All India Difficult Airway Association 2025 guidelines for the management of unanticipated difficult airway in paediatrics under general anaesthesia

Abstract

The paediatric airway differs from the adult airway both anatomically and physiologically. These guidelines are recommended for use in unanticipated difficult airways in children aged 1–12 years. If the initial intubation attempt fails, the anaesthesia team should “Call for help” (Code D) and prioritise providing oxygen to maintain peripheral oxygen saturation (SpO₂) above 95%. While awaiting help, the anaesthesia team may re-attempt tracheal intubation, this time by a more experienced operator, after reoptimising position and considering alternate airway devices. The anaesthesiologist may opt for a 2^nd generation supraglottic airway (SGA) device as a rescue device or continue the anaesthetic using a face mask (FM). Maintaining oxygenation throughout the period is essential. The current guidelines introduce a circular design for the algorithm, allowing device interchangeability. If satisfactory oxygenation is achieved with either a 2^nd generation SGA device or FM, the decision to continue anaesthesia or wake the child will depend on the urgency of the procedure and the comfort of the anaesthesiologist. If satisfactory ventilation cannot be maintained with a 2^nd generation SGA device or FM or following a failed tracheal intubation, declare “complete ventilation failure” and prepare for an emergency surgical airway. The options for emergency surgical airway depend on the availability of trained surgical help and the age of the child. Post-resuscitation care should address the various steps taken to return the child to normalcy and to discharge. This should include giving an “Airway Alert Card” to the parents to avoid similar life-threatening situations in future.

DISCLAIMER

These guidelines have been developed to help clinicians manage unanticipated difficult intubations in patients using evidence-based recommendations or Delphi consensus opinions from airway experts, wherever evidence was lacking or weak. These guidelines do not represent the minimum standard of practice, nor are they a substitute for good clinical judgment. The recommendations in the guidelines assume that the airway operator has adequate experience with the devices and techniques described and that these are applied within the scope of their practice. Recommendations regarding the use of specific resources (devices, medications, or workforce) apply where these resources are available. These recommendations should be viewed as aspirational, when this is not the case. While careful attention has been paid to provide accurate and updated information, the authors acknowledge that the literature related to airway management is rapidly changing, altering our attitudes and clinical practice. It is important to note that the application of these recommendations in specific settings remains the responsibility of the clinician.

INTRODUCTION

The paediatric airway differs from the adult airway both anatomically and physiologically. Children have higher metabolic oxygen demands, lower functional residual capacity (FRC), and a shorter safe apnoea time. They are at risk of rapid desaturation and trauma when securing the airway.[1] Managing a difficult airway (DA) in children can be particularly challenging even for an experienced anaesthesiologist. Encountering an unexpected difficult airway after induction of anaesthesia is one of the most concerning clinical situations as it can rapidly result in life-threatening complications.

All India Difficult Airway Association (AIDAA) published its first guidelines in 2016, and since then, numerous studies have highlighted the issue of unanticipated difficult airway in the paediatric population.[2] The Pediatric Difficult Intubation (PeDI-C) study found that 20% of difficult paediatric intubations led to peri-operative complications, with 3% of these complications being severe and 1% resulting in cardiac arrest.[3] The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) trial reported a high incidence of unanticipated difficult intubation in neonates and infants, emphasising the need to minimise attempts and related complications.[4,5] The APRICOT study identified a 3.1% incidence of respiratory critical events in children undergoing anaesthesia, with difficult intubation rates of 0.28% in 15-year-olds, rising to 1%–1.1% in those under 1 year.[6] Additionally, the Pediatric Perioperative Cardiac Arrest (POCA) Registry highlighted that airway and respiratory complications are major causes of paediatric peri-operative cardiac arrest, with underreporting affecting the true incidence rates.[7]

Paediatric airway management is constantly evolving with the introduction of new devices and techniques. Recently, a diverse range of airway equipment has been developed specifically for the paediatric population.

HOW DO THE AIDAA 2025 GUIDELINES DIFFER FROM THE 2016 GUIDELINES?

In the AIDAA 2025 guidelines, the recommendations and best practice statements have been categorised according to the American Heart Association (AHA) Class of Recommendation and Level of Evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care. In addition, for interventions where the evidence was absent or weak, a Delphi process among airway experts was convened to generate expert practice statements. The AIDAA 2016 guidelines did not include graded recommendations.

The AIDAA 2016 Paediatric guidelines were based on the premise that tracheal intubation was the primary method for airway management. It followed a hierarchical linear design that lacked flexibility for using different airway devices.[2] It also did not consider alternative approaches if intubation failed. Airway management has witnessed major advances in recent times, providing various new techniques and options.

AIDAA has updated its guidelines for difficult airway management (2025) in children aged 1–12 years. The current guidelines introduce a circular design for the algorithm, allowing device interchangeability. A terminology, “Code D”, has been introduced as the hospital emergency code to indicate that the patient has a difficult airway and immediate assistance and intervention is needed. These guidelines are designed to assist specialist paediatric anaesthesiologists and those anaesthesiologists who work infrequently with paediatric patients. The role of peri-intubation oxygenation and use of waveform capnography to confirm tracheal tube placement has been further emphasised in the AIDAA 2025 guidelines. They should be used alongside the “All India Difficult Airway Association 2025 Guidelines for the Management of Unanticipated Difficult Airway in Adults under General Anaesthesia”.[8]

METHODS

Based on the literature review and discussions among the Paediatric Guideline Subcommittee members, five PICO (Patient/Population, Intervention, Comparison, and Outcome) questions were formulated. A systematic literature search, data extraction, and evidence synthesis were conducted for each PICO question. The literature search was performed in PubMed and Scopus, covering the period from January 2000 to December 2024, using search strings tailored to each PICO question. A concept table, search strings, and PRISMA flowcharts outlining the search process for each PICO question are summarised in Appendices (1–5). All retrieved articles were imported into the Rayyan software (Rayyan Systems Inc., Cambridge, Massachusetts, USA; http://rayyan.qcri.org)[9] for initial screening. Two reviewers independently screened the titles and abstracts of each article and selected the final list of full-text studies for inclusion. A table of the shortlisted articles was compiled.

The evidence was summarised, and recommendations were categorised according to the AHA Class of Recommendations and Level of Evidence for clinical strategies, interventions, treatments, or diagnostic testing in patient care.[10] [Table 1] Where evidence was absent or weak, the Steering Committee initiated a Delphi process to reach consensus (75% or above) among airway experts.[11] [Table 2] Statements were included in successive Delphi rounds until stability criteria were met. Expert consensus statements were then drafted based on survey items that reached consensus. Complete details of the guideline development process and methodology, including the Delphi process, are provided in the All India Difficult Airway Association 2025 guidelines for the management of unanticipated difficult airway in adults, obstetrics, and paediatrics and the management of at-risk extubations: Guideline development process and methodology.[12]

Table 1.

Summary of recommendations and best practice statements

Clinical Research Question	Recommendation/best practice statement	Type of statement	Class (strength) of recommendation	Level (quality) of evidence
Does apnoeic oxygenation increase the time to desaturation in paediatrics?	HFNO or low-flow nasal oxygen can be beneficial in increasing the time to desaturation in paediatric patients (1–12 years)	Best Practice Statement	Class 2a	B-R
Does videolaryngoscopy enhance the success rate of intubation compared to direct laryngoscopy in paediatric patients?	Videolaryngoscopy is not beneficial in enhancing the success rate of intubation compared to direct laryngoscopy, despite improving the glottic view in children.	Best Practice Statement	Class 3 (benefit=risk)	B-R
Does neuromuscular blockade improve face mask ventilation in children?	The neuromuscular blockade may be considered to improve face mask ventilation in children.	Best Practice Statement	Class 2b	B-NR
Does two-handed mask ventilation technique improve face mask ventilation in children?	Two-handed mask ventilation technique may be considered to improve face mask ventilation in children.	Best Practice Statement	Class 2b	B-R
Is tracheostomy the preferred technique for emergency surgical airway in children when trained surgical help is available?	Whenever experienced surgical help is available, tracheostomy may be considered as the preferred technique in situations of complete ventilation failure in paediatric patients.	Best Practice Statement	Class 2b	C-LD

HFNO=High Flow Nasal Oxygen

Table 2.

Expert consensus statements using Delphi methodology

Clinical Question	Expert Consensus Statement	Consensus (%)
What is the maximum number of attempts at tracheal intubation that should be permitted to limit airway management-related complications in paediatric patients*?	A maximum of 2+1 attempts (additional attempt should only be done by an anaesthesiologist with experience in paediatric airway management) at tracheal intubation should be permitted to limit airway management-related complications in paediatric patients*.	91%
What is the maximum number of attempts at supraglottic airway (SGA) insertion that should be permitted to limit airway management-related complications in paediatric patients*?	A maximum of two attempts at SGA insertion should be permitted to limit airway management-related complications in paediatric patients*.	87%
What nasal oxygen flow rate should be used for apnoeic oxygenation (during attempts at intubation) in paediatric patients*?	A nasal flow of 1–2 L/kg/min (using a HFNO cannula) should be used for apnoeic oxygenation (during attempts at intubation) in paediatric patients*.	92%
Can administration of CPAP improve mask ventilation when difficulty in mask ventilation is encountered in paediatric patients*?	Administration of CPAP may improve mask ventilation when difficulty in mask ventilation is encountered in paediatric patients*.	100%
Which anatomical site should be preferred in paediatric patients less than 5 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available?	A cricotracheal puncture should be preferred in paediatric patients less than 5 years of age for performing emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available.	100%
Which anatomical site should be preferred in paediatric patients between 5 and 12 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available?	A cricothyroid puncture should be preferred in paediatric patients between 5 and 12 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available.	100%

*1–12 years. HFNO=High-flow nasal oxygen; CPAP=Continuous positive airway pressure; SGA=Supraglottic Airway

AIRWAY MANAGEMENT IN PAEDIATRIC PATIENTS: SPECIAL CONSIDERATIONS – OPTIMISING MASK VENTILATION

Face mask ventilation is the most crucial rescue technique for unanticipated difficult airway situations, particularly in children. The importance of using appropriate age- and weight-based equipment for children cannot be overstated. When a difficulty is encountered with face mask ventilation despite appropriate equipment, the following aspects should be considered:

1. Ensure that an adequate depth of anaesthesia is provided and maintained using either inhalational or intravenous agents.

2. Maintain upper airway patency during face mask ventilation; use a chin lift and jaw thrust. Ensure that your fingers do not compress the cheeks or submandibular soft tissues.[13] Also, take care to avoid compressing the external nares while holding the face mask.

3. The head should be kept in a neutral position for children, and it is advisable to use a shoulder roll.[13,14] This technique helps prevent neck flexion and reduces the risk of upper airway obstruction caused by tongue fall. Due to a prominent occiput and relatively larger tongues, young children are particularly vulnerable to airway obstruction.

4. Use appropriately sized airway adjuncts, such as oropharyngeal and nasopharyngeal airways, which can be beneficial.

5. Consider lateral position if face mask ventilation does not improve with other techniques described above in the supine position.[15,16] (Appendix)

6. Administering continuous positive airway pressure (CPAP) with 100% oxygen may improve mask ventilation by splinting the airway during instances of difficulty in paediatric patients.[17]

7. Consider using a two-hand or two-person bag-mask technique when face mask ventilation is difficult, especially for obese children, or those with syndromic conditions or micrognathia.[18] (Appendix)

8. Laryngospasm is a common cause of difficult mask ventilation in children. It should be considered whenever face mask ventilation fails. It can result from hyperreactive airways due to upper respiratory tract infections, secretions, or noxious stimuli at inadequate anaesthetic depth.[19] Initial management includes administering 100% oxygen, CPAP, and increasing the depth of anaesthesia with intravenous propofol.[20,21] If laryngospasm persists and desaturation occurs, intravenous suxamethonium (1–2 mg/kg) is recommended.[21] If laryngospasm does not subside, pressure at Larson’s point and endotracheal intubation should be considered to avoid progression to negative pressure pulmonary oedema.

9. Gastric distension can occur due to improper face mask ventilation and should be managed by inserting an orogastric or nasogastric tube to decompress the stomach. A rise in peak airway pressure often leads to gastric distension, which results in further difficulty in face mask ventilation due to splinting of the diaphragm and a reduction in the functional residual capacity (FRC).[14,22]

10. Consider administering a neuromuscular blocking agent based on the clinical judgement of an experienced anaesthesiologist.[23]

OPTIMISING LARYNGOSCOPY AND TRACHEAL INTUBATION

Airway equipment

Children under 12 years of age necessitate specialised airway equipment suitable for their age and weight. In the absence of appropriately-sized equipment, it is advisable to refrain from attempting elective management of a paediatric airway, given the increased risk of trauma to the delicate structures of a child’s airway. Ensuring that all necessary equipment sizes are stocked in the difficult airway cart before proceeding with airway management is essential.

Prerequisites for laryngoscopy

• Essential monitoring includes an electrocardiogram, a pulse oximeter, non-invasive blood pressure, and capnography.

• Pre-oxygenation with 100% oxygen is recommended, targeting an end tidal oxygen of 90% or higher, although this can be challenging in younger children due to face mask compliance issues.

• Before laryngoscopy, ensure an intravenous access is secured as dominance of the parasympathetic nervous system can cause bradycardia.

• Adequate depth of anaesthesia is essential for successful laryngoscopy as it improves visibility and facilitates a better view.[24]

• Oxygen should be administered via nasal prongs, catheters, or high-flow nasal cannulae during laryngoscopy and intubation for apnoeic oxygenation, commonly known as the “NODESAT” technique. (Nasal Oxygen During Efforts at Securing A Tube).

Laryngoscope type and laryngoscopy techniques

For direct laryngoscopy, either a Miller or Macintosh blade can be used. The Miller blade (straight blade) lifts the epiglottis directly, while the Macintosh blade is better for older children. Videolaryngoscopy improves the view across all age groups [Appendix]; a videolaryngoscope can be used if the necessary equipment and expertise are available.

Optimal positioning for laryngoscopy

The head, especially the occiput, is relatively large in younger children. The best neck position is neutral or slightly extended. Using a pillow or head ring can result in excessive flexion of the neck due to the large occiput. Hence, a pillow or ring is best avoided to optimise neck extension and better glottic visualisation during laryngoscopy.[13,14] The tragus should align with the anterior tip of the shoulder/sternum. In older children, the “sniffing the morning air” position, like adults, is beneficial.

External laryngeal manipulation (ELM)

The elongated epiglottis and elevated laryngeal position in children may require the anaesthesiologist to apply external pressure on the neck to obtain a good view of the laryngeal inlet. This external laryngeal manipulation (ELM) can be done in younger children using the little finger or the little and ring fingers while holding the laryngoscope.[13]

Bimanual laryngoscopy/Two-handed laryngoscopy

In some children, relying on one hand for laryngoscopy may not achieve optimum ELM. In such instances, the anaesthesiologist can use the other hand to apply external pressure, helping to manipulate the larynx and improve visibility of the glottis. A second anaesthesiologist (two-person laryngoscopy) can then assist in passing the tracheal tube (TT) through the glottis. If only the epiglottis is visible, alternative methods such as bougie, videolaryngoscope, or fibreoptic intubation may be considered.[13] With VL, the second anaesthesiologist can effectively provide ELM while monitoring the screen during intubation.

Intubation technique

TT is gently inserted under vision between the vocal cords up to the mid-trachea. In young children, the vocal cords slant downwards, and the tip of the TT may get caught at the anterior commissure. A slight rotation of the TT can help. Once the TT is in place, it is crucial to mark the depth at the gums or teeth for reference, allowing for repositioning if it shifts during fixation. Due to the short trachea, accidental endobronchial migration or extubation can occur, necessitating extra caution.

Videolaryngoscopy in children

Videolaryngoscopes eliminate the need to align the oral, pharyngeal, and laryngeal axes, offering improved glottic visualisation in paediatrics. They reduce intubation failure and complications in infants, though the benefits are less for older children.[25,26,27]. Device performance varies, with some showing higher success rates.[28] However, videolaryngoscopy does not significantly shorten intubation time or improve first-attempt success in the general paediatric population (Appendix). Videolaryngoscopy should be used only when an appropriate device is available and the operator is proficient.

Videolaryngoscopy has been utilised in paediatric patients using channelled (Airtraq^®, King Vision^®) and non-channelled (C-MAC^{® -} both Mac and hyperangulated D-blade, GlideScope^® and Truview^®) videolaryngoscopes.[29,30,31]

To improve the success of videolaryngoscopy, adhere to these four refined steps: (1) Insert the videolaryngoscope under direct vision to prevent blind insertion, (2) Enhance the glottic view by focussing on the screen, (3) Insert the TT under direct vision while maintaining direct visual access of the mouth, and (4) Finally guide the TT into the trachea while monitoring the screen. Following these steps is essential for minimising the risk of trauma during the insertion process.

Hyperangulated blades have a pronounced curvature and are suitable for standard DL. They require the TT to be shaped with a stylet to match the curvature of the blade.[32]

Video-assisted direct laryngoscopy (DL) is increasingly used for trainee education. As the trainee performs the DL procedure, the mentor provides real-time feedback from the screen, while the assistant can improve the view using the ELM or BURP manoeuvre.[33]

Use of intubation aids – Airway introducers (Stylets and Bougies), optical stylets, and airway exchange catheters in children

A stylet is a malleable stainless-steel device that can be adjusted to the curvature of the TT for appropriate angulation. They are beneficial with hyperangulated VL blades or when the glottis is anterior. However, one must ensure the tip of the stylet does not extend beyond the tip of the TT. Newer atraumatic stylets feature a PVC coating for added safety. Gum elastic bougies with and without a stiffening stylet and angulated tip are available. The tracheal tube can be railroaded over these in cases where visualisation of the glottis is difficult. They are available in paediatric sizes of 8 Fr and 11 Fr. An optical stylet is a tool that has a camera and a light source at the tip. It is used to assist intubation for patients with restricted mouth opening. Available in straight or curved designs, they can be rigid or semi-rigid and include an oxygen port to provide supplemental oxygen and prevent fogging. Optical stylets can be used alone or alongside a laryngoscope as a hybrid technique. The Bonfils, C-Mac, and Shikani Video stylets are available in paediatric sizes.[34,35] Airway exchange catheters are hollow, semi-rigid devices used during intubation, re-intubation, and extubation. They are longer than similar devices described above and are available in sizes of 8 Fr, 11 Fr, and 14 Fr.[35] Intubation aids should never be blindly inserted into the trachea as such practices could result in or cause severe airway trauma.[2]

Number of attempts at laryngoscopy

According to the Delphi consensus statement [Appendix], only two attempts at laryngoscopy should be permitted in children. The risk of complications increases with each additional attempt at tracheal intubation. Consequently, more than two attempts are linked to a higher rate of complications.[3,36,37,38,39] The number of laryngoscopy attempts includes the first failed attempt, which may have been a part of the primary airway management plan. Limiting attempts is crucial to prevent trauma and hypoxia as the paediatric airway is delicate and susceptible to trauma. Intermittent face mask ventilation with 100% oxygen should be performed between attempts to maintain oxygenation. Nasal apnoeic oxygen insufflation should be continued to extend the safe apnoea time. If the first attempt fails, seek additional help. The second attempt should be performed only with extra support and an oxygen saturation above 95%. A third attempt should be performed only by an anaesthesiologist who has experience in paediatric anaesthesia for exploratory purposes to understand the anatomy and plan a strategy. Consider changing the device, operator, technique, position, or a combination of these for subsequent attempts. All attempts should be performed, prioritising adequate oxygenation, anaesthetic depth, optimal equipment, proper positioning, ELM, and available help.

Role of nasal apnoeic oxygenation during intubation

Continuing apnoeic oxygenation with nasal prongs, a catheter, or high-flow nasal oxygen during laryngoscopy and intubation is strongly recommended.[40,41] This requires an additional oxygen source with an auxiliary flow meter. The oxygen flow rate should be adjusted to achieve an oxygen saturation of more than 95%. A literature search suggested a varied flow of oxygen ranging from 0.5 to 50 litres/min.[41] According to the Delphi consensus statement, a flow rate of 1–2 L/kg/min is recommended [Appendix]. Additionally, it is preferable that the nasal oxygen is warmed and humidified.

Confirmation of successful intubation

Capnography is the gold standard for confirming successful endotracheal intubation, indicated by six consistent square wave capnography traces of carbon dioxide without decline. Additional methods, such as 5-point auscultation, bilateral chest rise, and condensation of moisture inside the TT during exhalation, though less specific, may also be used to help confirm intubation and rule out oesophageal intubation.[2]

OPTIMISING THE USE OF SUPRAGLOTTIC AIRWAY (SGA) AS A RESCUE DEVICE WHEN A DIFFICULT AIRWAY IS ENCOUNTERED

The use of SGA devices, both as a primary airway management tool and as a rescue device, has increased significantly over the past decade. The AIDAA recommends using second-generation SGA devices with a gastric drainage tube over the first-generation devices.[2] Second-generation SGAs have improved oropharyngeal seal pressure, fit the airway contour better, and feature a gastric drain tube port that aligns with the upper oesophageal sphincter for easier orogastric tube passage and stomach decompression.

The number of attempts to insert an SGA device should be limited to two, according to the Delphi consensus statement [Appendix]. To enhance oxygenation, resume face mask ventilation between attempts. If the first attempt is unsuccessful, consider changing the size and type of SGA device before proceeding with the second attempt.[2]

If the placement of the SGA device is successful,

• Evaluate whether it is safe and essential to continue the procedure using the SGA device as the primary ventilation device.

• If it is unsafe to proceed with the SGA in place, or if endotracheal intubation through SGA is not feasible and the surgery is not urgent, consider waking the child.

• If endotracheal intubation is essential for the surgical procedure to proceed, consider passing a TT through the SGA device using a flexible bronchoscope, but only if the necessary equipment and expertise are available. Blind intubation through the SGA device is not recommended due to the risk of causing trauma and airway oedema.[2]

• A tracheostomy may be considered only in the case of an emergency or when it is a part of the surgical plan. It is important to note that paediatric tracheostomies are challenging to perform and maintain, with a higher incidence of complications even in expert hands.

If ventilation with the SGA device fails, consider switching to laryngoscopy and endotracheal intubation or face mask ventilation if not already attempted earlier. Consider interchanging between the devices and techniques. If intubation, ventilation with an SGA and face mask fail despite using a neuromuscular blocking agent (NMBA), declare Complete Ventilation Failure (CVF) and follow the steps outlined below.

COMPLETE VENTILATION FAILURE AND EMERGENCY SURGICAL AIRWAY ACCESS

CVF occurs when efforts to provide ventilation using a face mask, endotracheal intubation, and SGA are all unsuccessful. Typically, CVF precedes oxygenation failure and a decline in oxygen saturation. CVF and emergency surgical airway situations are rare in children with unanticipated difficult airways.[39] Due to the emergency nature of these scenarios, no formal randomised controlled trials exist. Most of the available evidence comes from extrapolating findings from adult studies and simulations, which may not accurately portray the specific challenges faced in children.[42]

The unique anatomical features of children, such as the higher position of the larynx, the small size of the cricothyroid membrane, and the presence of adipose tissue in the neck, render many emergency airway techniques impractical and potentially hazardous.[43,44] The cricothyroid membrane exhibits a mean vertical dimension of 2.6 mm (standard deviation [SD], 0.7) and a width of 3 mm (SD, 0.6) in neonatal cadavers, whose average height is 44.9 cm and mean weight is 2 kg. In contrast, adult dimensions range from 8 to 19 mm vertically (mean 13.7 mm) and from 9 to 19 mm transversely (mean 12.4 mm).[44] Anatomy can complicate the identification and delineation of the cricothyroid membrane. The cricothyroid membrane is angulated at approximately 60°–70° to the tracheal axis, whereas it is nearly parallel in adults.[45] This angulation likely adjusts to the adult configuration at around 5 or 6 years old. Consequently, if a needle is inserted, the tip may inadvertently be directed toward children’s laryngeal inlet and hypopharynx.[45]

The decision to get an emergency surgical airway access should not be delayed until the child begins to desaturate. We recommend proceeding with emergency surgical airway access whenever there is CVF. This should ideally be done while oxygenation is still maintained, and it is important not to wait for oxygen saturation levels to drop. Seek additional assistance, preferably from a surgical expert skilled in paediatric tracheostomies, and continue efforts at rescue face mask ventilation while preparing for the emergency surgical procedure.

Available evidence for emergency surgical airway access in children

In children, when trained surgical assistance is available, tracheostomy is the preferred method for emergency surgical airway access.[2,14,42] The use of a scalpel bougie technique for tracheostomy, along with railroading a tracheal tube over the bougie, has been reported to be superior to conventional rapid sequence tracheostomy.[46,47] The approach of railroading an uncuffed TT over a bougie during tracheostomy is considered advantageous as it is associated with a lower risk of secondary tracheal injuries due to reduced force applied.[48] Throughout the tracheostomy procedure, efforts should be made to maintain oxygenation by keeping the upper airway patent and continuously administering 100% oxygen.

In situations where trained surgical assistance is unavailable, surgical and cannula cricothyrotomy are generally contraindicated in children, primarily due to the high risk of trauma and the small size of the cricothyroid membrane.[43,44,49,50] Commercially available cannula cricothyrotomy kits have the potential to damage the child’s airway. The guidelines set forth by the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) advise against using cannulae with a diameter of greater than 4 mm in children under the age of 8 years.[14] The dimensions of the cricothyroid membrane are typically insufficient to accommodate a TT. The dimensions of the TT exceed the size of the cricothyroid membrane, potentially risking fractures to the laryngeal cartilages.[43] Therefore, surgical cricothyroidotomy and the passage of a tracheal tube through it are strongly cautioned against in children under 12 years of age. Instead, it is advisable to perform a transtracheal needle puncture or needle cricothyroidotomy using a needle with a diameter of less than 4 mm, followed by jet ventilation with a pressure-regulated jet ventilation device.[2]

In children under 5 years of age, the cricothyroid membrane is relatively small and difficult to locate, often situated high up, just beneath the mandible. This makes it a less ideal site for emergency surgical access.[2] As such, cricotracheal or transtracheal needle puncture is typically recommended for this age group instead of needle cricothyroidotomy with 14/18 G needles.[43] Successful aspiration of air serves as a reliable indicator of correct placement.[50] To minimise direct force and potential injury to the child’s airway, indirect aspiration of air utilising extension tubing is advised.[51] It is crucial to avoid dislodgement of needles, and jet ventilation devices should operate at the lowest possible pressures while ensuring the upper airway remains patent to prevent barotrauma.[2] Injuries to the lateral and posterior tracheal walls, paratracheal placement, and placement in false passages should also be diligently avoided.

In children between 5 and 12 years of age, a needle puncture of the cricothyroid membrane is advised. It is crucial to ensure that needles and jet ventilation devices remain securely in place, utilising the lowest possible pressures while maintaining patency of the upper airway to prevent barotrauma.[2]

Kinking or dislodgement of the cricothyroidotomy cannula can result in subcutaneous emphysema.[14]

Pressure-regulated jet ventilation devices

After inserting the needle into the trachea, use a pressure-regulated jet ventilation device such as the Manujet or Sanders injector for oxygenation. Start at the lowest pressure (0.5 bar) and gradually increase until you see the chest rise and improved oxygenation.[2,14]

The diameter of the small-bore cannula may be insufficient for complete expiration. It is essential to maintain upper airway patency to facilitate expiration while using a jet ventilation device. Failure to do so may result in barotrauma and pneumothorax. Continuous administration of oxygen through the upper airway is crucial.

Adequate time for expiration

To ensure adequate expiration time, the I:E ratio should be set at 1:4. This allows sufficient time for expiration, thereby helping to prevent barotrauma.

Alternative oxygenation methods, such as the Enk Oxygen Flow Modulator^®, Ventrain^®, and Rapid-O2^®, are recommended for adults; however, data on their safety and efficacy in paediatric patients are limited, and further studies are needed. Additionally, the three-way technique for oxygenation, utilising intermittent finger occlusion of the three-way port, is no longer recommended for children.[52]

A transtracheal, cricotracheal, or cricothyroid needle puncture should be replaced with a formal tracheostomy as soon as trained surgical assistance is available, in order to minimise the risk of dislodgment and injury.[2] A definitive tracheostomy should ideally be performed within 40 minutes to prevent the accumulation of hazardous plasma levels of carbon dioxide.[2]

Regular and repeated training using animal models, mannequins, and 3D-printed models is recommended at regular intervals for skill retention.[42]

DESCRIPTION OF ALGORITHM FOR THE MANAGEMENT OF UNANTICIPATED DIFFICULT AIRWAY IN CHILDREN (1-12 YEARS) UNDER GENERAL ANAESTHESIA [FIGURE 1]

Figure 1.

Algorithm for the management of unanticipated difficult airway in paediatrics under general anaesthesia

The algorithm [Figure 1] mentioned below is recommended for use in children between 1 and 12 years of age. Neonates and infants have special considerations and are ideally managed by persons with expertise in a special setup equipped to manage them.

Following pre-oxygenation and induction of general anaesthesia, continue with the primary airway management plan. The primary airway management plan may include, but is not limited to, the use of a tracheal tube/SGA/face mask/nasal cannula/airway adjuncts alone or in combination during spontaneous or controlled ventilation. If the primary airway management plan is successful [defined by the ability to maintain adequate ventilation and SpO₂>95% or the presence of 6 square wave capnograms (if feasible)], continue the procedure as planned.

An unsuccessful primary airway management plan is defined as the inability to insert an airway device or maintain adequate ventilation. If unsuccessful, call an experienced paediatric anaesthesiologist for help (Code D) if available, maintain adequate depth of anaesthesia, and deliver nasal oxygen at 1–2 L/kg/min through a nasal cannula via an auxiliary oxygen flowmeter. Depending on the primary airway management plan, consider using one of the following three devices or techniques (No preference for one technique over the other).

Laryngoscopy and tracheal intubation

Consider direct or videolaryngoscopy and endotracheal intubation after ensuring adequate neuromuscular blockade. Laryngoscopy should be attempted only if the SpO₂ is more than 95%. If SpO₂ <95%, consider mask ventilation or supraglottic device insertion. Optimise position; use external laryngeal manipulation (ELM/BURP manoeuvre)/bimanual laryngoscopy. Airway adjuncts such as a bougie and a stylet may be helpful. If the first attempt at laryngoscopy is not successful, resume mask ventilation, and the second attempt should be performed only if the SpO₂ is more than 95%. For the second attempt, consider changing the device, technique, or operator with the most experienced member performing the second attempt. Limit the number of laryngoscopy and intubation attempts to two as the chances of airway trauma and oedema increase with each failed attempt (Delphi consensus statement) (This includes the failed first attempt if intubation was a part of the primary airway management plan). The third and final attempt at laryngoscopy should be done only if an anaesthesiologist with paediatric experience is available.

If intubation is successful, confirm the tracheal tube placement with six consistent square wave capnograms.

If unsuccessful, consider interchanging between the other two devices (SGA/Facemask).

Supraglottic Airway insertion

If the primary airway management plan was unsuccessful, SGA insertion may be attempted. A second-generation SGA is preferred and strongly recommended. A maximum of two attempts at SGA insertion should be made (Delphi consensus statement). Consider changing the size and type of SGA during the second attempt. Rule out laryngospasm as a cause of inadequate ventilation and treat laryngospasm if suspected. Consider decompression of the stomach using a nasogastric or orogastric tube to avoid diaphragmatic splinting.

If successful, confirm adequacy of ventilation with six consistent square wave capnograms. Consider one of the following options with a successfully placed SGA. (1) Awaken the patient. (2) Consider proceeding with the procedure with the SGA in situ, if considered safe. (3) Consider intubation through the SGA with a flexible bronchoscope if expertise and correct size equipment are available. (4) Consider tracheostomy only if it is a part of the surgical plan. If SGA insertion is unsuccessful, consider interchanging between the other two devices (TT/Facemask).

Facemask ventilation

Consider facemask ventilation with the correct size of equipment. Ensure an open airway with a gentle chin lift and jaw thrust. There should be no pressure on the soft tissues. Airway adjuncts, such as the correct sizes of oropharyngeal and nasopharyngeal airways, may be used. Treat laryngospasm and ensure adequate neuromuscular blockade. Consider decompression of the stomach using a nasogastric or orogastric tube to avoid diaphragmatic splinting.

If successful, continue face mask ventilation. Consider one of the following options with successful face mask ventilation. (1) Awaken the patient. (2) Consider proceeding with the surgery if it is a short procedure and if it is considered safe. (3) Consider tracheostomy only if it is a part of the surgical plan. If facemask ventilation is unsuccessful, consider interchanging between the other two devices (TT/SGA).

While interchanging between the three devices, keep track of time and maintain SpO₂ more than 95%. In case of inability to ventilate the child due to failed intubation, SGA, or face mask ventilation despite the best efforts following neuromuscular blockade, declare Complete Ventilation Failure (CVF). Continue efforts at rescue face mask ventilation, and call for additional help from a surgical expert if available.

Emergency surgical airway

Proceed with emergency surgical airway before the child begins to desaturate. The further airway plan depends on the availability of trained surgical help. If trained surgical help is available, proceed with a tracheostomy using a scalpel bougie technique and railroading a tracheal tube over the bougie. In the absence of trained surgical help, in children less than 5 years, cricotracheal needle puncture with a 14/18 G needle is preferred as the cricoid cartilage is located very cephalad (Delphi consensus statement). Successful aspiration of air is a good predictor of correct placement.

In children between 5 and 12 years of age, a cricothyroid membrane needle puncture is recommended (Delphi consensus statement). Maintain oxygenation using pressure-regulated jet ventilation, ensuring upper airway patency and providing adequate time for expiration (I:E ratio 1:4). Care should be taken to avoid any dislodgement of needles. Jet ventilation devices should be used with the lowest possible pressures to prevent barotrauma.

Surgical cricothyrotomy and commercially available cannula cricothyrotomy sets are contraindicated in children due to the high likelihood of trauma and the small dimensions of the cricothyroid membrane.

A cricotracheal/cricothyroid needle puncture should be replaced with a formal tracheostomy as soon as trained surgical help is available to reduce the risk of dislodgements and injury.

Post-procedure plan

Post-procedure, one should look for complications, such as airway oedema, and treat them if suspected. A further airway management plan should be thought of and documented. Verbal communication and counselling of the parents and documentation of the airway difficulty and its management in the case records are mandatory. In addition, an “Airway Alert Form” should be filled out by the attending anaesthesiologist to complete the documentation and to have a standard reporting of a difficult airway.

Research Question 1

Does Apnoeic oxygenation increase the time to desaturation in paediatrics?

Appendix 1[41,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68]

Summary:

The review was done by SM and JD. A total of 17 articles were selected for the final inclusion from 299 articles. The review of selected articles focussed on the use of apnoeic oxygenation techniques in paediatric patients undergoing general anaesthesia, analysing the efficacy of High-Flow Nasal Oxygen (HFNO), low-flow nasal cannula, and other para-oxygenation techniques to prolong the time to desaturation during intubation.

HFNO was extensively studied across multiple randomised and non-randomised clinical trials (Riva et al., 2018[55] – Level B-R; Humphreys et al., 2017[56] – Level B-R, Ayanmanesh F, 2021, C-LD).[55,56,61] HFNO delivered at flow rates ranging from 0.2 to 2 L/kg/min up to 60 L/min demonstrated a significant ability to prolong safe apnoea time and reduce desaturation incidents during rapid sequence induction (RSI) and airway management in children. It was found particularly beneficial in high-risk cases such as recurrent respiratory papillomatosis (Sumit RC, 2022 – Level C-EO)[67] and cyanotic heart disease (Caruso et al., 2019[53] – Level C-LD).

Low-flow nasal cannula oxygenation (Naiyana A 2022 – Level B-R)[54] provided oxygen flow rates of 0.5–4 L/min and was used in neonates and toddlers undergoing minor surgeries. Although effective in certain cases, low-flow oxygenation was less effective than HFNO in maintaining oxygen saturation during prolonged intubation attempts.

Laryngeal oxygen insufflation (Steiner JW., 2016 – Level B-R)[57] provided low-flow oxygen of 2–4 L/min attached to the laryngoscope during intubation, reducing desaturation risk in children aged 1–17 years.

Systematic reviews and meta-analyses (Fuchs et al., 2023 – Level A)[41] show that apnoeic oxygenation techniques are superior to the conventional technique without apnoeic oxygenation, demonstrating higher minimum SpO₂ levels, reduced hypoxemia, and prolonged apnoeic time during paediatric intubation. However, the data were heterogeneous, and more high-quality RCTs are recommended.

The reviewed literature supports the use of HFNO (0.2–2 L/kg/min up to 60 L/min) as an effective apnoeic oxygenation technique in paediatric patients, significantly increasing time to desaturation during airway management. While low-flow oxygen (0.5–4 L/min) is suitable for minor procedures, HFNO remains the preferred method for high-risk and prolonged intubation cases due to better oxygenation outcomes. However, the evidence is not yet conclusive to determine the optimal flow rate for paediatric apnoeic oxygenation. A Delphi survey involving expert consensus was employed to establish standardised flow rates and refine clinical practice guidelines in paediatric anaesthesia.

Best Practice Statement: HFNO or low-flow nasal oxygen can be beneficial in increasing the time to desaturation in paediatric patients (1–12 years). Strength of recommendation: 2a, Level of evidence: B-R

Delphi survey question: What nasal oxygen flow rate should be used for apnoeic oxygenation (during attempts at intubation) in paediatric patients (1–12 years)?

Delphi survey result: Appendix 6

Expert consensus statement: A nasal flow of 1–2 L/Kg/min (using a HFNO cannula) should be used for apnoeic oxygenation (during attempts at intubation) in paediatric patients (1–12 years).

Research Question 2

Does the use of VL improve the success of intubation over DL in the paediatric population?

Appendix 2[25,26,27,28,59,69,70,71,72]

Summary:

A total of 446 articles were extracted, and 67 duplicates were removed. Two authors, AS and AM, screened the abstract for eligibility. Four articles were added from cross-referencing. A total of 11 articles were selected for the full-text review. Two articles were removed as they did not align with our research question. The final nine articles, including four meta-analyses, one systematic review, one RCT, one guideline, a review article, and a survey, were finally included.

Hu et al. 2020 (Level A)[27] conducted a meta-analysis of 27 articles covering 2461 children aged less than 18 years. Hu reported improvement in POGO scoring (WMD = 11.81, 95% CI: 4.31, 19.32, P = 0.002; I² = 79.6%, Pheterogeneity < 0.001) in the videolaryngoscopy group compared to direct laryngoscopy, but other parameters, like first attempt success rate, time to intubate, and complications, were the same in both groups. He concluded that VL provided no additional benefits for intubation time or intubation success at the first attempt in paediatric patients. However, VL improved the view of the glottic opening and reduced intubation trauma.

Hoshijima et al. 2022 (Level A)[25] did a systematic review and network meta-analysis for children below 10 years for intubation failure at first attempt and glottic visualisation and intubation time. They reviewed 34 articles and found similar results to Hu et al.[27] improving the glottic visualisation with some devices. However, the first attempt success rate was identical to direct laryngoscopy.

De Carvalho et al. 2022 (Level A)[26] published a systematic review with network meta-analysis of 46 randomised clinical trials. He compared multiple types of videolaryngoscopes with direct laryngoscopy with the primary aim of determining the risk of failure at first attempt. Videolaryngoscopy significantly lowered the risk of failed first intubation (RR 0.43) and failed intubation within two attempts (RR 0.33) in infants but not in older children. It also reduced the risk of major complications in both infants (RR 0.33) and children aged 0–18 years (RR 0.40). There was no significant difference in time to intubation between videolaryngoscopy and direct laryngoscopy for either age group. Different videolaryngoscopes showed varying performance, and the overall evidence quality ranged from low to very low.

Ming et al. 2023[28] did a network meta-analysis of 23 RCTs comparing the efficacy and safety of 12 intubating devices in children between 1 and 12 years with respect to first pass success, time to intubation, and local complications. Though the outcome did not vary significantly between devices, Airtraq (odds ratio [OR] =13.05, 95% confidence interval [CI] = 4.68 to 36.38), Miller (OR = 4.77, 95% CI: 1.32, 17.22), GlideScope (OR = 2.76, 95% CI: 1.60, 4.75) and McGrath (OR = 4.61, 95% CI:1.18, 17.99) obtained higher first pass success.

Videolaryngoscopy offers improved glottic visualisation in all paediatric age groups and reduces the risk of intubation failure and complications in infants, though its benefits diminish in older children. Performance varies across devices, with some showing higher success rates. However, VL does not significantly reduce intubation time or improve first-attempt success in general paediatric populations. Videolaryngoscopy should be preferred only if an appropriate device is available and the performer is proficient with the use of the particular device.

Best Practice Statement: Videolaryngoscopy is not beneficial in enhancing the success rate of intubation compared to direct laryngoscopy despite improving the glottic view. Strength of recommendation: Class 3 (benefit=risk), Level of evidence: B-R

Research Question 3

Do strategies such as the use of airway adjuncts, muscle relaxants, gastric deflation, or lateral positioning improve face mask ventilation in paediatric patients undergoing general anaesthesia?

Appendix 3[16,18,22,23,73,74]

Summary:

Reviewed by NB and JD through Rayyan software, selecting six final articles from an initial pool of 733 articles.

The review of six selected articles highlights key factors influencing mask ventilation in paediatric patients. The use of neuromuscular blocking agents (NMBs) was supported by two studies. Garcia-Marcinkiewicz et al. (2023, B-NR)[23] reported that NMBs improved ventilation in 31% of difficult cases, with 90% showing significant improvement. Pedersen et al. (2021, B-NR)[73] further supported NMB administration, showing a reduction in airway-related complications when used immediately after the loss of consciousness. However, Valois-Gomez T et al. (2013, B-NR)[74] suggest it may increase bag mask ventilation difficulty.

While none of the reviewed articles directly addressed the use of oral or nasal airway adjuncts, the importance of optimising airway management strategies, which often include adjuncts, was evident. Lagarde et al. (2010, Level C-LD)[22] emphasised the need to avoid gastric insufflation during mask ventilation, particularly in infants, by maintaining inspiratory pressures below 15 cm H₂O, suggesting that gastric tube deflation could improve ventilation efficiency.

In terms of techniques, Choudhry et al. (2021, Level B-R)[18] found that two-handed mask ventilation provided superior airway patency compared to the one-handed technique, particularly in children with obstructive sleep apnea. Litman et al. (2005, Level C-LD)[16] demonstrated that lateral positioning significantly increased upper airway volume and cross-sectional area in sedated children, reinforcing the importance of patient positioning in enhancing mask ventilation.

The review of literature suggests that mask ventilation in paediatric patients may be improved by muscle relaxation with NMBs, maintaining optimal inspiratory pressures to avoid gastric insufflation, employing effective techniques like two-handed mask holding and lateral positioning. Although oral and nasal airway adjuncts were not specifically studied, their potential role remains a vital part of airway management strategies in paediatric anaesthesia. With lower-level evidence for some of the techniques and modalities, a Delphi survey was conducted to get the expert opinion.

Best Practice Statement: Neuromuscular blockade may be considered to improve face mask ventilation in the paediatric population (1–12 years). Strength of recommendation – Class 2b, Level of evidence: B-NR

Best Practice Statement: Two-handed mask may be considered improve face mask ventilation in the paediatric population (1–12 years). Strength of recommendation – class 2b, Level of evidence: B-R

Delphi survey question 1: Can administration of CPAP improve mask ventilation when difficulty in mask ventilation is encountered in paediatric patients (1–12 years)?

Expert consensus statement 1: Administration of CPAP may improve mask ventilation when difficulty in mask ventilation is encountered in paediatric patients (1–12 years)

Delphi survey question 2: Does giving a lateral position improve mask ventilation when difficulty in mask ventilation is encountered in paediatric patients (1–12 years)?

Expert consensus statement 2: No consensus was achieved

Delphi survey result: Appendix 6

Research Question 4

How many attempts would you limit intubation to for fear of worsening the airway in children?

Appendix 4[3,36,37,38,39]

Summary:

A total of 193 articles were extracted, of which 28 duplicates were removed. Two authors, AS and SY, screened 180 abstracts for eligibility. One article was added from cross-references. A total of six articles were selected for full-text review. One article was removed as it included data only from the cross-reference. Finally, five articles, two prospective observational studies and three registries, were included.

Fiadjoe et al. (2016, C-LD)[3] presented the results of the Pediatric Difficult Intubation (PeDI) registry from 13 pediatric hospitals in the USA. From August 2012 to January 2015, 1018 difficult intubations were reported. On multivariate analysis, more than two attempts of intubation were found to be associated with the occurrence of complications (OR 3·1, 95% CI: 2·1, 4.6; P < 0·0001). Authors concluded that attempting tracheal intubation more than twice in children with difficult intubation resulted in a high failure rate and an increased incidence of complications.

Lee et al. (2016, C-LD)[37] reported the results of the National Emergency Airway Registry for Children (NEAR4KIDS), a prospective multicenter tracheal intubation (TI) collaborative from 19 PICUs (15 in the USA and one each in Canada, Japan, Singapore, and New Zealand). It includes the initial TI performed for acute respiratory failure using direct laryngoscopy. Multivariate analysis of data from 2080 TI showed that odds of developing desaturation (SpO2 < 80%) were higher with two attempts (OR 2.9, 95% CI: 2.3, 3.7, P < 0.001) and three or more attempts (OR 6.5, 95% CI: 5.0, 8.5, P < 0.001) compared to one attempt of TI. The odds of other adverse events were also higher with two attempts (OR 3.7 (95% CI: 2.9, 4.9, P < 0.001) and ≥ 3 attempts (OR 5.5, 95% CI: 4.1, 7.4), P < 0.001) compared to one attempt. The authors concluded that an increasing number of attempts of TI is associated with desaturation and adverse events.

Park et al. (2017, C-LD)[38] analysed the data of the PeDI registry from August 2012 to April 2017 from 20 hospitals from USA, Canada, Mexico, and Australia. They included patients where either a direct laryngoscope or a GlideScope videolaryngoscope was used. Multivariate regression analysis revealed that every additional attempt of TI doubled the odds of complications (OR 2.0, 95% CI: 1.5, 2.5, P < 0.001), irrespective of the laryngoscope used.

Engelhardt et al. (2018, C-LD)[39] reported the results of a large multi-centre prospective observational study, Anaesthesia Practice in Children Observational Trial (APRICOT), conducted in 33 European countries and 261 institutions, in which data from 31,024 children undergoing general anaesthesia over consecutive 2 weeks were collected and analysed. There was a significant increase in the risk for critical respiratory events with more than two attempts of tracheal intubation (RR 2.1, 95% CI: 1.3, 3.4, P < 0.001).

Stein et al. (2024, C-LD)[36] reported the results of PeDI registry data from March 2017 to March 2023 from 43 hospitals and 3925 patients and compared the results with those of the earlier cohort (August 2012 to January 2015). The incidence of all complications and severe complications increased as the number of tracheal intubation attempts increased. The median (IQR) number of intubation attempts was 2 (1–3) in children who did not develop severe complications and was 3 (2–5) in children who developed severe complications (OR 1.58, 95% CI: 1.45, 1.73, P < 0.001) in the current cohort. More than two attempts at tracheal intubation with a direct laryngoscope were associated with a higher incidence of severe complications (aOR 2.92, 95% CI: 1.41, 6.06, P = 0.004). There was a significant reduction in the number of intubation attempts in the current cohort compared to the earlier cohort. There was also a significant reduction in the incidence of severe complications in the current cohort.

The incidence of complications increases with the number of attempts at tracheal intubation in children. More than two attempts of tracheal intubation are associated with a higher complication rate. Considering the low level of evidence, a Delphi survey of experts was done to finalise the number of attempts for intubation in the paediatric age group.

Delphi survey question: What is the maximum number of attempts at tracheal intubation that should be permitted to limit airway management-related complications in paediatric patients?

Delphi survey result: Appendix 6

Expert consensus statement: A maximum of 2 + 1 attempts (additional attempt should only be done by an anaesthesiologist with experience in paediatric airway management) at tracheal intubation should be permitted to limit airway management-related complications in paediatric patients.

Research Question 5

In paediatric patients with failure of endotracheal intubation, supraglottic device placement, and facemask ventilation, how do emergency rescue methods such as needle cricothyrotomy, surgical cricothyroidotomy, or tracheostomy compare in terms of effectiveness and complications for securing the airway and ensuring ventilation and oxygenation?

Appendix 5[46,47,48,49,50,51,75,76]

Summary of Techniques for Emergency Surgical Airway in Paediatric Population (1–12 years)

Reviewed by JD and SM from 435 articles, with a final selection of eight studies (animal and animal model studies) due to the rarity and life-threatening nature of such emergencies, making prospective studies in children unfeasible (Level C-LD evidence).

Complete ventilation failure (CVF) and emergency surgical airway access are rare but critical events in paediatric difficult airway management (Ulmer et al. 2020, C-LD).[76] Due to the emergency nature, no formal randomised controlled trials exist, and current evidence relies on animal models and mannequin data, which may lack standardisation and fail to replicate real CVF scenarios fully (Stacey et al. 2012,[50] C-LD; Prunty et al. 2015, C-LD[49]). A Delphi survey of experts was conducted to recommend the procedure in an emergency situation.

The unique paediatric airway anatomy, including the cephalad larynx, small cricothyroid membrane, and neck adipose tissue, makes emergency airway techniques challenging and risky (Metterlein et al., 2011,[75] C-LD; Prunty et al., 2021, C-LD).[51] Emergency surgical airway access should be performed promptly when ventilation fails, without waiting for desaturation.

Tracheostomy is the first choice when trained surgical help is available, with scalpel-bougie tracheostomy (SBT) preferred over rapid sequence tracheostomy (RST) due to higher success rates (96.7%) and fewer tracheal injuries (Riva et al., 2024, C-LD).[47] Railroading an uncuffed tracheal tube over a bougie is recommended for reduced tracheal trauma (Thomas et al., 2022, C-LD).[48]

Commercial devices like Quicktrach Baby showed high reliability, but availability remains a concern (Metterlein et al., 2011, C-LD).[75] Cannula cricothyrotomy had lower success rates and higher complications (Stacey et al., 2012, C-LD).[50]

In children under 5 years, cricotracheal or transtracheal needle puncture with 14/18 G needles is preferred, with successful air aspiration indicating proper placement (Stacey et al., 2012, C-LD).[50] Indirect aspiration via extension tubing reduces airway trauma (Prunty et al., 2021, C-LD).[51]

In children aged 5–12 years, cricothyroid membrane needle puncture is recommended, using minimal jet ventilation pressures to avoid barotrauma (Both et al., 2021, C-LD).[46]

Training and Skill Retention: Regular training on animal models, mannequins, and 3D-printed models is essential for skill retention (Ulmer et al., 2020, C-LD).[76] Studies show that clinicians acquire proficiency within four attempts, achieving airway access in under 1 minute with repeated practice (Both et al., 2021, C-LD).[46]

Tracheotomy (Scalpel-bougie tracheotomy) with bougie guidance is the most reliable technique when an experienced surgeon is available for all age groups. If needle cricothyrotomy is chosen, cricotracheal puncture is recommended for children under 5 years, and cricothyroid puncture for children over 5 years. Since the evidence is not robust, a Delphi survey among experts was conducted to identify the most appropriate technique for emergency surgical airway access in paediatric patients. Regular simulation training is vital for maintaining proficiency in paediatric airway emergencies.

Best Practice Statement: Whenever experienced surgical help is available, tracheostomy may be considered as the preferred technique in situations of complete ventilation failure in paediatric patients (1–12 years). Strength of recommendation: 2b, Level of evidence: C-LD

Delphi questions:

1. Which anatomical site should be preferred in paediatric patients less than 5 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available?

2. Which anatomical site should be preferred in paediatric patients between 5 and 12 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available?

Delphi Survey results: Appendix 6

Expert consensus statements:

1. A cricotracheal puncture should be preferred in paediatric patients less than 5 years of age for performing emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available.

2. A cricothyroid puncture should be preferred in paediatric patients between 5 and 12 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available.

GUIDELINE SUMMARY

The AIDAA 2025 Paediatric guideline provides a comprehensive structured approach for the management of an unanticipated difficult airway under general anaesthesia in children between 1 and 12 years of age. It includes guidance for a difficult or failed supraglottic airway insertion, tracheal intubation, face mask ventilation, or other strategies commonly used as part of the primary airway plan under general anaesthesia, not restricting to guidance following a failed intubation. A systematic literature search, data extraction, and evidence synthesis was conducted for the five PICO questions drafted by the Steering Comminate and recommendations were categorised according to the AHA Class of Recommendation and Level of Evidence. Where evidence was absent or weak, the Steering Committee initiated a robust Delphi process to reach consensus (75% and above) among airway experts to provide guidance.

If the primary airway plan fails, activate ‘Code D’ as the hospital emergency code to call for help. Airway rescue should then be attempted with any of the three devices (tracheal tube, supraglottic airway, or face mask), switching promptly between them as needed, with no hierarchy, until effective ventilation and adequate SpO₂ are achieved. Emphasis has been laid on limiting device attempts and proceeding with the next attempt at laryngoscopy only if the SpO2 remains ≥95%. AIDAA suggests a maximum of up to two failed attempts with tracheal intubation (with a third attempt only by a paediatric airway expert), SGA use, and mask ventilation. Nasal oxygen delivery during airway rescue, keeping track of SpO2 and the time lapsed, has been emphasised. Complete ventilation failure (ventilation using a tracheal tube, SGA, and face mask have all failed, even if oxygenation may be maintained) is the trigger to perform an emergency surgical airway access. A call for additional help especially for a surgeon trained in paediatric tracheostomies is advised when there is complete ventilation failure. When trained surgical help is available, a surgical scalpel bougie tracheostomy is suggested as the preferred technique. When surgical help is unavailable, a needle cricotracheal puncture for children less than 5 years and a needle cricothyroid puncture for children between 5 and 12 years are recommended. A jet ventilation device is recommended for oxygenation maintaining the upper airway patent and allowing adequate time for expiration. A post-procedure plan including team debriefing, team support, parent counselling, and documentation have been included.

In addition to the management of an unanticipated difficult airway in children, guidance on pre-oxygenation and optimisation of tracheal intubations including proper positioning, choice of laryngoscope and other adjuncts, apnoeic oxygenation, and confirmation of tracheal tube position using waveform capnography are provided in the guidelines. Optimising SGA use and mask ventilation have also been discussed. The timing and method to call for help and the use of critical language such as complete ventilation failure and emergency surgical airway during airway management along with the rationale for their use have been discussed.

Endorsements

These guidelines are endorsed by Indian Association of Paediatric Anaesthesiologists (IAPA)

Presentation at conferences/CMEs and abstract publication

Nil.

Study data availability

De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared upon request.

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

The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.

Declaration of use of permitted tools

The tables and figures are self-made and not copyrighted.

Authors contributions

JRD served as the lead for the AIDAA 2025 paediatric guidelines. APS served as the project administrator and led the literature review process. JRD, APS, PK, RV, RG, JVD, SNM, SRS, SMA as Core Committee Members, were involved in the concept and design of the guidelines, contributed to the literature search, manuscript drafting, editing, and critical review, and approved the final version. ADM, SY, NB, DP, RS as Experts, provided specialised inputs in the development of recommendations, contributed to the refinement of content, reviewed the manuscript critically for accuracy and relevance, and approved the final version. All authors agree to be accountable for all aspects of the work in ensuring the accuracy and integrity of the manuscript.

Supplementary material

This article has supplementary material and can be accessed at this link. Supplementary Material at http://links.lww.com/IJOA/A45.

Conflicts of interest

Dr Amit Shah- inventor of Patwashahi video laryngoscope (non-commercial), designer of HFNO device HuFlo2. Dr Rakesh Garg, Dr Pankaj Kundra, Dr Syed Moied Ahmed, Dr Anila Malde, Dr Sheila N Myatra and Dr Jeson R Doctor who are the co-authors of this manuscript, are Editors of this journal. They were not involved in the decision-making process, and an independent editor handled this manuscript. Other authors declare that they have no conflicts of interest.

APPENDIX 1

Research Question 1: Does Apnoeic oxygenation increase the time to desaturation in paediatrics?

• Population: Paediatric age group requiring general anaesthesia

• Intervention: Apnoeic oxygenation/Para oxygenation/HFNC/HFNO

• Comparator: No Nasal Oxygen (Pre-oxygenation, nasal oxygenation)

• Outcomes: Desaturation, Time to desaturation, Number of attempts, Trauma (during intubation)

Supplementary Table 1a.

Concept table for Research Question: Does Apnoeic oxygenation increase the time to desaturation in paediatrics?

Key concepts	Concept 1 Paediatric age group	Concept 2 GA	Concept 3 Intervention	Concept 4 Comparator	Concept 5 Outcomes
Free text terms/ natural language terms (synonyms, UK1 US terminology, medical/laymen's terms, acronyms/ abbreviations, drug brands, more narrow search terms) Consider: phrase searching, proximity operators, truncation, wildcards, field qualification (e.g. textword)	Preschool Child Children, Preschool Preschool Children Children	Anaesthesia, General/methods* Anesthesia* Anesthesias, General General Anesthesia General Anesthesias	(“apnea”[MeSH Terms] OR “apnea”[All Fields] OR “apnoeic”[All Fields] OR “apnoeic”[All Fields] OR “apnoeics”[All Fields] OR “apnoeics”[All Fields]) OR “oxygenation”[AN Fields] OR “oxygen”[MeSH Terms] OR “oxygen”[All Fields] OR “oxygen s”[All Fields] OR “oxygenate”[All Fields] OR “oxygenated”[All Fields] OR “oxygenates”[All Fields] OR “oxygenating”[All Fields] OR “oxygenations”[All Fields] OR “oxygenative”[All Fields] OR “oxygenator s”[All Fields] OR “oxygenators”[MeSH Terms] OR “oxygenators”[All Fields] OR “oxygenator”[All Fields] OR “oxygene”[All Fields] OR “oxygenic”[All Fields] OR “oxygenous”[All Fields] OR “oxygens”[All Fields])) AND ((humans[Filter]) AND (english[Filter])) “HFNC”[All Fields] [tiab] “FiO2” [tiab] (“face”[MeSH Terms] OR “face”[All Fields]) AND (“masks”[MeSH Terms] OR “masks”[All Fields] OR “mask”[All Fields]) AND (“cell respiration”[MeSH Terms] OR (“cell”[All Fields] AND “respiration”[All Fields]) OR “cell respiration”[All Fields] OR “oxygenation”[All Fields] OR “oxygen”[MeSH Terms] OR “oxygen”[All Fields] OR “oxygen s”[All Fields] OR “oxygenate”[All Fields] OR “oxygenated”[All Fields] OR “oxygenates”[All Fields] OR “oxygenating”[All Fields] OR “oxygenations”[All Fields] OR “oxygenative”[All Fields] OR “oxygenator s”[All Fields] OR “oxygenators”[MeSH Terms] OR “oxygenators”[All Fields] OR “oxygenator”[All Fields] OR “oxygene”[AN Fields] OR “oxygenic”[All Fields] OR “oxygenous”[All Fields] OR “oxygens”[All Fields])	“preoxygenate”[All Fields] OR “preoxygenated”[All Fields] OR “preoxygenation”[All Fields] (“nasalance”[All Fields] OR “nasality”[All Fields] OR “nasalization”[All Fields] OR “nasalized”[All Fields] OR “nasally”[All Fields] OR “nose”[MeSH Terms] OR “nose”[All Fields] OR “nasal”[All Fields] OR “nasals”[All Fields]) AND (“cell respiration”[MeSH Terms] OR (“cell”[All Fields] AND “respiration”[All Fields]) OR “cell respiration”[All Fields] OR “oxygenation”[All Fields] OR “oxygen”[MeSH Terms] OR “oxygen”[All Fields] OR “oxygen s”[All Fields] OR “oxygenate”[All Fields] OR “oxygenated”[All Fields] OR “oxygenates”[All Fields] OR “oxygenating”[All Fields] OR “oxygenations”[All Fields] OR “oxygenative”[All Fields] OR “oxygenator s”[All Fields] OR “oxygenators”[MeSH Terms] OR “oxygenators”[All Fields] OR “oxygenator”[All Fields] OR “oxygene”[All Fields] OR “oxygenic”[All Fields] OR “oxygenous”[All Fields] OR “oxygens”[All Fields])	“desaturate”[All Fields] OR “desaturated”[All Fields] OR “desaturates”[All Fields] OR “desaturating”[All Fields] OR “desaturation”[All Fields] OR “desaturations”[All Fields] OR “desaturator”[All Fields] OR “desaturators”[All Fields] “desaturation time”[All Fields] OR “desaturation times”[All Fields] “intubation trauma”[All Fields]
Controlled vocabulary terms/Subject terms (MeSH terms, Emtree terms) Consider: explode, major headings, subheadings	“Child, Preschool”[Mesh] “Child”[Mesh] “Pediatrics”[MeSH]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, Obstetrical”[Mesh]	“Apnea/therapy”[Mesh] “Oxygen Inhalation Therapy”[Mesh] “Oxygen”[Mesh] “Carbon Dioxide”[Mesh]

Search string:

PubMed: 189 results

((“Preschool Child”[All Fields] OR “children preschool”[All Fields] OR “Preschool Children”[All Fields] OR “Children” [All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms])) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language] AND (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms: noexp])) AND ((“anesthesia general methods”[Title/Abstract] OR “anesthesia*”[Title/Abstract] OR “General Anesthesia”[Title/Abstract] OR “General Anesthesias”[Title/Abstract] OR “anesthetics, general”[MeSH Terms] OR ‘Anesthesia”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language] AND (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms: noexp]))) AND ((“apnea”[MeSH Terms] OR “apnea”[All Fields] OR “apnoeic”[All Fields] OR “apnoeic”[All Fields] OR “apnoeics”[All Fields] OR “apnoeics”[All Fields] OR “oxygenation”[All Fields] OR “Oxygen”[MeSH Terms] OR “Oxygen”[All Fields] OR “oxygen s”[All Fields] OR “oxygenate”[All Fields] OR “oxygenated”[All Fields] OR “oxygenates”[All Fields] OR “oxygenating”[All Fields] OR “oxygenations”[All Fields] OR “oxygenative”[All Fields] OR “oxygenator s”[All Fields] OR “oxygenators”[MeSH Terms] OR “oxygenators”[All Fields] OR “oxygenator”[All Fields] OR “oxygene”[All Fields] OR “oxygenic”[All Fields] OR “oxygenous”[All Fields] OR “oxygens”[All Fields] OR (((“HFNC”[Title/Abstract] OR “FiO2”[Title/ Abstract] OR (“face”[MeSH Terms] OR “face”[All Fields])) AND (“masks”[MeSH Terms] OR “masks”[All Fields] OR “mask”[All Fields])) OR “oxygenation”[All Fields] OR “Oxygen”[MeSH Terms] OR “Oxygen”[All Fields] OR “oxygen s”[All Fields] OR “oxygenate”[All Fields] OR “oxygenated”[All Fields] OR “oxygenates”[All Fields] OR “oxygenating”[All Fields] OR “oxygenations”[All Fields] OR “oxygenative”[All Fields] OR “oxygenator s”[All Fields] OR “oxygenators” [MeSH Terms] OR “oxygenators” [All Fields] OR “oxygenator” [All Fields] OR “oxygene”[All Fields] OR “oxygenic”[All Fields] OR “oxygenous”[All Fields] OR “oxygens”[All Fields]) OR “apnea/therapy”[MeSH Terms] OR “Oxygen Inhalation Therapy”[MeSH Terms] OR “Oxygen”[MeSH Terms] OR “Carbon Dioxide”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication]) AND (“humans”[MeSH Terms] AND “english”[Language] AND (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms: noexp])) AND ((“desaturate”[All Fields] OR “desaturated”[All Fields] OR “desaturates”[All Fields] OR “desaturating”[All Fields] OR “desaturation”[All Fields] OR “desaturations”[All Fields] OR “desaturator”[All Fields] OR “desaturators”[All Fields] OR “desaturation time”[All Fields] OR “desaturation times”[All Fields] OR “intubation trauma”[All Fields]) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language] AND (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms: noexp])))) AND ((humans[Filter]) AND (english[Filter]))

Scopus: 124 results

((TITLE-ABS-KEY (“preschool child” OR “children preschool” OR “preschool children” OR “child”) AND TITLE-ABS-KEY (“anesthesia general methods” OR “general anesthesia” OR “anesthetics, general” OR “anesthesia*”) AND TITLE-ABS-KEY (“apnea” OR „apnoeic“ OR “apnoeic” OR “oxygenation” OR ’’oxygen” OR “HFNC" OR “FiO2” OR “face mask” OR “oxygen inhalation therapy” OR “carbon dioxide” OR “desaturation” OR “intubation trauma”) AND PUBYEAR > 1999 AND PUBYEAR < 2026 AND LANGUAGE (english))) AND (apnoeic AND oxygen)

Supplementary Figure 1

PRISMA flow chart for Research Question: Does Apnoeic oxygenation increase the time to desaturation in paediatrics?

Supplementary Table 1b.

Summary table for included studies for Research Question: Does Apnoeic oxygenation increase the time to desaturation in paediatrics?

Apnoeic oxygenation technique in paediatrics
Author	Journal	Type of Article	Level of evidence (AHA)	Intervention	Supports Apnoeic Oxygenation	Flow Rate
Alexander F (2023)[41]	Br J Anaesth.	Systematic review and meta-analysis	A	HFNO, Nasal Cannula, Mask, Nasopharyngeal Oxygenation vs no apnoeic oxygenation	Yes	HFNO (2-50 L/ min), Low flow (0.5-4 L/min)
Naiyana A (2022)[54]	Transl Pediatr.	RCT	B-R	Low-flow nasal oxygen with RSI vs classic RSI without apnoeic oxygen. 0-7 years	No	Low flow (0.5-4 L/min)
T Riva (2018)[55]	Br J Anaesth.	RCT	B-R	HFNO comparison of three flow - 0.2 L/ kg/min vs 2 L/kg/min 100% vs 2 L/kg/min 30%, 1-6 years	Yes	0.2 -2 L/kg/min, 100% with HFNO
S Humphreys (2017)[56]	Br J Anaesth.	RCT	B-R	HFNO vs No apnoeic oxygen. 1-10 years	Yes	2 L/kg/min up to 50 L/min
JW Steiner (2016)[57]	Br J Anaesth.	RCT	B-R	Oxygen cannula attached to Laryngoscope vs no apnoeic oxygen	Yes	Low flow (2-3 L/ min)
N Jagannathan (2017)[58]	Br J Anaesth.	Editorial	C-EO	HFNO	Yes	1-2 L/kg/min
Luciana CL (2023)[59]	Braz J Anesthesiol.	Guideline	C-EO	LFNO, HFNO	Yes	Not specific
Scott DN (2020)[60]	Anesthesia & Analgesia	Narrative Review	C-LD	LFNO, HFNO	Yes	0.2L/kg/min up to 10 L/min
Fanny A (2021)[61]	Anaesth Crit Care Pain Med.	Prospective Observational	C-LD	THRIVE in RSI	Yes	2 L/kg/min up to 70 L/min
C Lyons (2020)[62]	Anaesthesia.	Narrative Review	C-LD	Apnoeic oxygenation - LFNO, HFNO	NO	Not specified
Codruta NS (2019)[63]	Paediatr Anaesth.	Prospective Observational	C-LD	Nasal Cannula	Yes	2 L/kg/min
Susan Humphreys (2019)[64]	Paediatr Anaesth.	Educational Review	C-LD	HFNO	Yes	2 L/kg/min up to 50 L/min
C Lyons (2018)[65]	Br J Anaesth.	Response to RCT	C-EO	HFNO vs Low-flow nasal oxygen	Yes	HFNO (2-30 L/min), Low flow (0.5-4 L/min)
JG McCormack (2017)[66]	Br J Anaesth.	Reply to RCT	C-EO	HFNO	Yes	2-30 L/min
Sumit RC (2022)[67]	Indian J Anaesth.	Case Report	C-EO	HFNO	Yes	Not specified
JJ McCloskey (2019)[68]	Pediatr Crit Care Med.	Editorial	C-EO	HFNO vs Oxygen cannula on laryngoscope	Yes	Not specified
TJ Caruso (2019)[53]	J Clin Anesth.	Case Report	C-EO	HFNO	Yes	2-30 L/min

HFNO=High Flow nasal Oxygen; LFNO=Low Flow nasal Oxygen; RSI=Rapid sequence Induction; THRIVE=Transnasal Humidified Rapid- InsufflationVentilatory Exchange

APPENDIX 2

Research question: Does the use of VL improve the success of intubation over DL in the paediatric population?

• Population- Paediatric age group (1-12 years) requiring tracheal intubation under anaesthesia

• Intervention- VL

• Comparator- DL

• Outcomes- Success of Intubation, time taken for intubation, Glottic view, Pogo score

Supplementary Table 2a.

Concept table for Research Question: Does the use of VL improve the success of intubation over DL in the paediatric population?

Key concepts	Concept 1 Paediatric age group	Concept 2 Intubation	Concept 3 GA	Concept 4 Direct laryngoscopy	Concept 5
					Videolaryngoscopy	video laryngoscopes (VL) C-Mac, Glidescope, King Vision, Macgrath	Classification 1. Macintosh type of VL, 2. Hyperangulated VL, 3. Channel type of VL**
Free text terms/natural language terms (synonyms, UK/US terminology, medical/ laymen's terms, acronyms/ abbreviations, drug brands, more narrow search terms) Consider: phrase searching, proximity operators, truncation, wildcards, field qualification (e.g. textword)	Preschool Child Children, Preschool Preschool Children Children	“intubate”[All Fields] OR “intubated”[All Fields] OR “intubates”[All Fields] OR “intubating”[All Fields] OR “intubation” [MeSH Terms] OR “intubation”[All Fields] OR “intubations”[All Fields] OR “intubator”[All Fields] OR “intubator s”[All Fields] OR “intubators”[All Fields]	Anaesthesia, General/ methods* Anesthesia* Anaesthesia, Obstetrical/ methods* Anaesthesia, Obstetrical* Anesthesias, General General Anesthesia General Anesthesias	“direct laryngoscopy”[All Fields] Direct laryngoscopy Direct laryngoscope Traditional laryngoscopy Conventional laryngoscopy (“miller laryngoscope”[All Fields] OR “miller laryngoscopes”[All Fields] OR “miller laryngoscopy”[All Fields] OR “miller laryngoscope blade”[All Fields]) AND ((humans[Filter]) AND (english[Filter]))	“videolaryngoscopy” [All Fields] Videolaryngoscopy Video laryngoscopy Video-assisted laryngoscopy Video Assisted Techniques and Procedures Video Assisted Techniques Techniques, Video Assisted Technique, Video- Assisted Video Assisted Technique Recordings, Video Recording, Video Video Recordings Audiovisual Recording Audiovisual Recordings Recording, Audiovisual Videorecording Videorecordings	“C-Mac” “glidescope”[All Fields] “king vision”[All Fields] (McGrath [tiab]) NOT (mcgrath [auth]) ((Macintosh [tiab]) OR “airtraq”[All Fields] OR “airtraq laryngoscope”[All Fields] OR “airtraq laryngoscopes”[All Fields] OR “airtraq laryngoscopy”	(“Macintosh laryngoscope”) NOT (Macintosh [auth]) “hyperangulated”[All Fields] **Nothing specific is coming for the Channel type of VL
Controlled vocabulary terms/Subject terms (MeSH terms, Emtree terms) Consider: explode, major headings, subheadings	“Child, Preschool” [Mesh] “Child” [Mesh] “Pediatrics” [MeSH]	“Intubation, Intratracheal” [Mesh]	“Anaesthetics, General” [Mesh] “Anesthesia” [Mesh] “Anaesthesia, Obstetrical” [Mesh]	“Laryngoscopy” [MeSH] “Laryngoscopes” [Mesh]	“Video-Assisted Techniques and Procedures”[Mesh] “Video Recording”[Mesh] Laryngoscope “Laryngoscopes” [Mesh] “Laryngoscopy” [Mesh]

Search string:

PubMed: 273 results

((“Preschool Child”[All Fields] OR “children preschool”[All Fields] OR “Preschool Children”[All Fields] OR “Children” [All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms])) AND (“humans”[MeSH Terms] AND “english”[Language]) AND ((“intubate”[All Fields] OR “intubated”[All Fields] OR “intubates”[All Fields] OR “intubating”[All Fields] OR “intubation”[MeSH Terms] OR “intubation”[All Fields] OR “intubations”[All Fields] OR “intubator”[All Fields] OR “intubator s”[All Fields] OR “intubators”[All Fields] OR “intubation, intratracheal”[MeSH Terms]) AND (“humans”[MeSH Terms] AND “english”[Language])) AND ((“anesthesia general methods”[Title/Abstract] OR “anesthesia*”[Title/Abstract] OR “General Anesthesia” [Title/Abstract] OR “General Anesthesias”[Title/Abstract] OR “anesthetics, general”[MeSH Terms] OR ‘Anesthesia”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language])) AND ((“Direct laryngoscopy”[All Fields] OR “Direct laryngoscopy”[All Fields] OR “Direct laryngoscope”[All Fields] OR “Traditional laryngoscopy”[All Fields] OR “Conventional laryngoscopy”[All Fields] OR ((“miller laryngoscope”[All Fields] OR “miller laryngoscopes”[All Fields] OR “miller laryngoscopy”[All Fields] OR “miller laryngoscope blade”[All Fields]) AND (“humans”[MeSH Terms] AND “english”[Language])) OR (“Laryngoscopy”[MeSH Terms] OR “Laryngoscopes” [MeSH Terms])) AND (“humans”[MeSH Terms] AND “english”[Language])) AND ((“Videolaryngoscopy”[All Fields] OR “Videolaryngoscopy”[All Fields] OR “Video laryngoscopy”[All Fields] OR “Video-assisted laryngoscopy”[All Fields] OR “video assisted techniques and procedures”[All Fields] OR “Video Assisted Techniques”[All Fields] OR “techniques video assisted”[All Fields] OR “technique video assisted”[All Fields] OR “Video Assisted Technique”[All Fields] OR “recordings video”[All Fields] OR “recording video”[All Fields] OR “Video Recordings”[All Fields] OR ‘Audiovisual Recording” [All Fields] OR ‘Audiovisual Recordings”[All Fields] OR “recording audiovisual”[All Fields] OR “Videorecording”[All Fields] OR “Videorecordings”[All Fields] OR (“video assisted techniques and procedures”[MeSH Terms] OR “Video Recording”[MeSH Terms] OR “Laryngoscope”[All Fields] OR “Laryngoscopes”[MeSH Terms] OR “Laryngoscopy”[MeSH Terms]) OR (“C-Mac”[All Fields] OR “glidescope”[All Fields] OR “king vision”[All Fields] OR (“mcgrath”[Title/Abstract] NOT mcgrath[ Author]) OR “Macintosh” [Title/Abstract] OR “airtraq”[All Fields] OR “airtraq laryngoscope”[All Fields] OR “airtraq laryngoscopes”[All Fields] OR “airtraq laryngoscopy”[All Fields]) OR (“Macintosh laryngoscope”[All Fields] NOT Macintosh[Author]) OR “hyperangulated”[All Fields]) AND (“humans”[MeSH Terms] AND “english”[Language]))) AND ((humans[Filter]) AND (english[Filter]))

Scopus: 169 results

(TITLE-ABS-KEY (“preschool child” OR “children preschool” OR “preschool children” OR “child”) AND TITLE-ABS-KEY (“intubate” OR “intubated” OR “intubation” OR “intubations” OR “intubator” OR “intratracheal intubation”) AND TITLE-ABS-KEY (“general anesthesia” OR “anesthetics general” OR “anesthesia”) AND TITLE-ABS-KEY (“direct laryngoscopy” OR “traditional laryngoscopy” OR “miller laryngoscope” OR “laryngoscopy”) AND TITLE-ABS-KEY (“videolaryngoscopy” OR “video laryngoscopy” OR “video-assisted laryngoscopy” OR “C-Mac” OR “glidescope” OR “king vision” OR “mcgrath” OR “macintosh” OR “airtraq” OR “hyperangulated”)) AND PUBYEAR > 1999 AND PUBYEAR < 2026 AND (LIMITTO (LANGUAGE, “English”))

Supplementary Figure 2

PRISMA flow chart for Research Question: Does the use of VL improve the success of intubation over DL in the paediatric population?

Supplementary Table 2b.

Summary table for included studies for Research Question: Does the use of VL improve the success of intubation over DL in the paediatric population?

Videolaryngoscopy in paediatric patients
Authors	Journal	Study Type	Level of evidence (AHA)	Intervention	VL vs DL Success Rate	Remarks
de Carvalho CC 2022[26]	Paediatric Anaesthesia	Meta-analysis	A	Multiple VL (8 devices) & DL (Macintosh, Miller, Mc Coy) (46 studies, <18 years) outcomes: failed first intubation attempt; failed intubation within two attempts; failed intubation; glottic view; time for intubation; complications.	Yes (in neonates)	Some benefit in neonates; overall, no significant advantage
Hu X 2020[27]	J Clin Anesthesia	Meta-analysis	A	VL vs DL, (27 trials, including 2461 - 28 days to 18 years). Outcomes included time to intubate, intubation failure at first attempt, CL view, IDS, POGO score, OLEM, and complications.	No	VL improves view & reduces trauma; no First Pass Success or time benefit
Ming Y 2023[28]	Scientific Reports	Meta-analysis	A	Multiple Devices (1-18 years, 23 studies, 1873 children, comparing 12 devices) FPS, TTI, complications	No	No significant difference in FPS, TTI, or LC
Hoshijima H 2022[25]	Children (Basel)	Meta-analysis	A	Multiple Devices (Thirty-four trials comparing 13 devices) The primary outcome was intubation failure at the first attempt. Secondary outcomes: glottic visualisation, intubation time.	No	VL improves glottic view, not the success rate
Kamal G 2024[69]	Paediatric Anaesthesia	RCT	B-R	CMAC D vs Mc Coy	No (not significant)	VL faster and better view; IDS not statistically better
Unal D 2022[70]	J Burn Care & Research	Systematic Review	B-NR	Airway management in patients with burn contracture.	Not directly addressed	VL used, among others, emphasised airway planning
Masui K 2023[71]	Minerva Anestesiologica	Case Series	C-LD	McGrath MAC	Not addressed	Descriptive only; small sample
Saracoglu A 2022[72]	Minerva Anestesiologica	Survey	C-EO	Not specified	Not applicable	88.8% clinicians use DL; VL adoption is low
Lima LC 2024[59]	Brazilian J of Anesthesiology	Guideline	C-EO	Not specified	Not applicable	Broad guidance; not a comparative study

FPS=First pass success, DL=Direct laryngoscopy, VL=Videolaryngoscopy, TTI=Time to intubation, LC=local complication; CL view=Cormack Lehane view; IDS=Intubation Difficulty Scale; POGO=Percentage of Glottic Opening; OLEM=Optimal External Laryngeal Manipulation.

APPENDIX 3

Research Question- Do strategies such as the use of airway adjuncts, muscle relaxants, gastric deflation, or lateral positioning improve face mask ventilation in paediatric patients undergoing general anaesthesia?

• Population- Paediatric age group requiring general anaesthesia with tracheal intubation

• Intervention-Mask ventilation with airway adjuncts (oral, nasal airway)/Gastric tube (deflation of stomach)/Muscle relaxation/Lateral position

• Comparator- Conventional mask ventilation

• Outcomes- Successful ventilation/chest rise/ETCO2 trace/desaturation/stomach inflation/expired TV

Supplementary Table 3a.

Concept table for Research Question: Do strategies such as use of airway adjuncts, muscle relaxants, gastric deflation, or lateral positioning improve face mask ventilation in paediatric patients undergoing general anaesthesia?

Key concepts	Concept 1 Paediatric age group	Concept 2 Intubation	Concept 3 GA	Concept 4 Mask ventilation	Concept 5 Airway adjuncts	Concept 6 Muscle relaxation	Concept 6 Gastric tube/ Ryle’s tube
Free text terms/natural language terms (synonyms, UK/US terminology, medical/ laymen's terms, acronyms/ abbreviations, drug brands, more narrow search terms) Consider: phrase searching, proximity operators, truncation, wildcards, field qualification (e.g. textword)	Preschool Child Children, Preschool Preschool Children Children	“intubate” [All Fields] OR “intubated” [All Fields] OR “intubates” [All Fields] OR “intubating” [All Fields] OR “intubation” [MeSH Terms] OR “intubation” [All Fields] OR “intubations” [All Fields] OR “intubator” [All Fields] OR “intubator s” [All Fields] OR “intubators” [All Fields] (“intubation, intratracheal” [MeSH Terms] OR (“intubation” [All Fields] AND “intratracheal” [All Fields]) OR “intratracheal intubation” [All Fields] OR (“tracheal” [All Fields] AND “intubation” [All Fields]) OR “tracheal intubation” [All Fields]) AND ((humans[Filter]) AND (english[Filter]))	Anaesthesia, General/ methods* Anesthesia* Anesthesias, General General Anesthesia General Anesthesias	Refer below	((“airway” [All Fields] OR “airway s” [All Fields] OR “airways” [All Fields]) AND (“adjunct” [All Fields] OR “adjunction” [All Fields] OR “adjunctions” [All Fields] OR “adjunctive” [All Fields] OR “adjunctively” [All Fields] OR “adjunctives” [All Fields] OR “adjuncts” [All Fields])) AND ((humans[Filter]) AND (english[Filter])) ((“oropharynx” [MeSH Terms] OR “oropharynx” [All Fields] OR “oropharyngeal” [All Fields]) AND (“airway” [All Fields] OR “airway s” [All Fields] OR “airways” [All Fields])) AND ((humans[Filter]) AND (english[Filter]))	(“muscle relaxation” [MeSH Terms] OR (“muscle” [All Fields] AND “relaxation” [All Fields]) OR “muscle relaxation” [All Fields]) AND ((humans[Filter]) AND (english[Filter]))	((“gastrics” [All Fields] OR “stomach” [MeSH Terms] OR “stomach” [All Fields] OR “gastric” [All Fields]) AND “tube” [All Fields]) AND ((humans[Filter]) AND (english[Filter])) (“ryle s tube” [All Fields] OR “ryle s tube drainage” [All Fields] OR “ryle s tube feeding” [All Fields] OR “ryle s tube insertion” [All Fields] OR “ryle s tube placement” [All Fields] OR “ryle s tubes” [All Fields] OR “ryle tube” [All Fields]) AND ((humans[Filter]) AND (english[Filter]))
Controlled vocabulary terms/Subject terms (MeSH terms, Emtree terms) Consider: explode, major headings, subheadings	“Child, Preschool” [Mesh] “Child” [Mesh] “Pediatrics” [MeSH]	“Intubation, Intratracheal” [Mesh]	“Anaesthetics, General” [Mesh] “Anesthesia” [Mesh]		“Intubation, Intratracheal/ instrumentation” [Mesh] “Airway Management” [Mesh] “Oxygen Inhalation Therapy/ instrumentation” [Mesh] “Oxygen Inhalation Therapy/methods” [Mesh]	“Muscle Relaxation” [Mesh]

Search String:

PubMed: 186 results

((“Preschool Child”[All Fields] OR “children preschool” [All Fields] OR “Preschool Children”[All Fields] OR “Children”[All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms])) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language]) AND ((((“intubate”[All Fields] OR “intubated”[All Fields] OR “intubates”[All Fields] OR “intubating” [All Fields] OR “intubation”[MeSH Terms] OR “intubation” [All Fields] OR “intubations” [All Fields] OR “intubator”[All Fields] OR “intubator s”[All Fields] OR “intubators”[All Fields] OR (“intubation, intratracheal”[MeSH Terms] OR (“intubation”[All Fields] AND “intratracheal”[All Fields]) OR “intratracheal intubation”[All Fields] OR (“tracheal”[All Fields] AND “intubation”[All Fields]) OR “tracheal intubation”[All Fields])) AND (“humans”[MeSH Terms] AND “english”[Language])) OR “intubation, intratracheal”[MeSH Terms]) AND 2000/01/01:2024/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language])) AND ((“anesthesia general methods”[Title/Abstract] OR “anesthesia*”[Title/Abstract] OR “General Anesthesia”[Title/Abstract] OR “General Anesthesias”[Title/Abstract] OR “anesthetics, general”[MeSH Terms] OR ‘Anesthesia”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language])) AND (((“face-mask”[All Fields] AND (“ventilated” [All Fields] OR “ventilates” [All Fields] OR “ventilating”[All Fields] OR “ventilation”[MeSH Terms] OR “ventilation”[All Fields] OR “ventilate”[All Fields] OR “ventilations”[All Fields] OR “ventilator s”[All Fields] OR “ventilators, mechanical”[MeSH Terms] OR (“ventilators”[All Fields] AND “mechanical”[All Fields]) OR “mechanical ventilators”[All Fields] OR “ventilator”[All Fields] OR “ventilators”[All Fields] OR “ventillation”[All Fields])) OR ((“masks”[MeSH Terms] OR “masks”[All Fields] OR “mask”[All Fields]) AND (“ventilated”[All Fields] OR “ventilates”[All Fields] OR “ventilating”[All Fields] OR “ventilation”[MeSH Terms] OR “ventilation”[All Fields] OR “ventilate”[All Fields] OR “ventilations”[All Fields] OR “ventilator s”[All Fields] OR “ventilators, mechanical”[MeSH Terms] OR (“ventilators”[All Fields] AND “mechanical”[All Fields]) OR “mechanical ventilators”[All Fields] OR “ventilator”[All Fields] OR “ventilators”[All Fields] OR “ventillation”[All Fields]))) AND (“humans”[MeSH Terms] AND “english”[Language]) AND 2000/01/01:2024/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language]))) AND ((humans[Filter]) AND (english[Filter])) AND (child[Filter] OR preschoolchild[Filter]))

Scopus: 536 results

(TITLE-ABS-KEY (preschool OR “preschool children” OR child* OR paediatrics) AND PUBYEAR > 1999 AND PUBYEAR < 2026 AND LANGUAGE (english) AND (TITLE-ABS-KEY (intubat* OR “tracheal intubation” OR “intratracheal intubation”) AND TITLE-ABS-KEY (“general anaesthesia” OR anesthe*) AND TITLE-ABS-KEY (“face mask” OR mask* AND ventilat*)))

PubMed: 41 results

((“Preschool Child”[All Fields] OR “children preschool” [All Fields] OR “Preschool Children”[All Fields] OR “Children”[All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms])) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language]) AND ((((“intubate”[All Fields] OR “intubated”[All Fields] OR “intubates”[All Fields] OR “intubating” [All Fields] OR “intubation”[MeSH Terms] OR “intubation” [All Fields] OR “intubations” [All Fields] OR “intubator” [All Fields] OR “intubator s”[All Fields] OR “intubators”[All Fields] OR (“intubation, intratracheal”[MeSH Terms] OR (“intubation”[All Fields] AND “intratracheal”[All Fields]) OR “intratracheal intubation” [All Fields] OR (“tracheal”[All Fields] AND “intubation” [All Fields]) OR “tracheal intubation” [All Fields])) AND (“humans”[MeSH Terms] AND “english”[Language])) OR “intubation, intratracheal”[MeSH Terms]) AND 2000/01/01:2024/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language])) AND ((“anesthesia general methods”[Title/Abstract] OR “anesthesia*”[Title/Abstract] OR “General Anesthesia”[Title/Abstract] OR “General Anesthesias”[Title/Abstract] OR “anesthetics, general”[MeSH Terms] OR ‘Anesthesia”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language])) AND ((((“Muscle Relaxation”[MeSH Terms] OR (“muscle”[All Fields] AND “relaxation”[All Fields]) OR “Muscle Relaxation” [All Fields]) AND (“humans”[MeSH Terms] AND “english” [Language])) OR “Muscle Relaxation”[MeSH Terms]) AND 2000/01/01:2024/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english”[Language]))) AND ((humans[Filter]) AND (english[Filter]))

Scopus: 135 results

(TITLE-ABS-KEY (“preschool child” OR “children preschool” OR “preschool children” OR “children”) AND PUBYEAR > 1999 AND PUBYEAR < 2026) AND (TITLE-ABS-KEY (“intubate” OR “intubated” OR “intubates” OR “intubating” OR “intubation” OR “intratracheal intubation” OR “tracheal intubation”) AND PUBYEAR > 1999 AND PUBYEAR < 2025) AND (TITLE-ABS-KEY (“anesthesia general methods” OR “anesthesia*” OR “general anesthesia” OR “general anesthesias” OR “anesthetics, general”) AND PUBYEAR > 1999 AND PUBYEAR < 2026) AND (TITLE-ABS-KEY (“muscle relaxation”) AND PUBYEAR > 1999 AND PUBYEAR < 2025) AND (LIMIT-TO (LANGUAGE, “English”))

Supplementary Figure 3

PRISMA flow chart for Research Question: Do strategies such as the use of airway adjuncts, muscle relaxants, gastric deflation, or lateral positioning improve face mask ventilation in paediatric patients undergoing general anaesthesia?

Supplementary Table 3b.

Summary table for included studies for Research Question: Do strategies such as use of airway adjuncts, muscle relaxants, gastric deflation, or lateral positioning improve face mask ventilation in paediatric patients undergoing general anaesthesia?

Supportive strategy for face mask ventilation
Author, Year	Journal	Type of Article	Level of Evidence (AHA)	Intervention	Technique Supported
Choudhry DK et al., 2021[18]	Paediatr Anesth	RCT crossover study	Level B-R	One-handed vs two­handed facemask technique in adeno-tonsillar hypertrophy (1-8 years)	Supports two-handed technique for better ventilation
Valois-Gomez T et al., 2013[74]	Paediatr Anesth	Prospective observational	Level B-NR	Study the incidence of difficult bag mask ventilation	Cautions against NMB use due to increased difficulty in BMV
Garcia-Marcinkiewicz AG, 2023[23]	Br J Anaesth	Retrospective registry analysis	Level B-NR	NMB in difficult mask ventilation	Supports NMB use for improved ventilation in selected cases
Pedersen TH et al., 2021[73]	Br J Anaesth	Prospective before/after	Level B-NR	Early NMB after LOC	Supports early NMB administration before BMV
Lagarde S et al., 2010[22]	Anesth Analg	Prospective observational	Level C-LD	Inspiratory pressure thresholds	Supports limiting inspiratory pressure to prevent GI
Litman RS et al., 2005[16]	Anesthesiology	Observational study	Level C-LD	Lateral vs supine positioning	Supports lateral position to improve airway patency

NMB=Neuromuscular blockers, BMV=Bag mask ventilation, GI=Gastric Insufflation, LOC=Loss of Conciousness

APPENDIX 4

Research Question: How many attempts would you limit intubation to for fear of worsening the airway in children?

• Population- Paediatric age group (1-12 years) requiring tracheal intubation under general anaesthesia

• Intervention- Attempts at Laryngoscopy and intubation

• Comparator- Attempts at Laryngoscopy and intubation

• Outcomes- Number of attempts, Trauma, airway oedema, stridor, bleeding, airway morbidity, laryngospasm, airway obstruction

Supplementary Table 4a.

Concept table for Research Question: How many attempts would you limit intubation to for fear of worsening the airway in children?

Key concepts	Concept 1 Paediatric age group	Concept 2 Intubation	Concept 3 GA	Concept 5 Direct laryngoscopy	Concept 6 Attempts at intubation Attempts at laryngoscopy
Free text terms/ natural language terms (synonyms, UK/ US terminology, medical/laymen's terms, acronyms/ abbreviations, drug brands, more narrow search terms) Consider: phrase searching, proximity operators, truncation, wildcards, field qualification (e.g. textword)	Preschool Child Children, Preschool Preschool Children Children	“intubate”[All Fields] OR “intubated”[All Fields] OR “intubates”[All Fields] OR “intubating”[All Fields] OR “intubation”[MeSH Terms] OR “intubation”[All Fields] OR “intubations”[All Fields] OR “intubator”[All Fields] OR “intubator s”[All Fields] OR “intubators”[All Fields]	Anaesthesia, General/methods* Anesthesia* Anaesthesia, Obstetrical/ methods* Anaesthesia, Obstetrical* Anesthesias, General General Anesthesia General Anesthesias	“direct laryngoscopy” [All Fields] Direct laryngoscopy Direct laryngoscope Traditional laryngoscopy Conventional laryngoscopy (“miller laryngoscope”[All Fields] OR “miller laryngoscopes”[All Fields] OR “miller laryngoscopy”[All Fields] OR “miller laryngoscope blade”[All Fields]) AND ((humans[Filter]) AND (english[Filter]))	((“attempt”[tiab] OR “attempted”[tiab] OR “attempter”[tiab] OR “attempters”[tiab] OR “attempting”[tiab] OR “attempts”[tiab]) AND (“intubate”[tiab] OR “intubated”[tiab] OR “intubates”[tiab] OR “intubating”[tiab] OR “intubation”[tiab] OR “intubations”[tiab] OR “intubator”[tiab] OR “intubators”[tiab])) AND ((humans[Filter]) AND (english[Filter])) Filters: Humans, English
Controlled vocabulary terms/Subject terms (MeSH terms, Emtree terms) Consider: explode, major headings, subheadings	“Child, Preschool”[Mesh] “Child”[Mesh] “Pediatrics”[MeSH]	“Intubation, Intratracheal”[Mesh]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, Obstetrical”[Mesh]	“Laryngoscopy”[MeSH] “Laryngoscopes”[Mesh]

Search string:

PubMed: 124 results

((“Preschool Child”[All Fields] OR “children preschool”[All Fields] OR “Preschool Children”[All Fields] OR “Children” [All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms])) AND (“humans”[MeSH Terms] AND “english”[Language]) AND ((“anesthesia general methods”[Title/ Abstract] OR “anesthesia*”[Title/Abstract] OR “General Anesthesia”[Title/Abstract] OR “General Anesthesias”[Title/Abstract] OR “anesthetics, general”[MeSH Terms] OR “Anesthesia”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication] AND (“humans”[MeSH Terms] AND “english” [Language])) AND ((“attempt”[Title/Abstract] OR “attempted”[Title/Abstract] OR “attempter” [Title/Abstract] OR “attempters”[Title/Abstract] OR “attempting”[Title/Abstract] OR “attempts”[Title/Abstract]) AND (“intubate”[Title/ Abstract] OR “intubated”[Title/Abstract] OR “intubates”[Title/Abstract] OR “intubating”[Title/Abstract] OR “intubation”[Title/Abstract] OR “intubations”[Title/Abstract] OR “intubator”[Title/Abstract] OR “intubators”[Title/ Abstract]) AND (“humans”[MeSH Terms] AND “english”[Language]) AND (“humans”[MeSH Terms] AND “english”[Language])) AND ((“Direct laryngoscopy”[All Fields] OR “Direct laryngoscopy”[All Fields] OR “Direct laryngoscope”[All Fields] OR “Traditional laryngoscopy”[All Fields] OR “Conventional laryngoscopy”[All Fields] OR ((“miller laryngoscope”[All Fields] OR “miller laryngoscopes”[All Fields] OR “miller laryngoscopy”[All Fields] OR “miller laryngoscope blade”[All Fields]) AND (“humans”[MeSH Terms] AND “english”[Language])) OR (“Laryngoscopy”[MeSH Terms] OR “Laryngoscopes” [MeSH Terms])) AND (“humans”[MeSH Terms] AND “english”[Language]))) AND ((humans[Filter]) AND (english[Filter]))

Scopus: 69 results

(TITLE-ABS-KEY (attempts AND laryngoscopy) AND PUBYEAR > 1999 AND PUBYEAR < 2025) AND (paediatric) AND (pediatric) AND (laryngoscopy) AND (attempts) AND (attempt) AND (intubation) AND (intubate) AND (LIMIT-TO (SUBJAREA, “MEDI”)) AND (LIMIT-TO (DOCTYPE, “ar”) OR LIMIT-TO (DOCTYPE, “re”)) AND (LIMIT-TO (LANGUAGE, “English”)) AND (LIMIT-TO (EXACTKEYWORD, “Human”) OR LIMIT-TO (EXACTKEYWORD, “Laryngoscopy”) OR LIMIT-TO (EXACTKEYWORD, “Endotracheal Intubation”))

Supplementary Figure 4

PRISMA flow chart for Research Question: How many attempts would you limit intubation to for fear of worsening the airway in children?

Supplementary Table 4b.

Summary table for included studies for Research Question: How many attempts would you limit intubation to for fear of worsening the airway in children?

Intubation attempts table
Author (Year)	Journal	Type of Article	AHA Level of Evidence	Intervention	Supports Reducing Attempts	Threshold of Increased Complications
Fiadjoe (2016)[3]	Lancet Respir Med	Registry	C-LD	>2 attempts increase complications	Yes	>2
Engelhardt (2018)[39]	British J Anaesthesia	Prospective Observational	C-LD	Attempt number vs. critical events	Yes	>2
Lee (2016)[37]	BMC Pediatrics	Prospective Observational	C-LD	Attempts linked to hypoxemia and AE	Yes	Not specified
Park (2017)[38]	British J Anaesthesia	Registry	C-LD	Odds of complications rise per attempt	Yes	Every additional attempt
Stein (2024)[36]	eClinical Medicine	Registry	C-LD	More attempts are linked to severe complications	Yes	Median 3 in the severe AE group

AE=Adverse Events

APPENDIX 5

Research question: In paediatric patients with failure of endotracheal intubation, supraglottic device placement and facemask ventilation, how do emergency rescue methods such as needle cricothyrotomy, surgical cricothyroidotomy, or tracheostomy compare in terms of effectiveness and complications for securing the airway and ensuring ventilation and oxygenation?^{[70-83][77-84]}

• Population- Paediatric age group after failure of endotracheal intubation, supraglottic device placement and facemask ventilation

• Intervention- Transtracheal puncture/ needle cricothyrotomy/ cannula cricothyrotomy/ cannula cricothyroidotomy/ Surgical cricothyroidotomy/ Tracheostomy/ Front of neck access/ FONA/ Emergency surgical airway/ Surgical airway/ Tracheotomy

• Comparator- Transtracheal puncture/ needle cricothyrotomy/ cannula cricothyrotomy/ Surgical cricothyroidotomy / Tracheostomy

• Outcomes-Successful tracheal tube placement/Successful ventilation/desaturation/successful oxygenation/ bradycardia/cardiac arrest/pneumothorax/false passage/Trauma

Supplementary Table 5a.

Concept table for Research Question: In paediatric patients with failure of endotracheal intubation, supraglottic device placement and facemask ventilation, how do emergency rescue methods such as needle cricothyrotomy, surgical cricothyroidotomy, or tracheostomy compare in terms of effectiveness and complications for securing the airway and ensuring ventilation and oxygenation?

Key concepts	Concept 1 Paediatric age group	Concept 2 failure of airway management after conventional techniques	Concept 3 Transtracheal puncture/ needle cricothyrotomy/ cannula cricothyrotomy/ Surgical cricothyroidotomy/ Tracheostomy/ Surgical airway	Concept 4 GA
Free text terms/ natural language terms (synonyms, UK/ US terminology, medical/laymen's terms, acronyms/ abbreviations, drug brands, more narrow search terms) Consider: phrase searching, proximity operators, truncation, wildcards, field qualification (e.g. textword)	Preschool Child Children, Preschool Preschool Children Children	Management, Airway Airway Control Control, Airway Airway Obstructions Obstruction, Airway Obstructions, Airway Choking Intratracheal Intubation Intratracheal Intubations Intubations, Intratracheal Intubation, Endotracheal Endotracheal Intubation Endotracheal Intubations Intubations, Endotracheal	“transtracheal puncture”[All Fields]” needle cricothyrotomy”[All Fields] “cricothyrotomy”[All Fields] “cricothyrotomy cannula”[All Fields] “cannula cricothyroidotomy”[All Fields]) “surgical cricothyroidotomy”[All Fields] “surgical cricothyrotomy”[All Fields] “tracheostomy”[All Fields] (((“surgical airway”[All Fields]) OR (“surgical airway access”[All Fields])) OR (“surgical airways”[All Fields])) OR (Surgical airway) (“emergency surgical airway”[All Fields]) OR (“emergency surgical airways”[All Fields]) OR (“emergency surgical airway procedures”[All Fields]) ((“front of neck access”[All Fields]) OR (“front of neck airway”[All Fields])) OR (“front of neck airway access”[All Fields]) “fona”[All Fields] “tracheotomy”[All Fields]	Anaesthesia, General/methods* Anesthesia* Anaesthesias, General General Anesthesia General Anesthesias
Controlled vocabulary terms/Subject terms (MeSH terms, Emtree terms) Consider: explode, major headings, subheadings	“Child, Preschool”[Mesh] “Child”[Mesh] “Pediatrics”[MeSH]	“Airway Management”[Mesh] “Airway Obstruction”[Mesh] “Intubation, Intratracheal”[Mesh]	“Tracheostomy”[Mesh] “Tracheotomy”[Mesh]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh]

Search string:

PubMed: 138 results

(“Preschool Child”[All Fields] OR “children preschool” [All Fields] OR “Preschool Children”[All Fields] OR “Children” [All Fields] OR “child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication] AND ((“management airway”[All Fields] OR ‘Airway Control”[All Fields] OR “control airway”[All Fields] OR ‘Airway Obstructions”[All Fields] OR “obstruction airway”[All Fields] OR “obstructions airway”[All Fields] OR “Choking”[All Fields] OR “Intratracheal Intubation” [All Fields] OR “Intratracheal Intubations” [All Fields] OR “intubation endotracheal” [All Fields] OR “Endotracheal Intubation”[All Fields] OR “Endotracheal Intubations”[All Fields] OR ‘Airway Management”[MeSH Terms] OR “Airway Obstruction”[MeSH Terms] OR “intubation, intratracheal”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication]) AND ((“transtracheal puncture”[All Fields] OR “needle cricothyrotomy”[All Fields] OR “cricothyrotomy”[All Fields] OR “cricothyrotomy cannula” [All Fields] OR “cannula cricothyroidotomy”[All Fields] OR “surgical cricothyroidotomy”[All Fields] OR “surgical cricothyrotomy”[All Fields] OR “Tracheostomy”[All Fields] OR “Surgical airway”[All Fields] OR “surgical airway access”[All Fields] OR “surgical airways”[All Fields] OR “Surgical airway”[All Fields] OR “emergency surgical airway”[All Fields] OR “emergency surgical airways”[All Fields] OR “emergency surgical airway procedures”[All Fields] OR “front of neck access”[All Fields] OR “front of neck airway”[All Fields] OR “front of neck airway access”[All Fields] OR “fona”[All Fields] OR “Tracheotomy”[All Fields] OR “Tracheostomy”[MeSH Terms] OR “Tracheotomy”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication]) AND ((“anesthesia general methods”[Title/Abstract] OR “anesthesia*”[Title/Abstract] OR “General Anesthesia”[Title/Abstract] OR “General Anesthesias”[Title/Abstract] OR “anesthetics, general”[MeSH Terms] OR ‘Anesthesia”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication])

Scopus: 387 results

TITLE-ABS-KEY (“Preschool Child” OR “children preschool” OR “Preschool Children” OR “Children” OR “child preschool” OR “Child” OR “Paediatrics”) AND TITLE-ABS-KEY (“management airway” OR ‘Airway Control” OR “control airway” OR “Airway Obstructions” OR “obstruction airway” OR “obstructions airway” OR “Choking” OR “Intratracheal Intubation” OR “Intratracheal Intubations” OR “intubation endotracheal” OR “Endotracheal Intubation” OR “Endotracheal Intubations” OR “Airway Management” OR “Airway Obstruction” OR “intubation intratracheal”) AND TITLE-ABS-KEY (“transtracheal puncture” OR “needle cricothyrotomy” OR “cricothyrotomy” OR “cricothyrotomy cannula” OR “cannula cricothyroidotomy” OR “surgical cricothyroidotomy” OR “surgical cricothyrotomy” OR “Tracheostomy” OR “Surgical airway” OR “surgical airway access” OR “surgical airways” OR “emergency surgical airway” OR “emergency surgical airways” OR “emergency surgical airway procedures” OR “front of neck access” OR “front of neck airway” OR “front of neck airway access” OR “fona” OR “Tracheotomy” OR “Tracheostomy”) AND TITLE-ABS-KEY (“anesthesia general methods” OR “anesthesia” OR “General Anesthesia” OR “General Anesthesias” OR “anesthetics general” OR ‘Anesthesia”) AND PUBYEAR > 1999 AND PUBYEAR < 2026

Supplementary Figure 5

PRISMA flow chart for Research Question: In paediatric patients with failure of endotracheal intubation, supraglottic device placement and facemask ventilation, how do emergency rescue methods such as needle cricothyrotomy, surgical cricothyroidotomy, or tracheostomy compare in terms of effectiveness and complications for securing the airway and ensuring ventilation and oxygenation?

Supplementary Table 5b.

Summary table for included studies for Research Question: In paediatric patients with failure of endotracheal intubation, supraglottic device placement and facemask ventilation, how do emergency rescue methods such as needle cricothyrotomy, surgical cricothyroidotomy, or tracheostomy compare in terms of effectiveness and complications for securing the airway and ensuring ventilation and oxygenation?

Emergency surgical airway in paediatric patients
Author, Year	Journal	Type of Study	Level of evidence (AHA)	Intervention	Outcome Summary/Preferred Technique
Riva T, 2024[47]	Pediatr Anesth	Prospective RCT (crossover)	C-LD	SBT vs RST in rabbits by a paediatric anaesthesiologist and paediatric intensivist	SBT preferred: faster, fewer injuries
Thomas J, 2022[48]	Br J Anaesth	Prospective RCT (crossover)	C-LD	Cuffed vs Uncuffed tracheal tube over Frova, in rabbits, paediatric anaesthesiologists and paediatric intensivists	3.5 mm uncuffed preferred: lower force, fewer injuries
Both CP, 2021 [46]	Br J Anaesth	Observational	C-LD	SBT with Frova in rabbits, by anaesthesiologists	SBT had high success and fewer injuries
Ulmer F, 2020[76]	Br J Anaesth	Observational	C-LD	Emergency tracheostomy on an infant rabbits' model - 50 experienced paediatric anaesthesiologists, novice in tracheostomy in paediatrics	High success after training; time improved with attempts
Prunty SL, 2021[51]	Pediatr Anesth	Observational	C-LD	Cannula cricothyroidotomy- Direct aspiration vs extension tubing set aspiration in rabbits,	Extension tubing set technique had fewer injuries.
Prunty SL, 2015[49]	Pediatr Anesth	Observational	C-LD	Cook Melker vs Scalpel Bougie in post­mortem white New Zealand rabbits	Cook Melker has better success and fewer complications
Stacey J, 2012[50]	Pediatr Anesth	Observational	C-LD	Cannula tracheotomy (14G vs 18G vs Quicktrach child) in rabbits	Cannula tracheotomy is difficult, overall success rate 60% for 14G and 18G, and Quicktrach failed in all cases
Metterlein T, 2011[75]	Pediatr Anesth	RCT	C-LD	Quicktrach baby in rabbits by post­graduates (with prior training)	Quicktrach baby is successful, but has limited availability

SBT=Scalpel Bougie Technique, RST =Rapid Surgical Technique, Cannula cric =Cannula Cricothyrotomy, Quicktrach=Commercial emergency cricothyrotomy device, Cook Melker – Cook Melker Emergency Cricothyrotomy Kit, Frova – Frova Intubating Introducer (a type of bougie)

APPENDIX 6

Supplementary Table 6.

Consensus and Stability Analysis of the Clinical Statements from the Delphi Survey

Paediatric Guidelines	Agree (%)	Neutral (%)	Disagree (%)	Median (IQR)	P
1. What is the maximum number of attempts at intubations that should be permitted to prevent airway management-related complications in paediatric patients (1-12 years)?
• Maximum 1	0				0.64
• Maximum 2	9
• Maximum 2 + 1 (additional attempt should only be done by an anaesthesiologist with experience in paediatric airway management)	91 0
• Maximum 4
2. What is the maximum number of attempts at SGA insertion that should be permitted to prevent airway management-related complications in paediatric patients (1-12 years)?
• Maximum 1	0				0.26
• Maximum 2	87
• Maximum 3	13
• Maximum 4	0
3. What nasal oxygen flow rate (in litres) should be used for apnoeic oxygenation (during attempts at intubation) in paediatric patients (1-12 years)?
• 0.2 L/Kg/min (nasal cannula)	0				0.06
• 1-2 L/Kg/min (HFNO)	92
• 2-4 L/Kg/min (HFNO)	4
• Availability of HFNO may be a limitation. Since low flow and high flow give comparable benefits, low flow systems may be used.	4
4. Giving a lateral position may improve mask ventilation when difficulty in mask ventilation is encountered in paediatric patients (1-12 years)	70	26	4	6(3)	0.22
5. Administration of continuous positive airway pressure (CPAP) may improve mask ventilation when difficulty in mask ventilation is encountered in paediatric patients (1-12 years)	100	0	0	7(0)	0.09
6. Which anatomical site should be preferred in paediatric patients less than 5 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available?
• Cricotracheal Puncture	100				0.07
• Cricothyroid Puncture	0
7. Which anatomical site should be preferred in paediatric patients between 5-12 years of age for performing an emergency surgical airway as a rescue technique, if surgical help for performing a tracheostomy is not available?
• Cricotracheal Puncture	0				0.07
• Cricothyroid Puncture	100

SGA=Supraglottic Airway; HFNO=High flow nasal oxygen; CPAP=Continuous positive airway pressure

Funding Statement

All expenses related to the development of the guidelines were entirely funded by the All India Difficult Airway Association (AIDAA).