The future of pediatric airway management

Abstract

Purpose of review – This review examines recent advances in pediatric airway management, including emerging technologies, updated guidelines, and innovative strategies for improving safety across diverse clinical settings. We address the unique challenges faced when managing airways in neonates, infants, and children with complex conditions. Recent findings – The 2024 ESAIC-BJA neonatal and infant airway guidelines provide the first evidence-based recommendations emphasizing preoperative identification of the difficult airway, the use of neuromuscular blockade, videolaryngoscopy, and optimized preoxygenation to mitigate risk in this vulnerable population. Use of videolaryngoscopy continues to increase, with multicenter randomized controlled trials demonstrating 5–10% absolute improvements in first-attempt success rates and significant reduction in severe complications including esophageal intubation and hypoxemia, particularly when combined with supplemental oxygen during laryngoscopy. Registry and meta-analysis data now provide robust evidence that neuromuscular blocking agents improve intubation conditions and reduce complications. Artificial intelligence applications show promise for predicting difficult airways and optimizing endotracheal tube sizing. Front-of-neck access strategies have been refined, acknowledging the limitations of cricothyrotomy in young children. Extracorporeal membrane oxygenation has emerged as a rescue strategy in anticipated cannot-intubate-cannot-oxygenate scenarios. Global disparities in pediatric anesthesia safety persist, with collaborative educational initiatives addressing workforce challenges in low- and middle-income countries. Summary – The future of pediatric airway management lies in individualized, technology-enhanced approaches guided by evidence-based algorithms, multidisciplinary collaboration, comprehensive education, and simulation-based training, with a commitment to equitable care delivery worldwide.