Practice Guidelines for Difficult Airway Management: Comment

We read with interest the 2022 America Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway by Apfelbaum et al.¹  We applaud the authors’ efforts and, in particular, the inclusion of a pediatric-specific algorithm for the first time. We question the recommendation to “minimize the use of an airway exchange catheter with pediatric patients.” The cited pediatric literature includes only a single case report of successful, uncomplicated use of an airway exchange catheter to facilitate extubation in a 30-kg patient with a difficult intubation.²  The reported survey findings indicate strong consensus to consider airway exchange catheter use with only 2 of 163 survey respondents dissenting (refer to table 5).¹  So why make this strongly worded recommendation, which we fear will discourage, if not altogether eliminate, the use of airway exchange catheters in pediatric patients?

Airway exchange catheters are helpful in facilitating tracheal extubation and providing a pathway for rapid reintubation in patients in whom tracheal intubation was difficult, as well as patients in whom fluid shifts and/or surgical manipulation may lead to airway edema and upper airway obstruction after extubation. There is limited literature on the use of airway exchange catheters in pediatric patients, but what has been published supports their usefulness and safety, although the study populations are small.^3,4 

There are many reports of airway exchange catheter failure, trauma, barotrauma, and death in adult patients.^5-8  We are unable to find similar published reports in pediatric patients, although children are susceptible to similar serious adverse events. Most if not all such events appear to be associated with insufflation of oxygen through the airway exchange catheter.^5,6,8 

Airway exchange catheters have great value when used properly to facilitate extubation and tracheal tube exchange in both pediatric and adult patients. Rather than discouraging the use of airway exchange catheters in pediatric patients, we recommend that clinicians be aware of risks, including airway trauma and barotrauma in both pediatric and adult patients, and consider steps to mitigate these risks, including providing oxygen by other means such as a simple facemask.⁶ 

The authors declare no competing interests.