Airway management in critically ill children, what clinicians and searchers must know

Paediatric airway management in critically ill children presents unique challenges for paediatricians and anaesthetists. However, it is the physiological disorder that presents the main risk of adverse events in the PICU beyond anatomical considerations, a concept known as the "physiologically difficult airway". Recent registry data reported a first-attempt success rate of only two-thirds in the PICU, with severe adverse events occurring in 15% of children and cardiac arrest in nearly 6% of those with physiologically difficult airway risk factors. Even children with normal anatomy may have unstable physiology (hypoxaemia, hypotension, raised ICP, and acidosis), which can make intubation unsafe. The main implications are respiratory (risk of rapid desaturation) and cardiovascular (collapse from induction drugs, loss of sympathetic tone, and positive pressure ventilation). For these reasons, management should focus on optimising conditions before intubation, such as providing fluids and vasopressors, ensuring preoxygenation and apnoeic oxygenation, and choosing medications wisely to reduce the risk. Practitioners should also optimise the technique itself, considering paediatric specificities, to ensure first-pass success. It is also important to secure the procedure by using checklists and protocols that take into account both physiological and anatomical difficult airways and the specificities of airway management in children. This review aims to synthesize current evidence and provide expert opinion for clinicians managing the airway in critically ill children.