The Difficult Pediatric Airway

The pediatric airway is different from the adult airway both anatomically and physiologically. Apart from obligate miniaturization, there are many clinical scenarios giving rise to a difficult airway situation in the pediatric population. In neuroanesthesia, these are commonly hydrocephalus, craniosynostosis, encephalocele, cervical spine instability, and immobility. Physical examination to predict the potentially difficult airway should be guided from the knowledge of normal anatomy and the associated syndromes. The gold standard of awake fiber optic intubation in adults does not apply to the pediatric population in most cases. Maintenance of spontaneous ventilation after induction of anesthesia is key to managing the difficult airway. A number of difficult airway tools are available. A plan for extubation is extremely important, and delayed extubation should be considered in situations of traumatic intubation. The critical patients may require interdisciplinary management between anesthesiologists, intensivists, pediatric otorhinolaryngologists, and surgeons.