Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.

BACKGROUND: In patients presenting for pyloromyotomy, most practitioners prioritize rapid securement of the airway due to concern for aspiration. However, there is a lack of consensus and limited evidence on the choice between rapid sequence induction (RSI) and modified RSI (mRSI). METHODS: The medical records of all patients presenting for pyloromyotomy from May 2012 to December 2018 were reviewed. The risk of hypoxemia (peripheral oxygen saturation [Spo 2], <90%) during induction was compared between RSI and mRSI cohorts for all patients identified as well as in the neonate subgroup by univariate and multivariable logistic regression analysis. Complications (aspiration, intensive care unit admission, bradycardia, postoperative stridor, and hypotension) and initial intubation success for both cohorts were also compared. RESULTS: A total of 296 patients were identified: 181 in the RSI and 115 in the mRSI cohorts. RSI was associated with significantly higher rates of hypoxemia than mRSI (RSI, 30% [23%–37%]; mRSI, 17% [10%–24%]; P = .016). In multivariable logistic regression analysis of all patients, the adjusted odds ratio (OR) of hypoxemia for RSI versus mRSI was 2.8 (95% confidence interval [CI], 1.5–5.3; P = .003) and the OR of hypoxemia for multiple versus a single intubation attempt was 11.4 (95% CI, 5.8–22.5; P < .001). In multivariable logistic regression analysis of neonatal subgroup, the OR of hypoxemia for RSI versus mRSI was 6.5 (95% CI, 2.0–22.2; P < .001) and the OR of hypoxemia for multiple intubation versus single intubation attempts was 18.1 (95% CI, 4.7–40; P < .001). There were no induction-related complications in either the RSI and mRSI cohorts, and the initial intubation success rate was identical for both cohorts (78%). CONCLUSIONS: In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.

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The COVID‐19 pandemic has prompted rapid development and deployment of a variety of unproven physical barriers intended to protect providers from aerosols generated during airway management 1,2 . The US Food and Drug Administration (FDA) initially granted an umbrella emergency use authorization (EUA) for passive protective barrier enclosures on May 1, 2020. Although anecdotal evidence drove widespread adoption of these devices, there are no data we are asware of demonstrating they protect providers from infection with the SARS‐CoV‐2 virus. Furthermore, some have expressed concern about their safety and efficacy for both patients and providers 3 , with particular concern that barriers may prolong intubation times and increase the risk of hypoxemia 4 .

The exposure of infants and children to volatile anesthetics, such as sevoflurane, has been a topic of concern with respect to the potential risk for long term neurocognitive effects. The primary objective of this study was to determine whether the perioperative utilization of Bispectral Index (BIS) monitoring alters the sevoflurane delivery and exposure to children. This is a prospective randomized trial of two groups of healthy ambulatory day surgery patients (2 to 12 years). The patients in both groups had the BIS applied soon after the induction of general anesthesia, but only the anesthesiologists in the group randomized to BIS visible were able to see the BIS values. All of the patients received general anesthesia with sevoflurane. This study found no difference in the overall exposure to sevoflurane between both groups (mean end-tidal sevoflurane level of 1.8 in both groups, P = 084). The duration of time in the recovery room, the time to meet discharge criteria, the Pediatric Agitation Emergence Delirium (PAED) scores and the Face, Legs, Activity, Cry, Consolability (FLACC) scores were not statistically different between the groups. The application and utilization of intraoperative BIS monitoring does not alter the sevoflurane administration nor the discharge readiness nor the recovery profile in healthy ambulatory children.

Background:The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID-19 pandemic. Methods:The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID-19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. Recommendations:In the setting of the COVID-19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. Reflection: These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID-19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID-19. They would likely be important initial steps in the face of novel respiratory viral pathogens. Conclusions: The consensus process cannot and should not replace evidence-based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown.| 1075 STEIN ET al.

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I n this issue of Critical Care Medicine, Giuliano et al (1) compared traditional direct laryngoscopy (DL) to video-enabled laryngoscopy (VL) using standard blades (i.e., Miller or Macintosh) when performing tracheal intubation across 10 different PICUs in North America. As the focus was on the effects of "coaching" during video-assisted DL, they only included the attempt(s) at intubation when either standard blade VL or DL were used as the primary method of intubation and excluded any rescue attempts with these techniques. The authors found that "implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs. " Of note, the first attempt intubation success rates of approximately 70% in this article (1) show that there is a need for improvement. Intubation success rates in infants and neonates are expected to be around 90% (2), and even in children with difficult airways, the success rate of standard blade VL is greater than 60% (3). While some of these differences may be a result of the physiologic derangement seen in ICU patients, it is probable that other issues, such as the intubating clinicians' level of experience and the stressors they are under, make more of a contribution.There are multiple limitations to this prospective, multicenter, interventional quality improvement study that the authors recognize. These include the lack of randomization between their groups and the absence of details, and presumably standardization, of the induction techniques used: for example, doses of muscle relaxation or the method of administration of supplemental oxygen. In particular, the heterogeneity of the patients makes it difficult to truly know if the comparisons are reasonable-intubating a neonate with Robin sequence and significant upper airway obstruction is very different to intubating a toddler with meningococcal sepsis, a child with life-threatening asthma, or a teenager with an isolated head injury who requires neuroimaging. It is also reasonable to assume that there is a huge variety of experience within the clinician groups who are "coaching" and intubating these patients: for example, some PICU residents and fellows in our institution are dual anesthetic/pediatric trainees who may have intubated many more patients than the attendings supervising them in the PICU, whereas others are complete novices. Anesthesia literature demonstrates that intermediate laryngoscopy competency is attained after 80 distinct attempts with intraoperative attending feedback (4). Unfortunately, most PICU trainees do not have this background and gaps in trainee ability are unknown without prior needs assessments. A pre-procedure understanding of ability and a shared attending-trainee individualized strategy may make the procedural instructions offered by the attending more impactful.The authors use the terminology "coaching" to describe the study intervention. Philosophically, "enhanced supervision" or "guided instruction" may be better *See also p. 936.