Investigation into the intraoperative management of the difficult pediatric airway: A scoping review

Introduction/Objectives: Pediatric airways can pose a significant challenge to anesthesia providers. Almost 20% of pediatric patients undergoing general anesthesia are considered to have a difficult airway due to congenital anomalies, craniofacial deformities, trauma, or infection. The majority of children with difficult airways can be identified preoperatively, but the variety of clinical scenarios in which difficult airways can quickly arise requires an individualized approach that considers the underlying condition and the patient’s physiological status. The objective of this scoping review is to identify clinical challenges and complications, summarize outcomes of airway methods, and identify existing knowledge gaps to guide future airway management research.

Methods: We performed a literature search using the Ovid (Embase), MEDLINE (PubMed), SCOPUS, Web of Science, and Cochrane databases for articles on pediatric airways that were published in the 10-year period spanning from 2014 to 2024 and written in English. Included studies were systematic reviews, meta-analyses, retrospective database reviews, clinical trials, case-control studies, cross-sectional analyses, and cohort studies. The data were imported into Rayaan, and two independent investigators screened records for inclusion criteria in a masked, duplicate fashion. Investigators then completed a data extraction form that identified the frequencies, types, and complications of airway methods used to provide anesthetic care.

Results: The initial database search yielded 1,097 articles, and 82 ultimately met the inclusion criteria to be evaluated in our study. The sample in our study consisted of research from 50 different journals. The most frequent journal featured in our sample was Cureus: Journal of Medical Sciences, with 11 studies (11/82; 13.4%). The continent with the most studies was Asia, with 43 studies (43/82; 52.4%). Case reports/Case series comprised most of the study design types (62/82; 75.6%), followed by Cohort studies (15/82; 18.3%). There was only one of each, a Randomized Controlled Trial and systematic review with meta-analysis. The studies focused on anatomical/congenital difficult airways most commonly (42/82; 51.2%). The approach/technique included in these studies was most commonly direct laryngoscopy (36/82; 43.9%), fiberoptic bronchoscopy (37/82; 45.1%), and video laryngoscopy (39/82; 47.6%).

Conclusion: In conclusion, the importance of a proper preoperative examination to identify anatomical, pathological, or physiological characteristics of pediatric patients cannot be emphasized enough. This scoping review provides an overview of the current techniques and methods of intraoperative pediatric difficult airway management and identifies the knowledge gaps and areas for future research. More systematic research, like randomized controlled trials and systematic reviews, could benefit the anesthetic community with different approaches to handling these critical situations.