All India Difficult Airway Association 2025 guidelines for the management of unanticipated difficult airway in paediatrics under general anaesthesia.

Abstract

The paediatric airway differs from the adult airway both anatomically and physiologically. These guidelines are recommended for use in unanticipated difficult airways in children aged 1-12 years. If the initial intubation attempt fails, the anaesthesia team should "Call for help" (Code D) and prioritise providing oxygen to maintain peripheral oxygen saturation (SpO₂) above 95%. While awaiting help, the anaesthesia team may re-attempt tracheal intubation, this time by a more experienced operator, after reoptimising position and considering alternate airway devices. The anaesthesiologist may opt for a 2^nd generation supraglottic airway (SGA) device as a rescue device or continue the anaesthetic using a face mask (FM). Maintaining oxygenation throughout the period is essential. The current guidelines introduce a circular design for the algorithm, allowing device interchangeability. If satisfactory oxygenation is achieved with either a 2^nd generation SGA device or FM, the decision to continue anaesthesia or wake the child will depend on the urgency of the procedure and the comfort of the anaesthesiologist. If satisfactory ventilation cannot be maintained with a 2^nd generation SGA device or FM or following a failed tracheal intubation, declare "complete ventilation failure" and prepare for an emergency surgical airway. The options for emergency surgical airway depend on the availability of trained surgical help and the age of the child. Post-resuscitation care should address the various steps taken to return the child to normalcy and to discharge. This should include giving an "Airway Alert Card" to the parents to avoid similar life-threatening situations in future.