You are called to another operating room by your colleague for a failed intubation on a 2-year-old patient.

Most nonsyndromic children are easy to intubate. Typically, “what you see is what you get” is true. Any dysmorphic child, especially those with hypoplastic mandibles or low-set ears, should raise a red flag, and some diseases warrant special mention.

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  Treacher Collins syndrome. There is an unfortunate combination of difficult mask ventilation and difficult intubation. The difficult mask ventilation is worse than expected from just the physical appearance. Intubation does not get easier with age.

  
  
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  Pierre-Robin sequence. Intubation is difficult, but does get better with age. As the mandible grows or is surgically advanced, the intubation gets easier.

Lower airway problems such as anterior mediastinal mass and tracheoesophageal fistula are discussed in the appropriate chapters.

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  Consider an awake fiberoptic intubation whenever this is a realistic option.

  
  
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  If an awake fiberoptic intubation is not possible, establish an intravenous access, and consider giving glycopyrrolate 4 μg/kg before inducing anesthesia.

  
  
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  Inhalational induction of anesthesia is more gradual and is preferred by some anesthesiologists because it is easier to maintain spontaneous ventilation. Induction with propofol might produce a less obstructed airway.

  
  
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  A regular oral airway can be cut longitudinally and be used as a conduit, similar to the way one would use an Ovassapian or Williams airway in an adult.

  
  
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  In smaller patients, consider placing a laryngeal mask airway (LMA) before attempting the fiberoptic intubation, then use the LMA as a conduit. Often this will make the fiberoptic intubation easier. Always ensure that the endotracheal tube (ETT) you are planning to use fits through the appropriate LMA size. In some cases, the pilot balloon does not fit through the LMA; in such cases, either the LMA can be left outside the patient or the pilot balloon can be positioned outside the LMA by retrogradely inserting the ETT through the LMA and leaving the pilot balloon in the oropharynx during the use of the LMA. Air-Q LMAs have a removable connector and are designed with fiberoptic intubation in mind.

  
  

  The risk of this approach is that if the glottis does not come into view, the LMA has to be removed, and more secretions or blood may make the fiberoptic visualization even harder. Special care must be taken to remove the LMA without removing the endotracheal tube: a long grasper (typically used for direct laryngoscopies by an ear, nose, and throat surgeon) is used to hold the ETT in place as the LMA is removed. Alternatively, a second ETT of the same size can be inserted into the first ETT to make it longer and easier to grasp.

  
  
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  Do not attempt a direct laryngoscopy for an intubation that is expected to be truly difficult. Use whatever technique is most likely to work on the first attempt. Most anesthesiologists are considering this to be a case for a fiberoptic intubation (Fig. 12-1).

  
  
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  Fiberoptic intubation and the advancement of the ETT over the fiberoptic scope are easiest in a patient with relaxed vocal cords. Consider paralyzing the patient if you are sure about your ability to mask ventilate.

  
  
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  Video laryngoscopes are now available in a wide range of variations and sizes. Often the pediatric sizes are simply miniaturized versions. Your experience with a given device is the most important predictor of success.

  
  
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  After successful intubation, perform a direct laryngoscopy to verifiy that visualization of the larynx is really difficult. This is important information for extubation planning and for the next anesthetic.