Paeds · acute-care-resuscitation-and-toxicology
Difficult paediatric airway and emergency front-of-neck access
Also known as Difficult paediatric airway · Paediatric difficult intubation · Cannot intubate cannot oxygenate in children · Emergency front-of-neck access · Paediatric surgical airway
Fellowship guide to the difficult paediatric airway and emergency front-of-neck access: why the child's airway is anatomically and physiologically unforgiving, how to anticipate and recognise difficulty, the recognise-oxygenate-escalate-rescue sequence from a best-attempt laryngoscopy through early help and supraglottic-airway rescue to the rare emergency front-of-neck access, and the ANZ, UK and North American guideline differences.
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Target exams
Red flags
- A child who cannot be intubated AND cannot be oxygenated despite a supraglottic airway — this is cannot-intubate-cannot-oxygenate, the final common pathway to death; declare it and perform emergency front-of-neck access without delay
- Repeated direct laryngoscopy attempts in a child — each attempt traumatises the airway, swells the tissues and turns a difficult airway into an impossible one; stop after a small number of best attempts and call for help
- Rapid desaturation during airway instrumentation despite preoxygenation — children desaturate within a minute because of high oxygen consumption and low reserves; keep oxygen on at every step
- Bradycardia during laryngoscopy or suctioning in an infant — vagally mediated and a pre-arrest sign; stop, oxygenate and give atropine
- A syndromic child, a known difficult airway, or a child with stridor, trauma or infection of the upper airway — treat the airway as anticipated-difficult from the start and assemble the full team and equipment before inducing
Life stages
Care settings
Clinical exam formats
Board mappings
- Acute and emergency care
- Recognition and management of the acutely unwell child
- Airway and ventilation in resuscitation
- Current 2026 PREP curriculum — Learning goal 6: Acute and critical care
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Acute and critical care
- Management of the difficult airway and the deteriorating child
- Emergency Medicine 10–12
- Clinical Applications
- Acute airway emergencies and resuscitation
- Short Cases
- Acute airway scenarios
- Resuscitation and communication scenarios
- 6. Acute and emergency care
- Level 3: Manages the compromised airway and recognises cannot-intubate-cannot-oxygenate
- Patient management in time-critical emergencies
- Applied Knowledge in Practice (AKP)
- Acute airway and respiratory emergencies
- Recognition of the difficult airway and the deteriorating child
- Clinical
- History and management planning
- Acute airway assessment and resuscitation scenarios
- General Pediatrics Content Outline — Domain 2: Emergency Medicine
- General Pediatrics Content Outline — Domain 7: Emergency and Critical Care
- General Pediatrics EPA: Perform airway management in the acutely ill child
- Patient Care 5: Emergency and acute care
- Medical Knowledge 1: Clinical Knowledge
- Systems-Based Practice: escalation and airway-team coordination
- Medical Expert
- Collaborator
- Pediatrics: Core EPA — Manage the acutely ill child with a compromised airway
Overview & Definition
Picture the three-year-old with Pierre Robin sequence brought to the emergency department obtunded after a seizure, or the infant with bacterial tracheitis whose stridor has turned to silence. Either child can turn a routine intubation into a crisis within seconds, and the difference between a controlled airway and a cardiac arrest is whether you anticipated the difficulty, assembled the team and equipment, and rehearsed the rescue sequence before induction. That is the territory this page owns. [3] [4]
A difficult paediatric airway is any airway in a child that is hard to visualise, hard to intubate, or hard to oxygenate with standard technique — whether the difficulty was anticipated beforehand or only declared once you have tried and failed. The crucial practical split is between anticipated difficulty, where history or anatomy warn you in advance (a syndrome, a known hard airway, or an inflamed or injured upper airway), and unanticipated difficulty, the commoner form in children, where the problem only surfaces at laryngoscopy because bedside prediction is unreliable in the young. [1] [6]
Emergency front-of-neck access (eFONA) is the final rescue — a surgical airway through the front of the neck when you cannot intubate and cannot oxygenate by any other means. It is vanishingly rare in children, technically demanding, and the dominant teaching of every modern guideline is that the best eFONA is the one you never reach, by preventing the cannot-intubate-cannot-oxygenate state through early help and supraglottic-airway rescue. [1] [10]
Why this matters at fellowship level is that airway is the commonest resuscitation task a general paediatrician faces, children tolerate hypoxia poorly, and most airway disasters are preventable — they stem from failing to anticipate, from repeating a failing laryngoscopy until the airway is destroyed, or from delaying rescue. The skill being tested is reading the child, calling help early, and never letting a difficult airway become a cannot-oxygenate airway. [3] [4]
References10ShowHide
- [1]Black AE, Flynn PE, Smith HL, et al. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth, 2015.PMID 25684039
- [2]Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology, 2013.PMID 23364566
- [3]Engelhardt T, Weiss M. A child with a difficult airway: what do I do next? Curr Opin Anaesthesiol, 2012.PMID 22499162
- [4]Hsu G, von Ungern-Sternberg BS, Engelhardt T Pediatric airway management. Curr Opin Anaesthesiol, 2021.PMID 33935175
- [5]Matava CT, Kovatsis PG, Lee KA, et al. Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society. Anesth Analg, 2020.PMID 32287142
- [6]Disma N, Virag K, Riva T, et al. Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study. Br J Anaesth, 2021.PMID 33812665
- [7]Park R, Peyton JM, Fiadjoe JE, et al. The efficacy of GlideScope videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. Br J Anaesth, 2017.PMID 29028952
- [8]Garcia-Marcinkiewicz AG. The future of pediatric airway management. Curr Opin Anaesthesiol, 2026.PMID 42013372
- [9]Flynn A, Chen M A high-fidelity non-animal model for simulation of infant emergency front-of-neck access. Br J Anaesth, 2025.PMID 39694755
- [10]Tsuboi K, Tsuboi N, Suzuki N, et al. Emergency Front-Of-Neck Access in the Pediatric Intensive Care Unit: Development of an Institutional Protocol. Paediatr Anaesth, 2026.PMID 41195791