Tiny airways, high stakes: What every clinician should know about infant airway management in 2025

Paediatric airway management, particularly for neonates and infants, significantly differs from adult management due to unique physiological and anatomical considerations. Infants (under 1 year old) and neonates (under 30 days old) have high rates of oxygen consumption and reduced functional reserve capacity. Their closing capacity approaches functional reserve capacity, especially in the supine position.[1] Consequently, timely delivery of oxygenation is essential, as hypoxemia from apnoea can occur rapidly, leading to bradycardia and potential cardiac arrest.[1] In addition to this high-risk physiology, neonates and infants present challenging airway anatomy. Laryngoscopy is more difficult due to a larger tongue relative to the oropharynx, a weak hypoepiglottic ligament resulting in a floppy epiglottis, and a more cephalad laryngeal inlet.[1] A weight of under 10 kg is associated with increased risk of difficult bag-mask ventilation and laryngoscopy.[2,3] Together, these factors make neonatal and infant airway management a time-sensitive and high-risk task.

To address these challenges, clinicians and anaesthesiologists must limit cognitive errors, adopt evidence-based practices to prevent harm and improve outcomes, minimise intubation attempts, utilise video laryngoscopy (VL) when available, maintain flexible bronchoscopic skills, ensure access to appropriately sized supraglottic airways (SGAs), and selectively embrace emerging technologies. Despite advances in airway management technology, paediatric anaesthesia complications often stem from cognitive errors, technical skills issues, and the failure to integrate new evidence-based technologies into practice. In these high-stakes scenarios, positive outcomes depend on the provider’s skill, judgment, training, and familiarity with equipment.

The most important consideration in neonatal and infant airway management is not the airway itself or the equipment used but the clinician’s approach and mindset. Bordini et al.[4] found that cognitive errors occurred in 17.4% of cases from the Paediatric Difficult Intubation Registry. When cognitive errors occurred, complications were more likely. This retrospective analysis may not apply to all paediatric cases; however, it highlights that clinicians managing challenging airway situations often make specific mistakes, including fixation errors, omission errors, and overconfidence bias. Fixation errors involve focusing solely on one issue (e.g. successful intubation) without considering the broader clinical picture (e.g. increased airway swelling). Omission errors reflect a failure to act, such as hesitancy to perform advanced airway manoeuvres, including surgical airways. Overconfidence errors arise from the belief that additional help is unnecessary or that success can be achieved despite adverse circumstances. In Bordini et al.’s[4] analysis, all three types of errors occurred more frequently among non-anaesthesiologists.

To prevent cognitive errors, proper preparation for airway management is vital. In neonates and infants, preparation involves having the right equipment [Table 1], rescue options, considering apnoeic oxygenation, having extra personnel available, understanding the physiology of hypoxemia, and effective time management. Simple interventions, such as setting a time limit for each laryngoscopy attempt, can enhance patient care outcomes by mitigating human factors.[5] These care aspects should be organised into local guidelines that incorporate evidence-based recommendations from national organisations.

Table 1.

Necessary equipment for infant and neonatal airway management

Equipment	Description(s)
Oxygen delivery	Confirm functional oxygen source and backup.
Mask and oral delivery	Have appropriate-sized face masks and oropharyngeal airways on hand.
Tracheal tube, videolaryngoscope, and flexible bronchoscope	Select a proper endotracheal tube and videolaryngoscope blade, and have a flexible bronchoscope readily available.
Alternate tracheal tube sizes	Prepare smaller/larger tubes for rapid substitution.
Supraglottic airway (SGA)	Maintain SGA readily available for an unanticipated difficult airway
Patient positioning	Optimise head and neck position; adjust bed height; use shoulder roll as needed.
Suction	Test suction equipment and keep it accessible.
Apnoeic oxygenation	Implement apnoeic oxygenation techniques to reduce oxygen desaturation.
Intravenous access and emergency drugs	Ensure intravenous access; prepare induction and rescue medications.

Several guidelines outline principles for neonatal and infant airway management. The 2022 American Society of Difficult Airway Algorithm now includes a paediatric-specific difficult airway algorithm.[6] This algorithm serves as a crucial life-saving pathway in crisis situations. Hospitals and anaesthesiologists should familiarise themselves with and adopt this algorithm as standard practice. Additionally, the 2024 joint guidelines from the European Society of Anaesthesiologists and Intensive Care and the British Journal of Anaesthesia focus on best practices for neonatal and infant airway management. Clinicians should be familiar with and apply the 10 recommendations outlined in these guidelines [Table 2], particularly in situations involving a difficult airway or high risk.[7] Despite the guidelines being published in January 2024, a U.S. survey indicated limited adoption of some recommended principles, such as apnoeic oxygenation and initial use of VL.[8] Greater adoption is necessary to standardise airway management in this age group. These guidelines should also be integrated into national protocols across India as a resource. The goal of incorporating these guidelines is to delineate more invasive steps as the next appropriate action clearly.

Table 2.

Key principles adapted from the European Society of Anaesthesiologists and Intensive Care and the British Journal of Anaesthesia Neonatal and Infant Airway Management guidelines

Key Principle	Benefit
Thorough preoperative assessment	Identifies high-risk airways and guides preparation
Apnoeic oxygenation	Extends safe apnoea time and minimises desaturation
Video laryngoscopy	Improves glottic view and first-pass intubation success
Neuromuscular blockade	Enhances intubating conditions and laryngeal visualisation; reduction of reflex activation of the airway
Limit repeated intubation attempts.	Reduces overall complications, mucosal trauma, and airway oedema
Immediate supraglottic airway availability	Provides a rapid rescue strategy if intubation fails
Adequate level of sedation	Optimises intubating conditions and suppresses airway reflexes
Use of a stylet or pre-shaped tracheal tube for hyperangulated laryngoscopy	Aligns the tracheal tube trajectory with the curvature of the hyperangulated blade for smoother passage
Confirm tracheal tube placement with end-tidal carbon dioxide	Provides reliable confirmation of correct tracheal tube placement
Use high-flow nasal cannula or non-invasive positive pressure ventilation post-extubation	Supports oxygenation and functional residual capacity and extends the safe apnoea time for troubleshooting

Simulation and training regarding crisis scenarios for this age group, where time and oxygenation are critical, can help reduce cognitive errors. Education that focuses on crisis resource management principles and human factors enables teams to operate at their best and avoid common errors.[9] Additionally, hospitals might develop specialised paediatric airway teams to respond to crises.[10] Although these teams involve costs for equipment and personnel, they can provide valuable expertise in rare situations.[11]

As Bordini et al. noted, fixation errors are common, and repetitive use of the same technique in airway management should be avoided. Clinicians must limit attempts at direct laryngoscopy (DL) and quickly escalate to the most experienced airway provider. After 1–2 failed attempts at DL, no further attempts should be made without significant adjustments, which may include switching to a more experienced provider, using a different blade, optimising patient positioning, or transitioning to a VL system.[7] These steps are prudent because mortality and complications increase after more than two intubation attempts in paediatric difficult airways.[2] Repeated attempts can lead to rapid airway swelling, making a stable situation life-threatening by reducing the ability to effectively perform mask ventilation.[12]

When available, VL should be used instead of DL for the first attempt in neonatal and infant airways. VL improves first intubation success rates in these patients compared to DL.[13,14] However, exclusive use of VL could lead to insufficient training for new anaesthesiologists in DL, which may be necessary in emergencies such as equipment failure or power outages.[15] Nevertheless, DL skills can still be taught on VL systems with standard blades and the right educational setup.[16] Additionally, VL technology is expensive and not universally available.[17] Hospitals should invest in VL technology due to its life-saving potential and reduction in airway complications. Given the critical need for quick intubation attempts in this age group, making the first attempt the best attempt is essential.

While VL is a mainstay in difficult airway management, it is not the only tool available for use. Clinicians often have better success intubating children under 5 kg with flexible bronchoscopic intubation than with VL.[18] Although first-attempt success rates do not significantly differ between VL and flexible bronchoscopic intubation (43% vs 62%, respectively), eventual success is higher with bronchoscopic intubation (71% vs 90%).[18] To effectively manage challenging neonatal airway cases, airway experts must maintain proficiency in both VL and flexible bronchoscopic intubation, as neither is ideal for all patients. Specific anatomical features may lead a clinician to choose one method over the other. VL offers various blade options, including both standard and hyperangulated blades, each with unique advantages. Clinicians should recognise the strengths and weaknesses of both pieces of equipment and consider appropriate situations for their use.

Another important airway management device is the SGA. SGAs have long been used for airway rescue, especially in adults. With improved designs and additional sizes, SGAs have become essential in neonatal and infant airway management.[19] Appropriately sized SGAs should be readily available for all airway management situations. SGAs offer several advantages, including greater effectiveness than bag-mask ventilation in neonatal resuscitation,[20] rapid placement, use as a conduit for intubation,[21] and proactive use in anticipated difficult airways before induction.[22] Early use of SGAs is vital in counteracting hypoxemia and restoring oxygenation and ventilation in difficult situations.

While the last decade has seen dramatic improvements in SGA design, VL technology, and high-flow nasal cannula devices, ongoing technological advancements are likely to continue enhancing neonatal and infant airway management. One promising avenue is incorporating artificial intelligence and machine learning into airway equipment.[23] Additionally, 3D printing may increase access to VL technology by lowering costs and may provide patient-specific designs for anticipated difficult airway management.[24,25] Furthermore, airway exchange catheters with video capabilities and stylets designed for adult use may soon be adapted for neonatal or infant applications.[26,27] As technology evolves, these tools should be thoughtfully integrated into neonatal and infant airway management. Hospitals should carefully evaluate the advantages, disadvantages, and costs of new devices relative to existing airway technologies before investing.

Although neonatal and infant airway management presents significant risks, successful outcomes can be achieved with the use of appropriate algorithms, equipment, and training. International guidelines should be adapted to fit local realities, including available resources and staffing. Escalation pathways must be developed, understood, and implemented to prevent harm and ensure an effective response. To do this, hospitals and medical systems must invest in the necessary technology and staffing to ensure safe care delivery, alongside hands-on training and realistic simulations to minimise cognitive errors during airway management. By equipping teams with the right skills and tools, outcomes can improve. By taking these steps, we can bridge the gap between human error and technological potential. With the diligent application of the latest guidelines, the adoption of novel technology, standardisation of practices, and improved decision-making in airway management, even the smallest airways can be safely managed. Ultimately, the path to safer paediatric airway care lies in aligning our thinking, training, and tools to meet the needs of every child.

Authors contribution

MR: concept and design, interpretation of data, manuscript preparation. MJ: concept and design, literature search, acquisition. of data, manuscript preparation. NJ: concept and design, manuscript editing and review, and revising critically important intellectual content.

Conflicts of interest

There are no conflicts of interest except that NJ serves on the editorial boards of Anesthesia & Analgesia, Pediatric Anesthesia, & Journal of Clinical Anesthesia.

Presentation at conferences/CMEs and abstract publication

Nil.

Study data availability

Not applicable.

Declaration of Use of Permitted Tools

Not applicable.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI.

Funding Statement

Nil.