Anesthesia challenges for the difficult and critical neonatal airway

Anesthesia can be a significant stress on the neonate and infant with underlying airway disorders whether they have been recognized or unanticipated. This stress may be further compounded at induction or maintenance of anesthesia for the neonate and infant with underlying, underappreciated lung disease. For the patients with anticipated airway issues, this usually is not a problem; however, for the unanticipated issues that may only present during time of anesthesia, these situations can turn into a potential crisis and call for the immediate delivery of specialized equipment and personnel. Specialized training of personnel, implementation of decision algorithms, and acquisition of appropriate equipment are institutional elements that are essential in facilitating the optimal care of the neonate or infant with a difficult airway.Frequent neonatal comorbidities (increased oxygen consumption and pulmonary hypertension due to lung disease), exacerbate intolerance of apnea and hypoventilation. The clinical impact of these factors on airway management underscores the immediate response time that is critical in airway management during anesthesia and intubation.The neonatal airway is radically different from that of the older child or adult. The differences can make laryngoscopy and tracheal intubation challenging even in a normal neonate. Understanding the impact of anatomy and physiology on airway management is critical in order to provide high quality care to neonates with difficult or critical airways.This chapter details the approach and roles anesthesiologists take when dealing with neonates and infants with challenging airways. We describe the preoperative preparation needed, the necessary equipment, and drugs and detail techniques that facilitate tracheal intubation on the first attempt. First attempt success should be the goal of every airway encounter and is most critical in these patients with the smallest airways. Finally we highlight postoperative concerns and describe various approaches to extubate the neonate with a challenging airway.Comparative trials of various airway management approaches remain rare; however, several new tools are now available to assist with securing the neonatal airway. Many of the techniques and approaches described are based on our collective clinical experiences.