Development of a guideline for the management of the unanticipated difficult airway in pediatric practice

Paediatr Anaesth. 2015 Apr;25(4):346-62. doi: 10.1111/pan.12615. Epub 2015 Feb 16.


Background: Most airway problems in children are identified in advance; however, unanticipated difficulties can arise and may result in serious complications. Training for these sporadic events can be difficult. We identified the need for a structured guideline to improve clinical decision making in the acute situation and also to provide a guide for teaching.

Objective: Guidelines for airway management in adults are widely used; however, none have been previously devised for national use in children. We aimed to develop guidelines for the management of the unanticipated difficult pediatric airway for use by anesthetists working in the nonspecialist pediatric setting.

Method: We reviewed available guidelines used in individual hospitals. We also reviewed research into airway management in children and graded papers for the level of evidence according to agreed criteria. A Delphi panel comprising 27 independent consultant anesthetists considered the steps of the acute airway management guidelines to reach consensus on the best interventions to use and the order in which to use them. If following the literature review and Delphi feedback, there was insufficient evidence or lack of consensus, regarding inclusion of a particular point; this was reviewed by a Second Specialist Group comprising 10 pediatric anesthetists.

Results: Using the Delphi group's deliberations and feedback from the Second Specialist Group, we developed three guidelines for the acute airway management of children aged 1-8 years.

Conclusions: This paper provides the background, available evidence base, and justification for each step in the resultant guidelines and gives a rationale for their use.

Keywords: cricothyroidotomy; intratracheal; intubation; pediatric anesthesia; practice guidelines; supraglottic airway.

Publication types

  • Guideline
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Airway Management / instrumentation
  • Airway Management / methods*
  • Child
  • Child, Preschool
  • Consensus
  • Delphi Technique
  • Humans
  • Infant
  • Intraoperative Complications / therapy*
  • Intubation, Intratracheal / adverse effects
  • Intubation, Intratracheal / methods
  • Laryngeal Masks / adverse effects
  • Oxygen / blood
  • Patient Positioning
  • Stomach Diseases / etiology
  • Tracheostomy


  • Oxygen