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''Originally from Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia''


Michelle C White* and Jonathan M Linton
:<i>*Correspondence email: mcwdoc@doctors.org.uk</i>

Dr Michelle White, Consultant Anaesthetist, Mercy Ships, Guinea

Dr Jonathan Linton, Specialist Trainee Anaesthesia, University Hospital, Southampton, UK

{| class="wikitable" 
|+
!Summary
|-
|Unexpected difficult airways in paediatric practice are rare. Many problems can be prevented by routine preoperative airway assessment, pre- oxygenation, and preparation of equipment. A simple step-wise approach to management improves outcome. Anaesthetists have a responsibility to be familiar with airway algorithms and make pragmatic modifications to account for available resources.
|}

== INTRODUCTION ==
Airway management in children is generally
straightforward in experienced hands. Problems are
more common for the non-paediatric anaesthetist,
and are a major cause of anaesthesia-related morbidity
and mortality. Genuine ‘difficult airways’ are rare in
children compared to adults and many are predictable.
However, differences in adult and paediatric physiology
mean irreversible hypoxic damage occurs more quickly
in children if there is an airway problem. Simple stepwise
strategies are essential. Many guidelines exist for
the management of difficult airways in adults, but there
are few specifically designed for use in children.
The aim of this article is to outline the basic principles
of paediatric airway assessment and to discuss the
management of unexpected and expected difficult
paediatric airways.
Evidence to support best practice is difficult to obtain
for unpredictable events such as management of the
paediatric difficult airway, and there is a lack of high
quality data. Many new devices and techniques are
available, but most are evaluated in healthy children
or simulated ‘difficult’ situations. Due to this lack of
evidence, guidelines are often based on a consensus of
expert opinion, which may have a bias against newer
devices and techniques, or indeed bias towards the
latest technique that has gained popularity. This review
takes a pragmatic and cautious approach in applying
existing guidelines to settings where experts and a range
of technology are not always available.

== BACKGROUND ==
Management of the difficult airway can be divided into
three critical areas:

:1. Difficult mask ventilation
:2. Difficult tracheal intubation
:3. Can’t intubate and can’t ventilate (CICV).

The incidence of difficult airways in children
is unknown. The incidence of impossible mask
ventilation is reported as 0.15%, and is more frequently
encountered by inexperienced paediatric anaesthetists.
Difficult intubation ranges from 0.05%, rising to
0.57% in children less than one year of age.<ref>Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult
pediatric airway. Pediatr Anesth 2010; 20: 454-64. http://onlinelibrary.wiley.com/
doi/10.1111/j.1460-9592.2010.03284.x/pdf</ref><sup></sup> Difficult intubation is more common in children with cleft lip
and palate (4.7%) and cardiac abnormalities (1.25%),
most likely related to associated syndromes or limited
cardiac reserve.

An audit of difficult airway management in the UK
in 2001 (the 4th National Audit Project, NAP 4),
prospectively measured major airway complications
in almost 115,000 patients undergoing anaesthesia.<ref>The 4th National Audit Project of the Royal College of Anaesthetists and the
Difficult Airway Society: Major Complications of Airway Management in the
United Kingdom. March 2011. http://www.rcoa.ac.uk/nap4/</ref><sup></sup>
Children comprised a small proportion of the total
population, and complications were rare (only 7-8%
of total complications).

Common contributing factors to bad outcomes were:
:• Poor airway assessment
:• Poor planning
:• ‘Failure to plan for failure’
:• Repeated attempts at intubations
:• Lack of monitoring (oxygen saturation and capnography)
:• Slow response to hypoxia resulting in bradycardia leading to cardiac arrest
:• Failure to use devices such as the laryngeal mask airway (LMA) when faced with a difficult intubation.

One of the key findings in NAP4 was the ‘failure to
plan for failure’. Airway management plans should
always include a back-up plan to use if the first plan
fails. Whenever unexpected difficulties occur, seek
experienced help immediately. Another key finding
of NAP4 was that repeated attempts at intubation can
cause severe airway oedema in children and worsen the
situation, hence their recommendation, ‘a change of
approach is required, not repeated use of a technique
that has already failed’.
Many countries have adult guidelines for management
each of difficult airways, but few have child specific
guidelines. The Association of Paediatric Anaesthetists
of Great Britain and Ireland (APA) published paediatric
guidelines in 2012, which are shown in Figures 1-3
and form the basis for management of the unexpected
difficult airway discussed here.<ref>The Association of Paediatric Anaesthetists (APA) Guidelines for difficult airway
management in children. 2012. http://www.apagbi.org.uk/publications/apaguidelines</ref><sup></sup>

== AIRWAY ASSESSMENT ==
Proper airway assessment, proper planning for airway management,
and the use of monitoring are essential basic principles for safe
anaesthesia in children.
Airway assessment may be considered in two parts:

Will facemask ventilation be difficult?
:• A tumour or abnormal face shape may prevent the facemask from sealing easily over the face.
:• Syndromes associated with midface hypoplasia
:• Children with severe obstructive sleep apnoea (e.g. tonsillar hypertrophy).

Will intubation be difficult?

Factors that may predict difficult intubation in children include:
:• Mandibular hypoplasia e.g. syndromes such as Pierre Robin
:• Poor mouth opening
:• Obstructive sleep apnoea
:• Stridor
:• Syndromes associated with facial asymmetry. Note ear abnormalities are often associated (e.g. Goldenhar syndrome).


Various tests and scoring systems have been suggested for use in
adults. Many have a very poor sensitivity and/or specificity and are
not validated in children. However, assessment of the following is
essential. The anaesthetist may need some ingenuity to achieve these
assessments in a small uncooperative child!
:• Mouth opening
:• Range of neck movement
:• Mandibular hypoplasia - micrognathia makes intubation difficult.

Assess the airway by observing the child in side view rather than
from the front.
:• Mandibular hyperplasia - ameloblastoma may cause jaw protrusion and can make laryngoscopy and intubation difficult
:• Inspection of the oral cavity (e.g. for intraoral masses).

The Mallampati score can be used for older children who are
cooperative. Even though there is no validated scoring system in infants
and young children, the anaesthetist must still make a risk assessment,
and decide on the anticipated difficulty of intubation. This airway
assessment must be documented in the anaesthetic record.<ref>World Health Organisation. Guidelines for Safe Surgery 2009. http://whqlibdoc.
who.int/publications/2009/9789241598552_eng.pdf and http://www.who.int/
patientsafety/safesurgery/en/</ref><sup></sup>

== PLAN FOR AIRWAY MANAGEMENT ==
After airway assessment, a structured plan for airway management
is required before induction of anaesthesia. The plan must consider:
:• Choice of airway e.g. facemask, supraglottic airway device or tracheal tube
:• Mode of ventilation e.g. spontaneous ventilation or positive pressure
:• Monitoring e.g. pulse oximeter (minimum); end tidal carbon dioxide.

Due to a lower functional residual capacity (FRC) and higher
metabolic rate, oxygen saturation falls much faster in infants and
young children than adults. Preoxygenation before induction of
anaesthesia establishes a reservoir of oxygen in the lungs by displacing
nitrogen. This means a patient can remain oxygenated for longer than
otherwise expected, which gives more time to address unexpected
airway problems. Therefore preoxygenation is an important part of the
airway management plan and should form part of normal anaesthetic
practice wherever possible, even in children.

== THE UNEXPECTED DIFFICULT AIRWAY ==
Problems with airway management may be due:
:1. Difficult mask ventilation
:2. Difficult tracheal intubation
:3. Can’t intubate and can’t ventilate (CICV).


The first step is to administer 100% oxygen and call for help. Another
pair of hands is always useful.

The next step is to consider – is this a problem with the equipment or
the patient? All equipment should be checked prior to induction of
anaesthesia to minimise the chance of equipment failure.
===1. Difficult mask ventilation===
A simple algorithm for the management of difficult mask ventilation
is given in Figure 1.

====Difficult mask ventilation – equipment problems====
Equipment failure should be excluded quickly – check the mask,
circuit, and oxygen supply. Always have a self-inflating bag available
in case of equipment problems.
====Difficult mask ventilation – patient factors====
These can be divided into anatomical or functional problems.
Anatomical problems associated with difficult mask ventilation may
be due to poor head positioning, large adenoids/tonsils, or due to
airway obstruction from cricoid pressure (if used).
Functional problems may arise in the upper or lower airways. Upper
airway obstruction may be due to inadequate depth of anaesthesia and
laryngospasm; lower airway problems include inflation of the stomach
(very common in infants), bronchospasm or chest wall rigidity (rare).
====Management of difficult mask ventilation:====
:• Adjust the head position – does the child need a head roll (or
should the head roll be removed)
:• Use simple airway opening manoeuvres (chin lift, jaw thrust)
:• Apply positive end expiratory pressure (PEEP)
:• Adjust cricoid pressure if it has been used
:• Insert an oropharyngeal airway (if the patient is deep enough)
:• Increase depth of anaesthesia
:• Ventilate using a two-person technique (one holding the mask with two hands, the other ventilating by squeezing the bag)
:• Pass a nasogastric tube to deflate the stomach.

[[File:Difficult_mask_ventilation_algorithm.jpg|800px|center|thumb|Figure 1. Difficult mask ventilation algorithm. Reproduced with kind permission of Association of Paediatric Anaesthetists]]

If mask ventilation is impossible despite all the above measures or the
child’s oxygen saturation begins to fall:
:<b>EITHER</b> insert an LMA (if available),
:<b>OR</b> deepen anaesthesia, attempt to visualise the vocal cords and intubate the trachea.

There is no randomised controlled trial to assess which is the best
response, but insertion of an LMA is recommended first, and then
intubation (Figure 1).

If oxygenation and ventilation is satisfactory through the LMA or
tracheal tube then it is safe to proceed with surgery.

If in doubt, wake the child up.

===2. Unexpected difficult tracheal intubation===
A simple algorithm for the management of unexpected difficult
tracheal intubation is given in Figure 2.

The key point is, if tracheal intubation fails, DO NOT simply repeat
what has just failed. Multiple attempts at intubation may traumatise
the airway and will cause airway oedema, which may make the child
impossible to intubate. Intubation attempts must be limited to a
maximum of three or four (Figure 2).

If the first intubation attempt fails, it is essential to make changes
that improve the chance of successful intubation. These may include:
:• Change of personnel (a more senior anaesthetist);
:• Change of position
:• Change of equipment.

Visualisation of the larynx and successful tracheal intubation are
improved by:
:• Proper positioning of the child,
:• External laryngeal manipulation
:• Adequate depth of anaesthesia and adequate muscle paralysis (if this has been used).

Simple aids such as a bougie or stylet may make intubation
straightforward even when the view of the larynx is poor. An alternate
laryngoscope may also be used if available and if the operator is familiar
with its use.

Straight bladed laryngoscopes are traditionally used in children under
one year old, but may be useful in older children, or in patients
with relative macroglossia. They can be used with a paraglossal or
retromolar technique. McCoy levering laryngoscopes are also available
for paediatric use, based on a Seward blade (sizes 1 and 2) and may
improve the view of the larynx, particularly if the view is obstructed
by a large epiglottis.

In addition to straight bladed and McCoy laryngoscopes, new alternate
laryngoscopes have been developed recently (see table 1). High quality
evidence supporting efficacy is largely absent in the life-threatening
scenario of unexpected failed intubation. Firm recommendations
cannot be made so many algorithms suggest alternate laryngoscopes/
techniques ‘should be considered’.

[[File:Difficult Tracheal Intubation Algorithm.jpg|800px|center|thumb|Figure 2: Difficult tracheal intubation algorithm. Reproduced with kind permission of Association of Paediatric Anaesthetists]]

{| class="wikitable"
|+Table 1. <i>Classification of rigid indirect laryngoscopes</i>
|'''Classification'''
|'''Description of technique'''
|'''Examples'''
|+
|‘Non-guided’ devices
|Provide an indirect view of larynx but require direction of tracheal tube towards larynx.
|Bullard laryngoscope
Glidescope

Storz DCI Videolaryngoscope

Storz C-MAC laryngoscope
|-
|‘Guided’ devices 
|Provide indirect view and act as a conduit for passage of tracheal tube.
|Airtraq
|-
|Optical stylets
|Provide indirect view via rigid or semi-rigid stylet, with a ‘loaded’ tracheal tube for railroading.
|Bonfils and Brambrink

Shikani

Lightwand
|}


<i>Alternate techniques</i>

Traditional laryngoscopes (curved, straight or McCoy levering blades)
give a direct view of the larynx. Alternate techniques use an indirect
approach with flexible or rigid equipment.

:• Flexible indirect laryngoscopy, in the form of fibreoptic intubation, is the established ‘gold standard’ for the management of the predicted difficult airway in adults (see below).
:• New rigid indirect laryngoscopes are available, including in paediatric sizes. Rigid indirect laryngoscopy has a place in the unexpected difficult tracheal intubation algorithm. The choice of device depends on local availability and expertise.

If visualising the larynx is impossible, then an LMA should be inserted.
LMAs provide a clear airway in the vast majority of children. This
allows delivery of ventilation, oxygenation and anaesthetic gases with
a lower risk of gastric insufflation. The LMA may also be used as a conduit for fibreoptic intubation (FOI) where necessary, or in older
children, the specifically designed intubating LMA, may be used.
If LMA insertion fails, then oxygenation and ventilation must be
provided by mask ventilation.

==== 3. Cannot intubate, cannot ventilate (CICV) - ‘rescue techniques’ ====
A simple algorithm for the management of ‘cannot intubate, cannot
ventilate’ is given in Figure 3.

Rescue techniques for the CICV situation have been extensively
researched in the adult literature, but their use in paediatric emergencies
is more anecdotal than evidence-based. The choice is between a surgical
or needle (cannula) technique for cricothyroidotomy. The technique
for cannula cricothroidotomy is shown in Figure 3, and for surgical cricothyroidotomy, in Table 2.


[[File:CICV_Algorithm.jpg|800px|center|thumb|Figure 3: Can’t intubate can’t ventilate algorithm. Reproduced with kind permission of Association of Paediatric Anaesthetists ]]

{| class="wikitable"
|+Table 2. <i>Technique for surgical cricothyroidotomy</i>
|1. Position the patient so that the neck is fully extended so that the trachea and larynx are pushed forward
|-
|2. Locate the cricothyroid membrane and stabilise the trachea
|-
|3. With a scalpel blade make a stab incision through the skin and cricothyroid membrane*
|-
|4. Insert a tracheal hook or retractor at the lower edge of the incision
|-
|5. Pass an appropriately sized tracheal or tracheostomy tube
|-
|6. Ventilate patient and assess effectiveness
|-
|7. Secure the tube
|-
|}
<i>*Arterial forceps, the scalpel blade and tracheal dilators may be used to dilate the orifice</i>


Since there is no randomised controlled trial of one technique versus
another, the choice should be determined by local experience and
availability of equipment. This includes utilising the surgeon who may
be more experienced than the anaesthetist. Adult evidence suggests
surgical cricothyroidotomy is preferable, so this is recommended in
older children.

The important factor is that at least one technique is actually attempted
by someone in the CICV situation when the oxygen saturations are
less than 80% and falling and/or the heart rate is decreasing.
The CICV situation is a particular challenge in infants and small
children, due to important anatomical differences:
:• The trachea is small, elastic, flaccid and mobile, and so prone to collapse during insertion of a transtracheal device.
:• The cricothyroid membrane is much smaller, with an average size of only 2.6 x 3mm, smaller than the smallest tracheal tubes.
:• It is more difficult to locate the cricothyroid membrane than in adults due to a differing orientation of the hyoid bone and the cricoid and thyroid cartilage. This orientation also increases the chance of laryngeal trauma during cricothyroidotomy.
:• It is easier to locate the space between the tracheal rings rather than the cricothyroid membrane.

Together these factors mean it may be more appropriate in infants
and small children to perform a surgical tracheostomy.

All ‘rescue techniques’ have significant potential for complications so
should only be performed in life threatening situations. Clearly, all the
steps for difficult facemask ventilation should be tried first. If muscle
relaxants have been used and can be reversed, wake the child up.

== THE EXPECTED DIFFICULT AIRWAY ==
If the preoperative airway assessment alerts the anaesthetist to expected
difficulties in airway management then there are three key questions:
:1. Does the anaesthetist have the necessary paediatric airway experience?
:2. Does the hospital have the necessary paediatric equipment?
:3. Does the relative benefit of the planned surgery outweigh the possible risks of anaesthesia?

If there is any doubt, full discussion should take place with the parents
(or carers), child, surgeons and anaesthetists. It may be appropriate
for the child to be referred to specialist hospital or wait for a more
experienced paediatric anaesthetist to attend.

The anaesthesia plan must be carefully considered, including what to
do if tracheal intubation is unsuccessful; will the child be woken up,
or will a tracheostomy be necessary. The anaesthesia plan should be
communicated clearly to the whole theatre team including surgeons
and nursing staff. Difficult airway equipment must be checked and
prepared.

The primary plan for management of the expected difficult paediatric
airway will likely be one of the following:
:1. Laryngoscopy anticipated to be difficult but may be possible: Attempt laryngoscopy and intubation. If fails, consider repositioning and try alternate laryngoscopes if available, or insert LMA and perform fibreoptic intubation (FOI) via LMA.
:2. Laryngoscopy predicted to be impossible: Perform nasal FOI or insert LMA and perform FOI via LMA.
:3. Laryngoscopy and LMA insertion known to be impossible: perform nasal FOI.
:4. Laryngoscopy, LMA insertion and nasal FOI not available or known to be impossible: perform tracheostomy either using inhalational anaesthesia via face mask or  intravenous ketamine especially if face mask anaesthesia impossible.

Blind intubation through an LMA is NOT recommended in children
due to risk of airway trauma. Attempts at FOI should be limited to two
and if unsuccessful, consider waking child, or continue with surgical
procedure on an LMA. In situations where LMAs are unavailable,
ventilation by face mask is the alternative. If neither LMAs nor FOI
are available, the surgeon and anaesthetist need to discuss whether
the benefits of surgery outweigh the risk of attempting anaesthesia
in a child with a known difficult airway with insufficient equipment
to provide safe management. This is a very difficult decision and will
depend on the individual merits of each case.

=== Premedication ===
The use of sedative premedication in a child with a potential airway
problem is controversial. A frightened, screaming child producing
lots of secretions and in whom it is difficult to place monitoring,
intravenous cannula, and even approach to do an inhalational
induction, is also a risk.

Therefore, a small dose of sedative premedication, such as midazolam
0.3-0.5mg.kg<sup>-1</sup> is often appropriate. Atropine is useful as an antisialogue
(30-40 micrograms.kg<sup>-1</sup> PO or 20 micrograms.kg<sup>-1</sup> IM). Peak effect of
atropine is 90 minutes if given PO, 25 minutes if given IM.

=== Anaesthetic technique ===
The most important principle in managing the difficult airway in
children is to maintain spontaneous ventilation until the airway is
secure.

‘Awake’ techniques require good patient co-operation, which is rarely
possible in children. Therefore, the child must be anaesthetised so the
choice is between an inhalational or intravenous technique. The variety
of airway problems encountered in children means the anaesthetic
must be tailored to the individual situation:
:• Large extraoral tumours may mean a face mask will not fit the child’s face, so an inhalational induction is impossible and IV induction/sedation must be used instead.
:• Large intraoral tumours prevent laryngoscopy and the use of an LMA - nasal fibreoptic intubation (FOI) should be used.
:• Conditions such a noma (cancrum oris) often cause severe limitation of mouth opening - nasal FOI is likely to be required.
:• Other problems such as partial mouth opening, severe retrongathia or bony abnormalities (ameloblastoma) often make laryngoscopy difficult but do permit the insertion of an LMA if laryngoscopy proves impossible.
:• Burns contractures causing fixed flexion of the neck may be released prior to intubation using ketamine anaesthesia and with local infiltration.

The variety of clinical conditions mean a one-size-fits all approach is
impossible. The best technique will depend on the equipment and
expertise available, as well as the nature of the difficult airway.

Inhalational induction, using halothane or sevoflurane in 100%
oxygen, is generally recommended Intravenous access may be
established either before or after induction but must occur before
airway instrumentation. The general technique is to deepen anaesthesia
until laryngoscopy is tolerated or LMA inserted or FOI performed
depending on the airway management plan.

If inhalational induction is impossible, small doses of IV induction
agent should be given to induce loss of consciousness but still
preserving spontaneous ventilation. Propofol 0.5-1mg.kg<sup>-1</sup> or ketamine
0.5-1mg.kg<sup>-1</sup> should be given and titrated to effect.

If inhalational induction is not possible due to pain, for instance, from
an infected facial mass/tumour (rather than because of a large extraoral
tumour meaning a face mask will not fit), give a small dose of ketamine,
then apply the face mask and deepen anaesthesia by spontaneous
inhalation with sevoflurane or halothane. In our experience, this
combination provides better conditions for laryngoscopy than when
using intravenous ketamine alone.


<i>Nasal fibreoptic intubation – general</i>
:• Maintain anaesthesia either with incremental doses of ketamine or inhalational anaesthesia either via a nasal airway in the other nostril connected to the breathing circuit or using a specially designed facemask with a port for insertion of the fibreoptic bronchoscope.
:• Use a topical vasoconstrictor to prevent bleeding from the nose during FOI, as otherwise this may make intubation impossible. Pseudoephedrine, ephedrine, phenylephrine, oxymetazoline, or nasal packs soaked in 1:10,000 adrenaline may be used, depending on local availability.
:• Apply topical lidocaine to the nose and oropharynx. Larger fibreoptic laryngoscopes often have a channel through which local anaesthesia can be injected. Alternatively an epidural catheter can be passed through the suction port (if present) and local anaesthetic injected through this. Be careful not to exceed the maximum dose of lidocaine (3mg.kg<sup>-1</sup> i.e. 0.3ml.kg<sup>-1</sup> of a 1% solution).

The correct size of tracheal tube is critical to success. Too large a
tube will fail and require the bronchoscope to be withdrawn and the
procedure repeated. Too small may make subsequent positive pressure
ventilation difficult. It is sensible to use a small cuffed tube if available,
rather than repeated bronchoscopy.

{| class="wikitable"
|+Table 3. <i>Size compatibility of tracheal tubes, bronchoscopes and LMAs</i>
|Tracheal tube size ||2.5 ||3.0 ||3.5 ||4 ||4.5|| 5|| 6
|-
|Will fit through classic LMA size: ||1 ||1 ||1.5 ||2 ||2 ||2.5 ||3
|-
|Will fit over bronchoscope Outer Diameter: ||2.0mm ||2.5mm ||2.8mm ||3.5mm ||3.5mm ||4.1mm ||5mm
|-
|Will fit over AEC size: ||7F ||8F ||8F ||11F ||11F ||11F ||14F
|}
<i>[Note: different brands of LMA vary in their internal diameter. It is important to determine the compatibility of equipment within your own department.]</i>


<i>Fibreoptic intubation through an LMA</i>

There are three main techniques available:
:1. Railroad the tracheal tube over the fibreoptic bronchoscope into the trachea
:2. Railroad an airway exchange catheter (AEC) over the bronchoscope into the trachea.
:3. Pass a soft tip wire through the suction channel of the bronchoscope into the trachea, then pass an AEC or similar over the wire as a guide for the tracheal tube.

The choice of technique depends upon size of the child, the size of the
LMA, and the diameter of available bronchoscope (Table 3). Removal
of the LMA once the tracheal tube is in situ may be challenging.

Options include:
:• Leave the LMA <i>in situ</i>
:• Use a long tracheal tube (croup tube)
:• Fix two tracheal tubes together over the FOB; the LMA may be withdrawn over the tracheal tubes.
:• Use an AEC.


<i>Tracheostomy</i>

A tracheostomy should be performed by an experienced practitioner,
normally an ENT surgeon. Inhalational anaesthesia or small
incremental doses of ketamine (as above) may be given to supplement
local infiltration anaesthesia. The child should breathe 100% oxygen
by facemask.

== DIFFICULT AIRWAY CART ==
The equipment available in different institutions will vary considerably.
It is good practice to organise airway equipment in such a way that
it is readily accessible in an emergency. Many hospitals use a ‘difficult
airway cart’ to do this. This is simply a trolley or cart where all the
useful equipment for managing difficult airways is stored according
to the step-wise approach to managing a difficult airway.

For example, using the algorithms presented in this review, the difficult
airway cart could consist of a series of drawers or boxes containing:
:Drawer 1: simple laryngoscopes and airway adjuncts.
:Drawer 2: alternative laryngoscopes and LMAs.
:Drawer 3: equipment for fibreoptic intubation
:Drawer 4: equipment for CICV situations.

Whatever the availability and variety of equipment, the difficult airway
cart (or boxes) should always be stored in the same place, close to the
operating rooms, and the contents regularly checked. The cart should
be physically present in the operating room for any child with an
anticipated difficult airway; and can be quickly fetched when faced
with an unexpected problem.

== CONCLUSION ==
Unexpected difficult airways in paediatric practice are rare. Many
problems can be prevented by routine pre-operative airway assessment,
pre-oxygenation, and preparation of equipment. A simple step-wise
approach to management improves outcome. Anaesthetists have
a responsibility to be familiar with airway algorithms and make
pragmatic modifications to account for available resources.

== ADDITIONAL READING ==

Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiol 2009; 110 : 891-7.

Holm-Knudsen R. The difficult pediatric airway - a review of new devices for indirect laryngoscopy in children younger than two years of age. Pediatr Anesth 2011; 21: 98-103

Doherty JS, Froom SR, Gildersleeve CD. Pediatric laryngoscopes and intubation aids old and new. Pediatr Anesth 2009; 19 (Suppl. 1): 30-37 http://onlinelibrary. wiley.com/doi/10.1111/j.1460-9592.2009.03001.x/pdf

Walker RWM and Ellwood J. The management of difficult intubation in children. Pediatr Anesth 2009; 19 (Suppl. 1): 77–87 http://onlinelibrary.wiley.com/ doi/10.1111/j.1460-9592.2009.03014.x/pdf

== REFERENCES ==