used to assess
the adult airway, such as thyromental and interincisor
distance, do not consistently correlate with the pediatric
patient population.5,16 However, the Mallampati classifi-
cation system has been shown to be applicable for use in
those 4 to 8 years of age.17 Because of this, the anesthesia
provider will commonly rely on his or her physical as-
sessment and the surgeons history and physical exami-
nation for predicting the DA in children.
As with all patients, the assessment process should
begin with a thorough chart review, including the sur-
 Incidence Potential related
Syndrome rate Common clinical features anatomical abnormalities
Down 11.8:10,000 Short stature, mental retardation, Macroglossia,21 cervical instability,22,23
live births20 hypotonia, epicanthal fold, mandibular hypoplasia/micrognathia,21,24
microcephaly, CHD maxillary/midfacial hypoplasia21,24,25
MPS (eg, 1:25,000 live Cognitive deficit, hearing/vision deficit, Macroglossia,27,28 cervical instability,27,28
Hurler, Hunter, births26 dwarfism, skeletal dysplasia, CHD, limited cervical movement27,28
Morquio) coarse facial features, myelopathy
Pierre Robin 1:8,500 live Respiratory compromise, feeding difficulty, Macroglossia (relative),30 mandibular
births29 glossoptosis, gastroesophageal reflux, CHD hypoplasia/micrognathia,30,31 cleft palate30,31
Treacher Collins 1:50,000 live Aplastic zygomas, microstomia, CHD Mandibular hypoplasia/micrognathia,33
births32 maxillary/midfacial hypoplasia,33 cleft palate32,34

Table. Congenital Syndromes and Their Related Anatomical Abnormalities

Abbreviations: CHD, congenital heart defect; MPS, mucopolysaccharidosis.

geons history and physical examination and any prior
anesthetic records, as well as the current airway physical
findings. Any mention of an abnormal birth or gestation-
al age, recent illnesses or surgeries, breathing problems,
or congenital abnormalities, should be further explored
with the parent or caregiver. Studies have shown that the
type of scheduled surgery may be a good indicator for a
DA. Pediatric patients undergoing cardiac surgery or oral
and maxillofacial surgery have the highest prevalence of
difficult intubations (40%),3 and half of these patients
presenting as a difficult intubation also have some form
of malformation.3
Once the chart has been reviewed, a physical as-
sessment should be performed. Some general observa-
tions should be made, starting with the head and face.
When viewed from the side, the chin and location of
the lower teeth in relation to the upper teeth should be
evaluated. A hypoplastic chin, or micrognathia, as seen
in many genetic malformations, is a good indicator of a
DA.8 Flexion and extension of the neck can also be as-
sessed from the side, potentially revealing limitations,
instabilities, tumors, or goiters. Some additional items
to assess are head size and symmetry, patients activity
level, breathing pattern and sounds, posture, and color.
It would also be prudent to ask the caregiver about any
recent upper respiratory tract infections, which could
predispose the patient to a hyperreactive airway. A child
who is resting in the sniffing position or tripod position
could indicate respiratory distress, as could unexplained
restlessness or agitation. The use of accessory muscles
for breathing should also be assessed. Noisy breathing,
snoring, nasal congestion, or an impaired sense of smell
without a runny nose could indicate adenoid or tonsillar
enlargement.18 Excessive daytime somnolence, morning
headaches, loud and abnormal mouth breathing, snoring,
attention problems, hyperactivity, or a history of apnea
could indicate an airway obstruction or obstructive sleep
apnea (OSA), which could worsen after induction of the
anesthetic.19 Asking the caregiver or caregivers how the
child prefers to sleep will give an indication as to how the
child breathes best.19 With pediatric patients, the physi-
cal examination may be incomplete because of a lack of
cooperation from the child. If the patient is cooperative,
the tongue and airway should be assessed, as well as in-
terincisor distance and the status of the teeth. Any loose
deciduous teeth should be documented on the chart; this
primarily affects the 5- to 10-year-old age group.
Anatomical Abnormalities of Congenital,
Genetic, and Acquired Malformations
One prominent reason for a DA in the pediatric patient is
an anatomical malformation. Although many congenital,
genetic, and acquired malformations and abnormali-
ties may present as a cluster, many may also present in
isolation (eg, cleft palate). Malformations presenting as
a group may also define a syndrome (eg, Pierre Robin).
Although most anesthesia practitioners may never en-
counter a rare malformation, other abnormalities may be
seen infrequently depending on the providers practice
setting; for example, Down syndrome has a reported inci-
dence of 11.8 cases per 10,000 live births.20 Although it is
outside the scope of this article to cover all acquired and
congenital malformations, as well as all types of airway
devices, some of the more familiar anatomical abnormali-
ties known to affect the pediatric airway are listed in the
Table.20-34
Macroglossia. Macroglossia, defined as a propor-
tionately large tongue, has the potential to create a DA
through posterior migration of the tongue, either during
or after induction. This can cause an airway obstruction
and make it difficult to mask ventilate and obtain an
adequate view of the vocal cords during laryngoscopy.
One congenital defect that commonly presents with
macroglossia is mucopolysaccharidosis (MPS).27 This ly-
sosomal storage disease consists of 7 different syndromes
(Hurler, Hunter, Sanfilippo, Morquio, Maroteaux-Lamy,
Sly, and Natowicz); with Hurler syndrome being associ-
ated with the highest incidence of difficult intubation
(27.6%-54%).27,35
Although macroglossia typically presents as a result of

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a congenital malformation,27 it may also occur second-
ary to acute trauma or an allergic response. This could
include angioedema of the tongue; angiotensin-converting
enzyme inhibitors, which are regularly prescribed to pedi-
atric patients with congenital heart defects (CHDs), have
been known to produce lingual subcutaneous edema.
Macroglossia is one of the more easily treated malfor-
mations, potentially requiring an oral airway while per-
forming mask ventilation and use of video laryngoscopy
during ET tube placement.36 Pulling the tongue forward
with padded forceps can aid in visualization of the vocal
cords. The straight blade, such as the Wisconsin or Miller
blade, has been recommended by many authors as being
the ideal blade of choice in neonates and infants with
macroglossia.37,38
Cervical Spine Abnormalities. Cervical spine abnor-
malities fall into 2 categories: those that cause instability
and those that limit mobility. Cervical spine instabil-
ity is a hallmark finding in some of the more common
congenital malformations, with Down syndrome being
the most widely known.22 Cervical spine instability also
can have an acute presentation, such as in patients with
injuries sustained from a motor vehicle accident or other
trauma. Patients with cervical instability are at risk of
compression of the cervical spinal cord, especially due to
manipulation of the cervical vertebrae during laryngos-
copy.28 Depending on the severity of the malformation
or trauma, preoperative lateral flexion and extension
images of the cervical spine may be beneficial.28 In-line
stabilization (not traction) is of utmost importance, and
the neck and head should remain in as neutral a position
as possible throughout the entire procedure.28
The fiberoptic bronchoscope, Bullard laryngoscope,
bougie, and light wand, may be useful in patients with
limited or unstable cervical vertebrae since these devices
do not require the neck to be mobilized during at-
tempted visualization of airway structures.39 The Bullard
laryngoscope has been shown in one prospective study
involving 18 fresh cadavers intubated by one anesthe-
siologist, to provide the best view of the vocal cords with
the least amount of cervical manipulation compared with
the GlideScope (Verathon) video laryngoscope, and the
Viewmax (Rusch) or Macintosh laryngoscope blades.39
The GlideScope also has been shown to improve the laryn-
goscopic view in the pediatric patient with a DA.40 In con-
trast, in normal pediatric airways, one prospective random-
ized study involving 134 patients (birth to age 10 years)
found the GlideScope and Truview PCD (Truphatek) video
laryngoscopes were inferior to direct laryngoscopy.41 In
patients not at risk of aspiration, a laryngeal mask airway
(LMA) is an excellent choice for airway management. It is
also recognized as being a rescue airway device for failed in-
tubations. Contraindications to the use of an LMA include
a full stomach, recent trauma, and the need for high (>
20-25 cm H2O) positive pressure ventilation.
38 AANA Journal February 2015 Vol. 83, No. 1 www.aana.com/aanajournalonline
Mandibular Hypoplasia and Micrognathia. Mandibular
hypoplasia and micrognathia are considered by some
authors as synonyms for an undersized mandible. One
syndrome commonly associated with this condition is
Pierre Robin syndrome. The clinical triad of this syndrome
consists of micrognathia, cleft palate, and glossoptosis, or
a downward displacement of the tongue.31,36 When this
clinical triad is accompanied by additional malformations
or syndromes, it is referred to as Pierre Robin sequence.
Although the jaw in the patient with Pierre Robin syn-
drome is hypoplastic, it is also retrognathic, meaning the
attachment location of the mandibular condyle to the skull
is in a more posterior position, further increasing the dif-
ficulty of intubation.31
Micrognathia causes the proportionately large tongue
to be forced to a more posterior position in the oro-
pharynx, making it difficult to obtain an adequate view
of the vocal cords with direct laryngoscopy. Because of
this, the posterior portion of the tongue and glottis is
more acutely angled. The GlideScope, Airtraq optical
laryngoscope (Prodol Meditec), DCI video laryngoscope
(Karl Storz), Truview PCD, and flexible fiberoptic bron-
choscope are well suited for attempting to intubate the
patient with a DA.42 Manual external tracheal manipula-
tion is also helpful in decreasing the angle of the base of
the tongue and glottis, aiding in the visualization of the
vocal cords. The proportionately large tongue is also a
hindrance during direct laryngoscopy because there is no
room to sweep the tongue when attempting to align the
axes of the head and neck.
Maxillary/Midfacial Hypoplasia. Maxillary hypo-
plasia, which is a primary component of midfacial
hypoplasia, is seen with several congenital malforma-
tions (see the Table), and intubating conditions may be
similar to those with micrognathia. Midfacial hypoplasia
typically consists of a hypoplastic nasal bone, maxilla,
and zygomas. One common problem encountered with
midfacial hypoplasia is OSA.25 The underdeveloped facial
bones force the tongue to a more posterior position,
making airway obstruction a common problem. Airway
management modalities are similar to those used for mi-
crognathia.25,36
Cleft Palate. One anatomical malformation that may
complicate the management of the pediatric airway is the
cleft palate. The incidence of cleft palate, with or without
cleft lip, is reported to be between 9.1 and 15.6 cases
per 10,000 live births worldwide, which makes it one of
the most common birth defects.43 Epidemiologic studies
have shown that clefts are an isolated malformation in
71% of occurrences, and 29% to 33% of cases are as-
sociated with a syndrome, chromosomal abnormality, or
multiple congenital anomalies of unknown etiology.43,44
Patients with Pierre Robin syndrome have a 50% to 80%
chance of presenting with cleft palate. Male occurrence is
also greater, with an odds ratio of 1.7.43,44
 During assessment of a patient with a cleft palate, there
are several other closely related maladies that should be
considered. Up to 29% of patients presenting with cleft
palate (with or without cleft lip) will have some form of
CHD, such as patent foramen ovale, patent ductus arterio-
sus, or coarctation of aorta.43-45 Depending on the severity
of the cleft palate, a complete airway obstruction may occur
if the tongue enters the cleft, effectively occluding both
the oral and nasal cavities simultaneously.46 Although the
general pediatric population has OSA at an occurrence of
2% to 3%, patients with cleft palate experience OSA at a
significantly higher rate (31%),19 and patients with Down
syndrome are at an even greater risk of OSA (45%).25
Airway management of patients with an isolated cleft
palate (ie, cleft palate with no cleft lip) is usually accom-
plished with minimal difficulty.41,47 One retrospective
study involving infants and toddlers (1 month to 3 years
of age) reported 4.77% of cases being classified as a dif-
ficult laryngoscopy and 1.93% as a difficult intubation.47
In that study, 985 subjects were scheduled for repair
of cleft lip and palate. The researchers also found that
the incidence of difficult laryngoscopy in infants (1-6
months of age) with cleft lip/palate was 7.06%.
For patients with bilateral cleft palates, the premax-
illa (the most anterior portion of the maxilla) is angled
forward, causing the upper incisors to hamper blade
movement and obstruct the line of sight during direct
laryngoscopy. During a direct laryngoscopy in a patient
with a unilateral left or bilateral cleft palate, the laryngo-
scope blade tends to drop into the left cleft palate, further
obstructing the view.47 This can be remedied by gently
packing the cleft palate with gauze before intubation or
by using a plastic tooth guard to span the cleft.8 An oral
airway placed immediately after induction typically pre-
vents the tongue from obstructing the oropharyngeal and
nasal cavities, allowing for easy mask ventilation.8
The Acutely Altered Airway
There are numerous conditions that may cause the pedi-
atric airway to become acutely difficult to secure. Some
examples include acute epiglottitis, hemangiomas, papil-
lomatosis, venous lymphatic malformations, burns, la-
ryngoceles, angioedema, or arteriovenous malformations;
fortunately, most of these are rare.
One potential alteration with an infectious etiology is
acute epiglottitis. In 1989, acute epiglottitis had an oc-
currence of 15 cases per 100,000 live births, but after the
development and subsequent mass administration of the
Haemophilus influenzae type B vaccination in 1990, the
rate dropped 73% to 4 cases per 100,000 live births.48
Epiglottitis occurs rapidly within 24 hours, is supraglot-
tic, and typically affects 2- to 7-year-olds, although it may
occur in adults. Elective early intubation in the operating
room (OR) is recommended for every patient presenting
with confirmed acute epiglottitis, effectively avoiding the
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risks associated with an emergent intubation.
For many of the acute airway alterations listed above,
inflammation of some part of the airway is a large contrib-
uting factor to the problem. One method of minimizing
this inflammation is with oral or intravenous (IV) dexa-
methasone (0.2-0.5 mg/kg orally or IV). Dexamethasone
is also useful in reducing inflammation from surgery and
airway manipulation during direct laryngoscopy. Airway
management methods of acute presentations are similar
to those used to treat congenital ones, as described previ-
ously and in the following section.
Considerations for Management of the
Difficult Airway
There are several recommendations the authors would
like to make that may assist anesthesia providers in man-
aging the difficult pediatric airway. For example, during
transport of patients with obstructive abnormalities to
the OR, the prone position may help to prevent airway
obstruction.36 This would include patients with macro-
glossia, acute airway masses, or epiglottitis.37,42,46 Once
the patient is in the OR, preoxygenation should begin
as soon as possible. An awake flexible fiberoptic intuba-
tion can be highly effective in securing a documented
and compromised DA. This may be accomplished with
prudent administration of sedation (midazolam, 0.3-0.5
mg/kg orally or per rectal, or ketamine, 1-2 mg/kg in-
tramuscularly [IM] or IV), antisialagogues (atropine,
0.02 mg/kg IM, or glycopyrrolate, 0.01 mg/kg IM), and
subsequent local anesthesia of the airway (lidocaine,
maximum of 4 mg/kg), administered either by aerosoliza-
tion or local injection. Maintenance of adequate sponta-
neous ventilation and effectively maintenance of normal
airway tone are essential components of this technique.
The use of IV medications at times may also be a
desired method of induction, although preserving spon-
taneous respirations may be difficult without judicious
titration. Propofol can be an ideal drug for this technique
because of its short time of onset and duration of action.
One caveat to an IV induction is that a peripheral IV
catheter is needed, which may be difficult to obtain in an
uncooperative child. It is important to note that airway
obstruction may occur with all forms of induction, and
methods of achieving effective ventilation, such as with
oral and nasal airways, LMAs, and jet ventilation, should
be readily available.
Following induction of general anesthesia for a surgi-
cal procedure requiring a protected airway, the anesthe-
tist may at his or her discretion intubate with or without
paralytics. Any concerns for substantial airway inflam-
mation due to a difficult intubation should be managed
before extubation.36 Extubation criteria for a child who
had a difficult intubation should include full reversal of
paralytics, evidence of an adequate spontaneous minute
volume, and being completely awake. If the patients
February 2015 Vol. 83, No. 1 39
postoperative pain is predicted to require the use of
high-dose narcotics, a prolonged intubation should be
considered because of the respiratory depressant effects
of opioids. After the patient has been extubated and
transferred to the postanesthesia care unit, all healthcare
providers and parents should be informed of any difficul-
ties with perioperative airway management.
Conclusion
Although many pediatric patients commonly present
with an unremarkable airway, it is prudent for the anes-
thetist to be vigilant for the occult challenging airway.
Being cognizant of clinical markers and diagnoses that
are associated with difficulties in securing an airway is
of value. This would include having a cardinal under-
standing of the anatomical and physiologic differences
between a pediatric and adult patients airway.
Furthermore, a working knowledge of how the airway
of neonates, infants, toddlers, children, and adolescents
may become altered because of congenital or acquired
malformations will allow the anesthetist to establish a
patent airway before or during induction of anesthesia.
For example, children born with Down syndrome are
known to have anatomical abnormalities such as macro-
glossia, cervical instability, and mandibular and/or maxil-
lary hypoplasia.
Because of the existence of many diverse congenital
and acquired malformations that can afflict pediatric
patients, it is difficult to establish recommendations for
airway management that would be universally applicable
to each abnormality. Thus, the authors intent with this
review was to compile the more prevalent syndromes that
anesthetists may encounter and their common clinical
features that can impose problems with ventilation, in ad-
dition to describing airway management techniques and
strategies that may minimize airway mishaps.
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AUTHORS
Joshua Belanger, CRNA, is a staff nurse anesthetist at Park Ridge Health,
Hendersonville, North Carolina. Email: belanger.josh@gmail.com.
Mark Kossick, CRNA, DNSc, is a tenured professor and graduate anes-
thesia simulation education coordinator at Western Carolina Universitys
Graduate Program of Nurse Anesthesia, Asheville, North Carolina. Email:
makossick@wcu.edu.
February 2015 Vol. 83, No. 1 41