Newsletter July 2023: Practice guidelines of airway management in children under one year of age - ESAIC-BJA Foundation joint guidelines

Nicola Disma, Arash Afshari

A multinational task force of 23 experts embarked on a mission to develop comprehensive clinical practice guidelines on airway management for neonates and infants. Motivated by the success of the Nectarine1 CTN and the recommendation of the Editor in Chief of the British Journal of Anaesthesia Foundation (BJA Foundation), the task force collaborated with BJA Foundation and ESAIC to address the critical aspects of paediatric airway management. The project aimed to reduce practice variability, enhance safety and knowledge, and identify areas for further research. Key areas of focus included preoperative evaluation, pharmacological sedation/anaesthesia, tracheal intubation, difficult airway management, extubation plan, and the influence of non-technical skills. 

The guidelines developed by the task force on airway management in children under the age of one year revolve around several key pillars. They recommend the identification of difficult airways, specific techniques for tracheal intubation, the importance of extubation planning, and the recognition of non-technical skills. The task force also emphasizes the need for a common algorithm that can be universally applied, even outside the operating room. These guidelines aim to improve patient safety, reduce practice variability, and facilitate future research in paediatric airway management. Their successful implementation will require the development of locally approved protocols and endorsement from specialist societies to ensure widespread adoption and benefit patients across Europe and beyond. 

The Nectarine1 CTN was successfully completed, with over 5,500 neonates and infants included in the database. Two articles, accompanied by an editorial, were published in the British Journal of Anaesthesia in 2022. Following the publication, the Editor in Chief of the BJA Foundation suggested the formation of a task force to develop new clinical practice guidelines on airway management for the youngest patients. This proposal led to an agreement between BJA Foundation and ESAIC to publish the first “joint guidelines” in collaboration with BJA Foundation and EJA. A task force consisting of 23 well-regarded experts from four continents was formed, initiating the process of this endeavour. 

The task force promptly began working on defining the PICOs. The objective was to identify supporting evidence for developing practice guidelines in six main domains: preoperative evaluation, pharmacological sedation/anaesthesia, tracheal intubation, difficult airway management, extubation plan, and the influence of human factors (or non-technical skills). A comprehensive literature search was subsequently designed for each PICO, comparing standard of care with the newest and most innovative techniques and strategies. 

As is often the case with guidelines, coordinating activities among task force members scattered around the globe was not always simple and straightforward. The initial search yielded thousands of articles, which were then divided according to the PICOs. Each round of screening required the assessment of three independent reviewers. The initial screening was based on titles and abstracts, while the second round involved reviewing the full articles. This proved to be a time-consuming task for the busy experts. After the initial screening, relevant articles were included, and the process of GRADE-ing to determine the strength of evidence began. Developing recommendations and suggestions based on a diverse range of literature posed the next complex and challenging task. 

Despite the aforementioned difficulties, the development of new guidelines on airway management for very young patients was seen as a significant opportunity. Airway management remains a fundamental objective for all paediatric anaesthesiologists. Implementing state-of-the-art and safe management based on the most recent evidence provides an opportunity to enhance clinical practice. The main aims were to reduce variability in clinical practice, improve safety and knowledge, and identify gaps in knowledge. The latter is crucial for synthesizing evidence and identifying areas of importance for future research and clinical trials when evidence is lacking. Finally, a meticulously devised and executed guideline like this facilitates future updates. 

These new 2023 guidelines on airway management in children under the age of one year are built upon several pillars. Firstly, it is recommended to identify difficult airways through physical examination and medical history to minimize unexpected difficulties. Techniques such as oxygen administration, video laryngoscopy, and adequate levels of anaesthesia or sedation are essential for facilitating tracheal intubation. Furthermore, extubation is equally important as intubation, and therefore, a routine plan for tracheal tube removal should be devised. The task force also recognizes the significance of “non-technical skills” for successful airway management. Thus, the identification of such skills through the development of a specific curriculum, along with the importance of pre-intubation briefing and post-difficult intubation debriefing, are highlighted in a concise scoping review. Lastly, the development of a “common” algorithm that can be applied in settings outside the operating room, endorsed by non-anaesthesia societies, is the next challenge to be addressed. 

Developing new guidelines is inherently challenging, especially in such a broad field. Moreover, the evidence for some steps of airway management was weak, requiring the task force to rely on aggregated and extrapolated evidence to bridge the gap with “clinical practice-based statements,” based on multiple rounds of expert opinion assessments. This implies that the practice still exhibits heterogeneity and lacks supporting evidence. These guidelines provide general rules that can be used in devising locally and institutionally approved protocols. In other words, it is crucial that our recommendations can be realistically implemented in daily clinical practice. The task force agreed to seek endorsement from specialist societies to enhance the “political” strength of our guidelines, despite the presence of internationally recognized experts from different cultures and settings spanning four continents. Widespread endorsement of these guidelines would facilitate broader dissemination and greater implementation for the benefit of our patients. 

The ultimate goal of every guideline is to improve patient safety. All recommendations, suggestions, and clinical practice statements were formulated based on published evidence while prioritizing safety. Additionally, where expert opinions were expressed, the diversity of the task force contributed to the strength of these new guidelines. Achieving full consensus for each statement required delicate balancing considering the socioeconomic and academic differences. Although these guidelines may not encompass the entire complexity of clinical practice, they represent a significant milestone in paediatric airway management, offering unique opportunities for future clinical research. 


  1. Disma N, Veyckemans F, Virag K et al. Br J Anaesth. 2021;126(6):1157-1172 
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