Children in this category are encountered on a daily basis. These children are usually healthy and have no previous symptoms or signs indicative of a difficult airway. Problems encountered are either due to an anatomical (mechanical) or functional airway obstruction (Table 11.1).

Swelling, trauma and infections can turn the normal airway of otherwise healthy children rapidly into an impaired normal airway. The severity of symptoms and speed of deterioration dictate the urgency and need of the anaesthetic intervention. The underlying disorder – infectious (epiglottitis), allergic or mechanical (inhaled foreign body, bleeding tonsil) – requires swift recognition and treatment. Most children, however, tolerate a certain delay in order to allow resuscitation, organisation and preparation of appropriate staff, location and equipment.

This refers to children who have a known or obvious difficult/abnormal airway.

Examples include but are not limited to head, neck and airway anomalies. They may be congenital (associated with syndromes) or acquired (burns, scars), associated with tumours and other masses and more rare causes such as subglottic and tracheal disorders or anterior mediastinal mass syndrome.

Unless there is an immediate threat to life or limb, these patients must be transferred to a specialised hospital with appropriate experience, personnel and equipment available to guarantee optimal safety.

The clear distinction between ‘normal’, ‘impaired normal’ and ‘known abnormal’ allows the non-specialist paediatric anaesthetist to determine the optimal approach to the child requiring airway interventions (Fig. 11.1). Whereas the ‘normal’ paediatric airway may be managed in most centres with appropriate staffing and resources, the establishment of simple, locally adapted, easy memorisable and rehearsed algorithms is essential for safe paediatric airway management (see below). The acutely impaired normal paediatric airway requires experience and skill. If these are available, the paediatric airway can be managed locally. The gravity of the underlying disease process (infectious, allergic swelling, trauma or burn) and speed of deterioration will guide the anaesthetic intervention. Resuscitation, organisation and preparation of appropriate staff, location and equipment should be arranged if the condition of the child allows. All other patients should be transferred to a dedicated paediatric unit unless intervention is critical. Surgical (ENT) support is required if the anaesthetist is not experienced enough or has doubts about the ability to oxygenate and ventilate.

Routine paediatric airway management is usually easy in experienced hands. However, as outlined above, children have an increased oxygen consumption and a lower oxygen reserve when compared with adults. Therefore, preparation, regular training and education are essential to prevent and recognise early unexpected difficulties in the otherwise ‘normal’ paediatric airway. Time critical concepts are required based on simple, forward only, easy memorisable, locally adapted and rehearsed algorithms. Such a simple proposal for the paediatric patient was published recently and is reproduced in an adapted form (Fig. 11.2).

Maintenance of the ability to oxygenate and ventilate is the key to successful airway management. Good daily clinical practice is required to achieve this. Anatomical/mechanical airway obstructions need to be recognised and treated first as described. No pharmacological intervention will solve this problem. If the situation does not improve early, call for help immediately. Recognition and treatment of functional airway obstruction using either an additional dose of hypnotic, muscle relaxant or epinephrine is essential. Limited and as of yet unpublished evidence suggests that all otherwise normal children can be oxygenated and ventilated if anatomical and functional airway problems are recognised and treated [11]. An unexpected foreign body (food/chewing gum – a mechanical obstruction) occluding the glottis must be removed or bypassed following muscle relaxation. A supraglottic airway device may be helpful in overcoming unexpected/unknown anatomical airway obstructions. Unexpected difficult tracheal intubation may occur, and similarly a simple, stepwise, forward only and locally adapted algorithm must be in place. It is essential to realise that repeated traumatic airway instrumentation will convert a difficult paediatric airway into an impossible situation.