Any approach to management of the difficult pediatric airway must include both adequate preparation and a realistic recognition that the original plan may not be successful. In this context, prior to anesthetic induction, it is important to have conceived of alternate plans for securing the airway. Persistence in repeating the same technique, without making adjustments, or changing the approach, can induce trauma and edema within the delicate pediatric airway and rapidly transform a situation of “cannot intubate” into a more precarious scenario of “cannot intubate, cannot ventilate.”

When practicing direct laryngoscopy with a standard laryngoscope, there are several maneuvers that may improve the laryngoscopic view, thus facilitating successful placement of the endotracheal tube (ETT). External pressure may be applied to the larynx, either by the laryngoscopist or an assistant, and may be particularly helpful during infant laryngoscopy. Placing a flexible stylet inside the ETT and using a hockey-stick shape may allow ETT placement, even when only the epiglottis or arytenoid cartilages are seen. The retromolar approach to direct laryngoscopy (Fig. 42-1) may be particularly useful in situations where routine rigid laryngoscopy is unsuccessful, such as in patients with micrognathia or macroglossia (Fig. 42-2). The head is turned slightly to the left, the right corner of the mouth is retracted, and a straight blade (Miller 1 with left-handed bulb or Phillips 1) is introduced through the right side of the mouth. The laryngoscope is advanced between the tongue and lateral pharyngeal wall, sweeping the tongue to the left, overlying the molars, until the epiglottis is visualized. The lateral placement of the blade and movement of the head bypasses the tongue, virtually eliminates the need for displacement of soft tissue, and improves line of site visualization.

The gold standard for management of the difficult airway remains the flexible fiberoptic bronchoscope. Proficiency in using this instrument remains a requisite skill for every practitioner. Positioning for fiberoptic bronchoscopy requires slight extension of the patient’s head at the atlanto-occipital joint, with performance of a jaw thrust by an assistant, and at times, tongue traction, to open the posterior pharyngeal space and provide an ideal view of the glottic opening. The flexible bronchoscope should be kept straightened, with the tip of the scope placed in the midline. Specially designed oral airways facilitate midline placement during oral fiberoptic intubation, whereas nasal fiberoptic bronchoscopy typically allows for easier midline placement. However, the risk of epistaxis or adenoid shearing is ever-present, and, hence, premedication with topical vasoconstrictors is ordinarily undertaken. The modified nasal trumpet can be of great assistance when performing nasal fiberoptic intubation, permitting spontaneous ventilation. Both volatile anesthetics and oxygen may be provided via this route (Fig. 42-3). Due to the shorter airway distances in children, it is critically important to advance slowly through the identifiable supraglottic structures of the airway, thus avoiding deep placement of the fiberoptic scope in the esophagus. A pitfall of fiberoptic-assisted intubation is resistance to advancement of the ETT into the larynx, despite successful placement of the fiberoptic scope. To avoid catching the ETT on the arytenoid cartilages, one should place the ETT bevel down on the fiberoptic scope for oral intubations and bevel up for nasal intubations (UNDO). One may also slightly withdraw the orotracheal or nasotracheal tube when resistance is encountered, rotate 90°, and attempt again.

Advantages of the flexible fiberoptic technique include its adaptability to multiple difficult airway scenarios, enabling the practitioner to secure the airway with minimal manipulation of the head or neck via both oral and nasal methods. This technique is particularly beneficial for patients with cervical instability; syndromic children with cervical inflexibility; and patients with temporomandibular joint (TMJ) abnormalities limiting translocation and, ultimately, rotation. Improved digital technology now allows for obtaining clearer images, even in the neonatal population, with the smallest scope sized 2.2 mm, and able to fit through a 2.5 ETT. Furthermore, light sources and video systems have been incorporated into the newer bronchoscopes, allowing for increased portability as well as the ability to display a larger image of the airway. However, there is a significant learning curve