Airway challenges are more common in pediatric patients undergoing specific types of surgeries, such as oromaxillofacial, otolaryngologic, and cardiac procedures. The American Society of Anesthesiologists (ASA) physical status classification can also provide insight into airway challenges, with children classified as ASA III or IV being at higher risk. Special care is needed for children under one year of age, as they are more likely to present with difficult laryngoscopic views (Cormack and Lehane grade III or IV).
Although no single test can definitively predict airway difficulty in all pediatric patients, a comprehensive history and physical examination are generally sufficient to identify those at risk for complications. The ultimate goal is to develop a clear airway management plan, including backup strategies such as the use of supraglottic devices, indirect laryngoscopy, or emergent surgical airway placement in the event that standard methods fail.
| Assessment domain | What to look for |
|---|---|
| Airway history | Prior anesthesia records: ease of mask ventilation, need for adjuncts, laryngoscope used, number of attempts, and the Cormack and Lehane view obtained |
| Congenital anomalies and syndromes | Pierre Robin sequence, Treacher Collins syndrome, Goldenhar syndrome, obstructive sleep apnea |
| Symptoms | Recent upper respiratory infection, hoarseness, noisy breathing |
| Physical examination | Symmetry of head, face and neck; mouth opening; oral pathology; mentohyoid and thyromental distances |
| Reliable pediatric predictors | Limited head extension, reduced mandibular space, increased tongue thickness |
| Scoring systems and indirect indicators | Cormack and Lehane grade (1 = full glottic view, 4 = no glottic structures seen); Mallampati score, applicable to cooperative children, though an abnormal score in an otherwise normal, uncooperative child may not reliably indicate difficulty; upper incisor characteristics, mandibular alignment, high-arched or narrow palate, reduced submandibular space, decreased head and neck motion |
| Patient and procedure context | Age under one year (more likely grade III or IV view); oromaxillofacial, otolaryngologic and cardiac surgery; ASA physical status III or IV |
| Adult predictors that do not transfer | Neck circumference and body mass index are not validated as independent risk factors in children |
