Although tracheal intubation remains the standard of care for intraoperative airway management in emergency surgery, some practitioners prefer a supraglottic device for elective surgery in neonates [32]. Initial studies and clinical experience with the Classic Laryngeal Mask Airways (LMAs) in neonates demonstrated a greater failure rate during insertion and decreased efficacy with the size 1 LMA compared with larger size airways in older children [33]. This was attributed to a cuff design flaw that failed to account for the unique anatomy of the neonatal airway. However, clinical experience suggests that placing an LMA is no more difficult in this age group than older children, although these small LMAs may be dislodged easily. Therefore, the capnogram must be observed continuously.

LMAs may offer advantages over tracheal intubation during airway resuscitation outside of the operating room because the LMA is simple to insert, requires technical skills that are easily acquired, and is associated with a high success rate, even in the hands of inexperienced operators [34]. Recent studies have demonstrated that the failure rates for tracheal intubation by resident pediatricians in the delivery room is substantial [35–38]. In one study, 87 % of residents reported their level of confidence with tracheal intubation as good or excellent after the completion of residency training, despite their failure to satisfy objective standards for technical competence [38]. Limited evidence to date suggests that the LMA is effective in neonatal resuscitation in infants >34 weeks and possibly comparable to tracheal intubation, although the LMA has not been compared with bag-mask ventilation [39, 40]. It remains to be established whether the LMA or other supraglottic airway should be used for primary airway management in neonatal resuscitation [41]. However, its use has been recommended as a secondary tool in near-term and term neonates who have failed resuscitation with bag-mask ventilation or tracheal intubation [42].

The ProSeal LMA is a laryngeal mask airway with a wider laryngeal bowl and a channel for gastric drain tube insertion. This device is now available in a size 1 and has been studied in neonates and infants weighing 2–5 kg [43, 44]. The initial results suggest that in addition to the 100 % success rate inserting the ProSeal LMA [43, 44], the quality of the initial airway, the effectiveness of the seal, and the maximum tidal volume were significantly better than with the cLMA [43, 44].

Laryngeal tube suction II (LTS II; VBM Medizintechnik, Sulz, Germany) is another supraglottic airway device available in a size suitable for use in neonates. It is inserted blindly in a manner similar to the LMA. The LTS II has an esophageal and a pharyngeal cuff that are interconnected as well as a channel for placement of a gastric drain tube. Ventilation is delivered through multiple holes in the tube that are positioned between these two cuffs. While a case series describing the utility of this device in 10 neonates and infants has been published [32], larger prospective trials evaluating its safety or efficacy in neonates have not yet been conducted.

The LMA can also be utilized as a valuable adjunct for tracheal tube placement in neonates with difficult airways. This is reviewed in the following sections of the chapter.

Indications for tracheal intubation are traditionally determined by the surgical procedure, duration of the surgery, risk of aspiration of gastric contents, and pulmonary function. In anesthetized neonates, airway maintenance with a face mask is less desirable because of the high dead space-to-tidal volume ratio and concerns for the development of atelectasis. As a general rule, tracheal intubation is indicated for open cavity procedures of the abdomen or chest, intracranial procedures, and in cases where control of arterial PCO₂ is required. It is also indicated when the anesthesiologist has limited access to the airway during surgeries such as those involving the head and neck and when positions other than supine are required. Tracheal intubation and mechanical ventilation are also useful in neonates to avoid atelectasis that could develop during prolonged anesthesia with spontaneous ventilation.

The “sniffing position” is classically described as the optimal head position to facilitate direct laryngoscopy and tracheal intubation. In adults, a number of recent publications suggested that the sniffing position offers no advantage over simple head extension [45, 46]. In children, there is better alignment of pharyngeal structures with simple neck extension as compared with the “sniffing position.” [47] Because of the relatively large occiput, the neonate may naturally be in the sniffing position without active head flexion. The large occiput of the neonate, when placed on a pillow, flexes the head and, in some extreme cases, may contribute to airway obstruction. Comparative trials to determine the optimal position for laryngoscopy and intubation in neonates have not been performed.

Direct laryngoscopy is the most common method of achieving tracheal intubation in neonates. Traditionally, the Miller blade has been favored in this age group because of anatomical considerations including a relatively cephalad larynx and to facilitate alignment of the oral and laryngeal axes [3], although there is no evidence that the straight blade provides either an improved view or easier tracheal intubation than the curved blade in neonates [48–50]. The Miller blade offers greater control and displacement of the base of the tongue, particularly for difficult intubations. The smaller size and reduced profile of the Miller blade (alternatively, the Wisconsin or Wis-Hipple size 0 blade) may also give the operator more room to pass the tracheal tube through the mouth and pharynx into the trachea rather than down the visual path under the blade. When laryngoscopy is performed with a straight blade, the blade is usually inserted into the mouth in the midline after sweeping the tongue to the left. However, when faced with a difficult intubation, this blade is preferably introduced at the right commissure of the lips, not in the midline, an approach known as the paraglossal approach [51, 52]. The blade follows the right alveolar groove until the tip reaches the epiglottis, at which point the epiglottis is lifted exposing the glottis. This approach yields a superior access to the glottis over the midline approach as the angle of the blade and the distance to the larynx are both reduced compared with the same variables that are associated with inserting the blade into the mouth in the midline.

Traditionally, the Miller is advanced to lift the epiglottis to expose the larynx. Some however use this blade in a manner analogous to the curved blade by advancing it into the vallecula to lift the tongue. If the glottis exposure is suboptimal after advancing the laryngoscope and positioning it, the laryngoscopist can externally manipulate the larynx to bring the glottis into view. A small amount of external, posterior pressure with or without lateral displacement often significantly improves laryngeal exposure and facilitates intubation. This practice should be a reflex maneuver for the pediatric anesthesiologist to improve the view of the glottis. In neonates, laryngeal manipulation can be performed using the operator’s fifth digit of the left hand (Fig. 5.2).

In select circumstances outside of the obstetric delivery room, tracheal intubation may be performed in unmedicated neonates who might not tolerate the cardiovascular depressant effects of anesthetic or sedative drugs or whose airways are compromised or potentially difficult to secure. However, infants and neonates experience pain, and performing laryngoscopy without sedative premedication or general anesthesia has untoward cardiovascular (and behavioral) effects and should be avoided whenever possible [53–55]. Furthermore, the administration of anesthetic, sedative, and neuromuscular-blocking drugs improves conditions for intubation and decreases the likelihood of trauma to the airway [56–59]. A consensus statement published by The International Evidence-Based Group for Neonatal Pain states “tracheal intubation without the use of analgesia or sedation should be performed only for urgent resuscitations in the delivery room or for life-threatening situations associated with the unavailability of intravenous access” [54]. In selected cases, such as when face mask ventilation or tracheal intubation is expected to be difficult, intubation may be performed after sedative premedication rather than general anesthesia. Various medication regimens have been evaluated for nonemergency tracheal intubation in the neonatal ICU [60–63], although most studies are seriously flawed precluding the determination of a preferred regimen [64].

Tracheal intubation in an unsedated critically ill neonate may be a lifesaving maneuver. Although it has been eschewed by many, if the need arises, it is important to know how to perform an “awake” intubation. This is not a technique that should be first attempted in a lifesaving situation. When planning an awake intubation, the operator should ensure that the stomach is empty (e.g., suction is readily available), and atropine 0.02 mg/kg IV and oxygen have been administered. In advance of the intubation, a styleted tracheal tube of the appropriate size (in a hockey stick configuration), laryngoscope handle and appropriate size blade, and suction should be available. An experienced assistant holds the infant’s arms fully extended against the side of the head to prevent the head and upper torso from wiggling and the shoulders from lifting off the table during laryngoscopy. Once laryngoscopy begins, tracheal intubation should be completed within 10–12 s. The laryngoscope blade should be inserted into the mouth at the right commissure aiming the tip of the blade toward the midline in one fluid motion. The laryngoscope should be held in one hand and the tracheal tube in the other. As soon as the neonate gags as the blade is inserted, the epiglottis should be lifted and the tube passed between the vocal cords. When carbon dioxide is detected, 2–3 mg/kg IV propofol or other anesthetics may then be administered to attenuate any cardiovascular responses to laryngoscopy. The tracheal tube should then be taped and secured at an appropriate depth.

Nasotracheal intubation is more challenging to perform than orotracheal intubation, especially in neonates. Although no studies have specifically reported the sequelae after nasotracheal intubation in neonates, complications in older children include epistaxis, retropharyngeal perforation, sinusitis, bacteremia, and turbinate avulsion [65–70]. Nonetheless, this approach is preferred for neonates undergoing cardiac surgery, posterior fossa neurosurgery, and for prolonged intubation in the intensive care in many institutions. A topical vasoconstrictor such as 0.025 % oxymetazoline may be applied before intubation to prevent bleeding from the nasal mucosa. The dose of the vasoconstrictor should be carefully calculated as severe hypertension and reflex bradycardia progressing to cardiac arrest have been reported after inadvertent overdoses of phenylephrine [71–74] and oxymetazoline [75, 76]. Hence, these agents should be used judiciously in neonates. An alternative technique to minimize nasal bleeding is to telescope the tracheal tube into the flange end of a red rubber catheter and draw the lubricated catheter containing the tube through the nose [77].

A variety of methods exist for determining the expected uncuffed tracheal tube diameter in children, including formulas based on age and height. However, in neonates, the diameter of the tracheal tube is determined empirically, based on the neonate’s weight. For neonates <1.5 kg, we use a size 2.5 mm ID uncuffed tube, for those between 1.6 and 3.5 kg, we use a size 3.0 mm ID uncuffed tube, and for those weighing > 3.5 kg, a 3.5 mm ID uncuffed tube. In the latter part of the first year after birth, for infants weighing 5 kg or more, we use a 4.0 mm ID tube. The appropriate tube size for each neonate may need to be adjusted based on preexisting medical conditions (e.g., subglottic stenosis, Down syndrome) (Fig. 5.3a–c) and whether the tube is cuffed or uncuffed.

Uncuffed tracheal tubes have traditionally been used in neonates out of the concern that a cuffed tube may cause subglottic injury. However, modern cuffed tracheal tubes with high-volume, low-pressure cuffs have not been associated with an increased incidence of subglottic airway injury or an increased incidence of post-extubation stridor during general anesthesia in children and may reduce operating room pollution and anesthetic gas waste compared with uncuffed tubes [78, 79, 80]. No long-term studies with cuffed tubes have been published in neonates. However, one study in the pediatric intensive care unit reported no cases of post-extubation stridor or significant long-term sequelae when cuffed tracheal tubes were in place for up to 6 days, although only 21 infants were allocated cuffed tubes [81]. In a recent study with the Microcuff^® tube in young children, 326 infants were studied with a 2.8 % incidence of stridor [79]. The number of neonates in the latter study was not reported as a distinct group. Recently, post-extubation stridor was reported in three neonates after the use of Microcuff^® tubes, although the tubes that were used were NOT recommended for their ages [82]. Readers should be cognizant of two additional issues regarding the Microcuff ^® tubes: 1. the 3.0 (not 3.5) mm ID Microcuff ^® tube is recommended for full–term neonates >3 kg up to 8 months of age, and 2. if the cuff of the Microcuff ^® tube is inflated, it is prudent to monitor the cuff pressure throughout the anesthetic to preclude excess cuff pressures, although the critical pressure that interrupts mucosal blood flow in the neonate is unknown.

When a cuffed tube is used, the cuff inflation volume should be adjusted to achieve the desired leak pressure. The Microcuff^® tracheal tube seals the airway at pressures that are less than traditional cuffed tubes. Accordingly, the time interval until the cuff pressure requires adjustment with the Microcuff^® tube exceeds that with traditional polyvinylchloride tracheal tube [83]. Irrespective of the brand of tracheal tube used and whether nitrous oxide is used or not, it is prudent to either monitor the cuff pressure intermittently or deflate and reinflate the cuff periodically to preclude excessive cuff pressures and possible mucosal ischemia.

Cuffed tracheal tubes offer a number of theoretical and practical advantages over uncuffed tubes. Theoretical advantages include a better seal of the trachea from macroaspiration than uncuffed tubes (Fig. 5.3e), although the incidence of aspiration pneumonia with an uncuffed tube is exceedingly small and aspiration is known to occur even with cuffed tubes. In addition, they enable the use of small fresh gas flows (and associated economic advantages) and decrease operating room pollution, although fresh gas flows in North America are minimal with uncuffed tubes [80, 84]. Third, cuffed tracheal tubes reduce the number of laryngoscopies to achieve a proper size tube as well as reducing the associated morbidity from multiple tube changes, although the morbidity from reintubation is exceedingly small in experienced hands. Subglottic damage after intubation has been attributed, for the most part, to intubation with oversized tubes, prolonged intubation, the use of cuffed tubes, and head movement [104]. There are, nonetheless, at least two practical advantages of cuffed tubes. The first is to facilitate ventilation of lungs with reduced lung compliance such as in chronic lung disease. The second is for surgical procedures close to the airway, where these tubes limit the escape of oxygen-enriched gases thereby decreasing the risk of fires.

Uncuffed tubes remain advantageous when a maximal internal airway diameter is a priority, as in spontaneous respiration. Because the resistance to turbulent airflow is inversely proportional to the fifth power of the radius of the tube, the work of breathing spontaneously may become impaired by selecting a cuffed tracheal tube with a radius that is smaller than the equivalent uncuffed tube. In addition, suctioning and pulmonary toilet are more difficult in tubes of smaller internal diameters. The magnitude of the differences in diameter is magnified in smaller size tubes that are used in preterm and very low birth weight infants.

It is important to estimate the diameter of the tracheal tube that will fit the neonate’s airway in preparation of tracheal intubation. A tube whose outer diameter is too large will be too snug in the cricoid ring and will exert excessive pressure on the subglottic or tracheal mucosa, resulting in mucosal ischemia. In the short term, this can lead to edema of the loose pseudostratified columnar epithelium that lines the subglottic region and to stridor from an edematous narrowed airway after extubation. In the long term, it may contribute to the development of scarring and subglottic stenosis.

The diameter of the uncuffed tracheal tube that is most appropriate for a neonate may be assessed using either the “air leak test” or by manually assessing the resistance to its passage through the subglottis. For the “air leak test,” the tip of the tube is positioned mid-trachea and the adjustable pressure-limiting (APL) valve is closed. While the pressure within the breathing circuit increases, a stethoscope is positioned over the suprasternal notch. The pressure at which a leak is first auscultated is noted. Indirect evidence indicates that the leak pressure should be limited to 15–20 cm H₂O to minimize the risk of mucosal edema and tissue damage in adults [86]. Comparable evidence in neonates has not been forthcoming. When performing the “air leak test,” it is important to avoid a slow and prolonged leak test as this might compromise the circulation, similar to that observed during a prolonged Valsalva maneuver.

A second sizing approach is to choose the tube that passes through the glottis and subglottis without substantial manual resistance. If resistance is detected as the tube passes through the subglottic region, then a half-size smaller tube should be inserted. If the tube passes easily through the subglottis, it is important to auscultate for excessive gas leak to ensure that the tube is not too small for the larynx, otherwise it is replaced with a tube a half-size larger.

It is noteworthy that the recommended diameter for Microcuff^® tracheal tubes is 3.0 mm ID for neonates >3 kg and up to 8 months. The diameter is 3.5 mm ID for infants >8 months of age. These sizes are one-half size smaller than those recommended for uncuffed tubes in neonates and infants of the corresponding ages. We recommend the readers follow the manufacturer’s guidelines for the appropriate tube size.

Ideally, the tip of the tracheal tube should be mid-tracheal level. A variety of formulae have been developed to predict the optimal positional length of the tracheal tube within the trachea. In neonates, a commonly used rule of thumb is the “123–789 rule,” where a 1 kg baby should have the tube taped at approximately 7 cm at the maxillary alveolar ridge, a 2 kg baby should have the tube taped at 8 cm, and a 3 kg baby should have the tube taped at 9 cm for a mid-tracheal position. When the cuff passes just beyond the vocal cords or in the case of an uncuffed tube, the tip passes 1–2 cm beyond the vocal cords; the centimeter marking on the tube at the level of the gums (or incisors) should be noted. Some operators advance the uncuffed tube until the breath sounds become unilateral, i.e., a right endobronchial intubation producing no breath sounds over the left chest. The centimeter depth at which breath sounds become unilateral is identified as the level of the carina. The tube is then withdrawn until it rests approximately midway between the carina and the vocal cords. Knowing the centimeter marking with this depth of insertion as well as the depth of the carina gives the anesthesiologist an idea of how much tracheal tube displacement can safely occur before an endobronchial intubation or tracheal extubation occurs. The distance between the glottis and the carina in full-term neonates is approximately 4–5 cm [87, 88]. Therefore, once the distance to the carina is found, the tracheal tube is pulled back approximately 2 cm to achieve a position that is mid-tracheal. A shortened tracheal length (i.e., a more cephalad bifurcation) is associated with certain medical conditions such as trisomy 21 [89] and myelomeningocele [90, 91]. These neonates are therefore at greater risk of accidental right main bronchial intubation, even when the tube is believed to be mid-tracheal. One should always be wary of a tracheal takeoff of the right upper lobe bronchus if a mild hemoglobin oxygen desaturation persists or air entry is diminished in the right upper chest. Confirmation of a mid-tracheal tube position can be determined by palpating the tube tip or the cuff in the suprasternal notch and by chest radiograph [92].

Investigators have determined that the markings on the Microcuff^® tube just proximal to the cuff more reliably ensure a properly positioned tube tip and cuff in the trachea than the cm markings at the lips (Fig. 5.3e) [93]. Since the Microcuff^® tube has no Murphy eye and does have a cuff, it is prudent to respect this recommendation and use the tube markings near the tip when positioning the tracheal tube rather than the distance at the lips.

The traditional rapid sequence induction (RSI) without ventilation is not usually feasible in neonates because of their relatively greater oxygen consumption, reduced FRC, and increased closing volumes compared with older children, all of which result in rapid desaturation and hypoxemia during the apneic period. Furthermore, it is difficult to preoxygenate the neonate because they cry and move, preventing the application of a tight face mask, and breathe shallowly. These factors lead most pediatric anesthesiologists to perform a “modified” RSI induction in neonates [94]. With this technique, the lungs are gently ventilated manually after loss of consciousness via a face mask using low airway pressures (<10–15 cm H₂O), which prevent a significant decrease in oxyhemoglobin saturation.

Controversy exists regarding the effectiveness of cricoid pressure to prevent regurgitation in patients after induction of anesthesia [95]. Although a full discussion of this subject is beyond the scope of this chapter, what is known is that the force required to occlude the lumen of the esophagus in neonates has not been established, that a force as little as 5 N may deform the airway in the infant [96], and that the esophagus is often displaced laterally, an effect that is far more prevalent in younger children [97]. In adults, the application of up to 50 newtons cricoid pressure reduced the visibility of the glottis by 50 % [98]. Furthermore, at 30 newtons cricoid pressure, the duration of fiber-optic intubation was prolonged compared with no cricoid pressure [99]. Although comparable data in neonates and children are not available, it is reasonable to expect the effect of cricoid pressure on visibility of the glottis opening to be limited even further. In the absence of evidence that cricoid pressure prevents regurgitation, we do not recommend the routine application of cricoid pressure in neonates. Nonetheless, supplementary maneuvers to minimize aspiration of gastric contents include emptying the stomach with a red rubber catheter before induction of anesthesia, as well as rapidly administering the induction agents and rapidly securing the airway with a tracheal tube. In the event that cricoid pressure is applied, it should be maintained until complete neuromuscular blockade is established. In support of this practice, appropriately applied cricoid pressure has been shown to be effective in preventing gastric inflation during gentle bag-mask ventilation in anesthetized infants and children [100]. If the initial attempt at tracheal intubation fails while cricoid pressure continues to be applied, gentle face mask ventilation should be performed. If ventilation is difficult while cricoid pressure is applied, despite the use of adjunctive devices such as an oral or nasopharyngeal airway or an LMA, cricoid pressure should be lessened or released [101, 102]. The evidence that cricoid pressure prevents pulmonary regurgitation in this clinical setting remains unproven [85].

The neonatal airway represents the extremes of the differences between pediatric and adult airways. Epidemiologically, difficult airways occur more frequently in infants <1 year of age (with neonates comprising the second most common age group), Mallampati 3 or 4, ASA physical status III and IV, cardiac and craniofacial surgeries, and a low BMI [103]. Consequently, anesthesiologists find airway management in this population to be the most challenging. The spectrum of congenital and acquired [104, 105], airway disorders ranges from difficult mask ventilation to difficult tracheal intubation due to a panoply of different causes (Table 5.1).

The difficult airway in the neonate presents several unique challenges, as well as sharing many challenges that parallel those of the older child. The dimensions of the face, mandible, and neck present challenges for maintaining a patent airway with the face mask. Superimposed on the difficulties of the normal neonatal airway, the flat face, maxillary hypoplasia, and small mouth of the neonate with Crouzon’s disease and Apert’s syndrome often lead to an obstructed airway. In many instances, an oropharyngeal airway or laryngeal mask airway will relieve the obstruction. However, direct laryngoscopy and orotracheal intubation is usually uncomplicated. As infants with these syndromes mature, mask anesthesia remains a challenge, whereas direct laryngoscopy remains uncomplicated. Neonates with Pierre Robin sequence (Fig. 5.4a) [106], Treacher Collins syndrome (Fig. 5.4c), and Goldenhar’s syndrome may also present challenging but not insurmountable airways. Mask anesthesia may be difficult as the mandibular deformities render temporomandibular joint subluxation difficult (Fig. 5.4b) [107]. Pierre Robin sequence is characterized by a triad of micrognathia, glossoptosis, and respiratory distress in the first 24–48 h after birth. Direct laryngoscopy may be particularly challenging in neonates with Pierre Robin sequence in part as a result of a short mandibular body length (Fig. 5.4b) [107]. However, the airway becomes easier to manage with age such that by 2 years of age, the mandible is often aligned with the maxilla [108]. In contrast, laryngoscopy in neonates with Treacher Collins syndrome is easier at birth and becomes progressively more difficult with increasing age [108, 109]. This may be directly attributable to a shortened ascending ramus of the mandible [107]. In both Pierre Robin sequence and Treacher Collins syndrome, the gonial angle (or the angle between the ascending ramus and body of the mandible) is significantly more obtuse than in unaffected neonates, which may contribute to difficult laryngoscopy exposure. Neonates with Goldenhar’s syndrome may be split in airway management: 50 % have airways that are not difficult to manage, and 50 % are exceedingly difficult to manage. Interestingly, the difficulty presented by the airway in this last syndrome does not change with age.

Neonates with subglottic webs (Fig. 5.3a), hemangiomas, cysts (Fig. 5.3b), tumors, and laryngomalacia as well as those with subglottic stenosis from prior tracheal intubation (Fig. 5.3c) may present a challenge to those using a face mask as well as a laryngoscope blade [110, 111]. The degree of airway obstruction and the dynamic changes that may occur with induction of anesthesia are often unknown in neonates with these defects.

Before embarking on an anesthetic for a child with a difficult airway, it is essential that a proper operating room and airway equipment setup is in place as well as expert assistance present before induction of anesthesia [112]. In elective cases, severely dysmorphic neonates and those with only a single means of accessing their airways (e.g., severe temporomandibular joint dysfunction that limits mouth opening and eliminates the ability to rescue ventilation with an LMA) should be evaluated by an otolaryngologist before induction of general anesthesia. This allows the otolaryngologist to assess the airway for alternate approaches to tracheal intubation (such as rigid bronchoscopy or surgical tracheostomy) (Fig. 5.2d) in the event that noninvasive attempts at tracheal intubation also fail. The availability of an otolaryngologist does not necessarily guarantee an expeditious airway rescue since the anatomical reasons that may lead to a failed intubation may also create difficulties for a tracheostomy [113].

The approach to the anticipated difficult neonatal airway is similar to that in older children. Although general anesthesia is the preferred approach to securing the airway in these infants, topical administration of local anesthesia supplemented with sedation and awake tracheal intubation should also be considered as alternative approaches. During induction of general anesthesia, spontaneous ventilation is preferred as it ensures ventilation is maintained and inhalational anesthesia can be reversed should the operators fail to secure the airway. However, spontaneous ventilation may be difficult to maintain in some neonates (particularly in the preterm neonate and those with hypoplastic mandibles) because of the small dimensions of their upper airways, sensitivity to inhalational agents, and chest wall instability in addition to the defect at the root of the difficult airway. The decision to administer a muscle relaxant depends on the risk/benefit ratio of paralysis including difficulty ventilating the lungs and realizing a “cannot-intubate-cannot-ventilate” scenario may develop, although the latter is rare in neonates [114–116]. Induction of anesthesia must be carried out carefully, avoiding upper airway obstruction, which in most neonates, results in the rapid onset of arterial hemoglobin desaturation.

Topical anesthesia applied to the airway combined with sedation has been used to blunt cardiorespiratory responses during laryngoscopy. However, a recent review (in older children) suggested that not only does topical local anesthesia not reduce the incidence of perioperative airway reflexes, but that it actually may paradoxically increase the incidence of laryngospasm, although this was only an observational study [117]. Alternately, sedation may be provided by midazolam and fentanyl, propofol, dexmedetomidine, or ketamine administered intravenously [57, 63, 118–122]. These approaches have all been used to secure the airway, although the responses were generally optimally controlled when a muscle relaxant was coadministered. Lastly, an awake intubation may be necessary in order to secure the difficult airway, particularly in the absence of otolaryngology support or alternatives. The approach described earlier in this chapter to performing an awake orotracheal intubation should be followed closely in order to reliably and rapidly secure the airway in the neonate. Once the airway is secured and carbon dioxide is identified in the airway, then a bolus of intravenous propofol should be administered immediately to induce general anesthesia.

We remain firmly committed to perfecting our skills with the laryngoscope and direct laryngoscopy. The discussion above provides a detailed description of how to properly use the Miller blade in neonates with a difficult airway. Nonetheless, in some circumstances, the airway cannot be secured by direct laryngoscopy and alternative airway devices are required. The following describes those airway devices.

Adjuncts such as an oropharyngeal airway or LMA may be useful, particularly in the child with a dysmorphic face, in whom the jaw thrust [31] only partially preserves the patent upper airway. The LMA has served as an effective bridge to tracheostomy in several difficult airway reports in neonates [108, 114, 123]. The appropriate size LMA should always be readily available in the event it is needed urgently. Before instrumenting the airway however, intravenous access should be established to facilitate the administration of resuscitative medications.