Specific airway-related diagnoses, such as listed above likely mandate a customized approach to neonatal resuscitation. Another group of conditions that deserves a special mention here, comprise conditions that are not directly associated with a specific airway diagnoses, nevertheless have implications for airway management in the delivery room. These mainly include conditions wherein the role of bag-mask ventilation is limited and prompt orotracheal intubation is recommended for example, esophageal atresia, and congenital diaphragmatic hernia.

Once an airway obstruction has been identified, the fetus needs to be evaluated for other possible coexisting conditions. The airway obstructions maybe an isolated finding or part of a global/syndromic condition. The latter raises serious ethical questions as more neonates with severe birth defects are now being born at Children’s Hospitals with immediate access to subspecialty services Figs. 1, 2, 3 and 4.



show how organization and practice can prepare for an airway emergency.

Understandably, the identification of fetal airway obstruction has significant implications for the plans surrounding the delivery. As with many other complex congenital anomalies, cases with suspected fetal airway obstruction should be referred for further evaluation to a tertiary center. Ideally such a referral center should have dedicated, multidisciplinary teams with advanced neonatal, otorhinolaryngology and pediatric surgery services with experience in fetal/neonatal airway issues. The course based on the diagnoses may comprise minimal noninvasive support to requiring EXIT delivery [5]. (Discussed in Chapters “Prenatal Assessment and Perinatal Management of Suspected Airway Compromise in the Fetus and Neonate” and “Operative Surgical Management of Fetuses with CHAOS, (Congenital High Airway Obstruction Syndrome): Management at Delivery”). The timing and choice of delivery will also be influenced by fetal and maternal health, particularly in cases of fetal hydrops and/or maternal “mirror syndrome” [6]. The most important thing when there is time to prepare is having experienced pediatric ENT present with full service tracheostomy tray and set up. Everyone should be prepared Figs. 5, 6, 7, 8 and 9.

In situations where the diagnoses of airway obstruction are not available or suggested prenatally, the clinician can get valuable information from the delivery room experience.

Respiratory distress, especially when unresponsive to routine resuscitative measures, is always an obvious presenting complaint of significant airway obstruction. Externally visible masses and dysmorphic features suggestive of micrognathia and/or retrognathia [7] can be important clues. Other such symptoms may include excessive secretions, stridor, and inability to pass suction catheters through one or both nostrils Figs. 10, 11, 12, 13 and 14.

Finally, the possibility of birth trauma causing airway obstruction or impairment should be considered. This is especially true for macrosomic neonates with history of prolonged shoulder dystocia. While, such delivery circumstances may result in perinatal asphyxia, the clinician should still be cognizant of the possibility of airway trauma. Cases of tracheal or laryngeal tears are rare but have been reported in the literature [8, 9].

Benefits exist in standardizing the care patients receive. We have discussed how things should be done in the delivery room regarding thermoregulation, oxygen titration, and respiratory support. However, the infrastructure to perform these interventions including who should perform which tasks requires some more detail. Understanding that we are trying to provide the best medical care, while training residents and fellows. We recommend the following guidelines to establish roles and responsibilities:

Opportunities to perform direct laryngoscopy and intubation are much less common in the pediatric than the adult population. It is estimated that airway management is required in 1–3 patients per 1,000 pediatric visits in the average ED compared with 6–10 intubations per 1,000 adult visits [10–12]. This number is further diluted when looking specifically at the care of young infants. The distribution of ages of patients requiring endotracheal intubation at a single tertiary care center for a 1-year period suggests that only a fraction of the pediatric population requiring airway management are neonates or young infants (Fig. 15). Given that the average ED physician will be unlikely to encounter opportunities for a significant number of pediatric airway procedures during typical clinical practice, skill acquisition, and retention can be difficult. Pediatric intubation success rates vary quite dramatically with experience. Studies performed in the operating room with anesthesia providers suggest that the success rate for endotracheal intubation after ten airways is less than 50 % while greater than 50 intubation attempts are required before success reaches 90 % [13, 14]. Therefore for emergency medicine providers with limited in situ clinical opportunities, the required number of intubations to attain “mastery” may therefore necessitate dedicated time in the operating room or augmentation of skills in a simulated environment [15].

There are many unique anatomic and physiologic features that impact emergent neonatal airway management. These differences are predictable, and therefore can be anticipated and addressed to optimize early success and mitigate adverse events.

Anatomic differences in neonates compared to larger children or adults include relatively large occiputs compared with body size, a superior and anterior larynx, a large tongue relative to the oral cavity, a weaker hyoepiglottic ligament, and a large floppy epiglottis. The impact of each of these unique features on airway management, as well as the strategies to accommodate them is reviewed in Table 5.