An update in paediatric airway management

Schmucker Agudelo, E.; Farré Pinilla, M.; Andreu Riobello, E.; Franco Castanys, T.; Villaverde Castillo, I.; Monclus Diaz, E.; Aragonés Panadés, N.; Muñoz Luz, A.
doi:10.1016/j.redare.2022.08.001
 array:24 [
  "pii" => "S2341192922001317"
  "issn" => "23411929"
  "doi" => "10.1016/j.redare.2022.08.001"
  "estado" => "S300"
  "fechaPublicacion" => "2022-10-01"
  "aid" => "1345"
  "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
  "copyrightAnyo" => "2021"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "fla"
  "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2022;69:472-86"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0034935621001833"
      "issn" => "00349356"
      "doi" => "10.1016/j.redar.2021.05.012"
      "estado" => "S300"
      "fechaPublicacion" => "2022-10-01"
      "aid" => "1345"
      "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "fla"
      "cita" => "Rev Esp Anestesiol Reanim. 2022;69:472-86"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:1 [
        "total" => 0
      ]
      "es" => array:11 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Art&#237;culo especial</span>"
        "titulo" => "Actualizaci&#243;n en el manejo de la v&#237;a a&#233;rea dif&#237;cil en pediatr&#237;a"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "472"
            "paginaFinal" => "486"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "An update in paediatric airway management"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0010"
            "etiqueta" => "Figura 2"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr2.jpeg"
                "Alto" => 1644
                "Ancho" => 3175
                "Tamanyo" => 724726
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algoritmo de la SCARTD ante una VAD imprevista en pediatr&#237;a</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SCARTD&#58; Sociedad Catalana de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor&#59; VAD&#58; v&#237;a a&#233;rea dif&#237;cil&#59; VA&#58; v&#237;a a&#233;rea&#59; FiO2&#58; fracci&#243;n inspirada de ox&#237;geno&#59; MF&#58; mascarilla facial&#59; VDL&#58; videolar&#237;ngoscopio&#59; RM&#58; relajante muscular&#59; DSG&#58; dispositivo supragl&#243;tico&#59; 2 da G&#58; segunda generaci&#243;n&#59; IT&#58; intubaci&#243;n traqueal&#59; FOB&#58; fibrobroncoscopio&#59; NINV&#58; no intubable no ventilable&#59; MCT&#58; membrana cricotiroidea&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "E&#46; Schmucker Agudelo, M&#46; Farr&#233; Pinilla, E&#46; Andreu Riobello, T&#46; Franco Castanys, I&#46; Villaverde Castillo, E&#46; Monclus Diaz, N&#46; Aragon&#233;s Panad&#233;s, A&#46; Mu&#241;oz Luz"
            "autores" => array:8 [
              0 => array:2 [
                "nombre" => "E&#46;"
                "apellidos" => "Schmucker Agudelo"
              ]
              1 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "Farr&#233; Pinilla"
              ]
              2 => array:2 [
                "nombre" => "E&#46;"
                "apellidos" => "Andreu Riobello"
              ]
              3 => array:2 [
                "nombre" => "T&#46;"
                "apellidos" => "Franco Castanys"
              ]
              4 => array:2 [
                "nombre" => "I&#46;"
                "apellidos" => "Villaverde Castillo"
              ]
              5 => array:2 [
                "nombre" => "E&#46;"
                "apellidos" => "Monclus Diaz"
              ]
              6 => array:2 [
                "nombre" => "N&#46;"
                "apellidos" => "Aragon&#233;s Panad&#233;s"
              ]
              7 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "Mu&#241;oz Luz"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2341192922001317"
          "doi" => "10.1016/j.redare.2022.08.001"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922001317?idApp=UINPBA00004N"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621001833?idApp=UINPBA00004N"
      "url" => "/00349356/0000006900000008/v1_202209280545/S0034935621001833/v1_202209280545/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2341192922001330"
    "issn" => "23411929"
    "doi" => "10.1016/j.redare.2022.08.003"
    "estado" => "S300"
    "fechaPublicacion" => "2022-10-01"
    "aid" => "1322"
    "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "rev"
    "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2022;69:487-92"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
      "titulo" => "Dexmedetomidine and perioperative analgesia in children"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "487"
          "paginaFinal" => "492"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Dexmedetomidina y analgesia perioperatoria en ni&#241;os"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "R&#46; Eizaga Rebollar, M&#46;V&#46; Garc&#237;a Palacios, M&#46;C&#46; Fern&#225;ndez Riob&#243;, L&#46;M&#46; Torres Morera"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "R&#46;"
              "apellidos" => "Eizaga Rebollar"
            ]
            1 => array:2 [
              "nombre" => "M&#46;V&#46;"
              "apellidos" => "Garc&#237;a Palacios"
            ]
            2 => array:2 [
              "nombre" => "M&#46;C&#46;"
              "apellidos" => "Fern&#225;ndez Riob&#243;"
            ]
            3 => array:2 [
              "nombre" => "L&#46;M&#46;"
              "apellidos" => "Torres Morera"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0034935621001444"
        "doi" => "10.1016/j.redar.2021.03.013"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621001444?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922001330?idApp=UINPBA00004N"
    "url" => "/23411929/0000006900000008/v1_202209300620/S2341192922001330/v1_202209300620/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2341192922001433"
    "issn" => "23411929"
    "doi" => "10.1016/j.redare.2022.08.008"
    "estado" => "S300"
    "fechaPublicacion" => "2022-10-01"
    "aid" => "1425"
    "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2022;69:463-71"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:14 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Comparison of intravenous ibuprofen versus ketorolac for postoperative analgesia in children undergoing lower abdominal surgery&#58; A randomized&#44; controlled&#44; non-inferiority study"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:3 [
        0 => "en"
        1 => "en"
        2 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "463"
          "paginaFinal" => "471"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Comparaci&#243;n de ibuprofeno y ketorolaco intravenosos para analgesia postoperatoria en ni&#241;os tratados mediante cirug&#237;a de la zona inferior del abdomen&#58; estudio aleatorio&#44; controlado y de no inferioridad"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0010"
          "etiqueta" => "Fig&#46; 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 1475
              "Ancho" => 2508
              "Tamanyo" => 170665
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0020"
              "detalle" => "Fig&#46; "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Distribution of the first rescue dose of morphine&#46; PACU&#58; Post anesthesia care unit&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "I&#46; Abdelbaser, N&#46;A&#46; Mageed, E&#46;-S&#46;M&#46; El-Emam, M&#46;M ALseoudy"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Abdelbaser"
            ]
            1 => array:2 [
              "nombre" => "N&#46;A&#46;"
              "apellidos" => "Mageed"
            ]
            2 => array:2 [
              "nombre" => "E&#46;-S&#46;M&#46;"
              "apellidos" => "El-Emam"
            ]
            3 => array:2 [
              "nombre" => "M&#46;M"
              "apellidos" => "ALseoudy"
            ]
          ]
        ]
      ]
      "resumen" => array:1 [
        0 => array:3 [
          "titulo" => "Highlights"
          "clase" => "author-highlights"
          "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0005" class="elsevierStylePara elsevierViewall">NSAIDs are used as primary analgesics or as part of multimodal analgesia to control postoperative pain&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Intravenous ibuprofen was approved only in 2009 to control fever and pain&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0015" class="elsevierStylePara elsevierViewall">In adults&#44; the use of intravenous ibuprofen for postoperative analgesia is safe and effective&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Intravenous ibuprofen can be used as an alternative to ketorolac for postoperative analgesia in children&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Intravenous ibuprofen and ketorolac provide safe and effective analgesia after pediatric lower abdominal surgery&#46;</p></li></ul></p></span>"
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0034935622000056"
        "doi" => "10.1016/j.redar.2021.12.005"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935622000056?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922001433?idApp=UINPBA00004N"
    "url" => "/23411929/0000006900000008/v1_202209300620/S2341192922001433/v1_202209300620/en/main.assets"
  ]
  "en" => array:17 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
    "titulo" => "An update in paediatric airway management"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "472"
        "paginaFinal" => "486"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "E&#46; Schmucker Agudelo, M&#46; Farr&#233; Pinilla, E&#46; Andreu Riobello, T&#46; Franco Castanys, I&#46; Villaverde Castillo, E&#46; Monclus Diaz, N&#46; Aragon&#233;s Panad&#233;s, A&#46; Mu&#241;oz Luz"
        "autores" => array:8 [
          0 => array:4 [
            "nombre" => "E&#46;"
            "apellidos" => "Schmucker Agudelo"
            "email" => array:1 [
              0 => "eschmuck@vhebron.net"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "M&#46;"
            "apellidos" => "Farr&#233; Pinilla"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "E&#46;"
            "apellidos" => "Andreu Riobello"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "T&#46;"
            "apellidos" => "Franco Castanys"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "I&#46;"
            "apellidos" => "Villaverde Castillo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "E&#46;"
            "apellidos" => "Monclus Diaz"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "N&#46;"
            "apellidos" => "Aragon&#233;s Panad&#233;s"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "A&#46;"
            "apellidos" => "Mu&#241;oz Luz"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:6 [
          0 => array:3 [
            "entidad" => "Hospital Universitario Vall d&#8216;Hebr&#243;n&#44; &#193;rea Materno Infantil&#44; Barcelona&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Hospital Universitari Arnau de Vilanova&#44; Lleida&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Hospital Universitari Germans Trias i Pujol&#44; Barcelona&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Hospital Universitario Dexeus&#44; Barcelona&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Hospital Universitario Joan XXIII&#44; Tarragona&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Hospital Universitario Dr&#46; Josep Trueta&#44; Girona&#44; Spain"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Actualizaci&#243;n en el manejo de la v&#237;a a&#233;rea dif&#237;cil en pediatr&#237;a"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1639
            "Ancho" => 3175
            "Tamanyo" => 628946
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0095"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">SCARTD paediatric unanticipated difficult intubation management algorithm&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">2nd G&#58; second generation&#59; CICV&#58; cannot intubate&#47;cannot ventilate&#59; CTM&#58; cricothyroid membrane&#59; FiO2&#58; fraction of inspired oxygen&#59; FM&#58; face mask&#59; MR&#58; muscle relaxant&#59; SCARTD&#58; Catalan Society of Anaesthesiology&#44; Resuscitation and Pain Management&#59; SGA&#58; supraglottic airway&#59; VDL&#58; video laryngoscope&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Airway management continues to be an area of special interest for anaesthesiologists and other specialists involved in child airway management&#44; particularly in light of the high number of complications resulting from inadequate airway management&#44; unfamiliarity with the characteristics of the paediatric population&#44; and shortage of material for this patient population&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This document is intended for professionals responsible for securing the paediatric airway&#44; such as paediatric and non-paediatric anaesthesiologists&#44; paediatricians&#44; emergency doctors&#44; ambulance staff&#44; and intensivists&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We reviewed the main paediatric airway &#40;PA&#41; studies published in the last decade in order to update the 2011 recommendations published by the Catalan Society of Anesthesiology&#44; Resuscitation and Pain Management &#40;SCARTD&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The main cause of morbidity and mortality in paediatric anaesthesia are adverse respiratory events&#44; which are the second leading cause of perioperative cardiorespiratory arrest in children<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Weiss et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> classified the difficult paediatric airway as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Unexpected or unanticipated difficult airway</span>&#58; patients with an apparently normal airway who present complications during anaesthesia management&#46; The incidence of difficulties in this group is 0&#46;08&#37;&#8211;1&#46;1&#37;&#44; increasing to 3&#46;5&#37; in children under 1 year of age&#46; The vast majority of these events are caused by functional and&#47;or dynamic changes in the airway arising from inadequate airway management<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Suspected or potentially difficult airway</span>&#58; healthy patients who present an acute condition that can alter airway patency and who must undergo non-deferrable surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Known difficult airway&#58;</span> patients with congenital syndromes and acquired anomalies &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The incidence of difficult airway is 4&#46;7&#37; in children with cleft palate and 1&#46;35&#37; in children with cardiac anomalies<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Patients with anticipated difficult airway &#40;DA&#41; should undergo anaesthesia in specialised hospitals<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a>&#46; In urgent surgery&#44; the risk-benefit of transferring the patient to a specialised centre must be assessed individually&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Methodology</span><p id="par0045" class="elsevierStylePara elsevierViewall">In January 2016&#44; the team of anaesthesiologists from the paediatric difficult airway division of the SCARTD collected evidence from recent studies in order to begin updating the paediatric difficult airway management algorithm published in 2011<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">For this purpose&#44; working groups were created based on personal preferences and experience in each subject&#44; and were coordinated by the main author&#46; The entire group of authors took part in updating the algorithm using an iterative process until all group members had reached an agreement&#46; Quarterly face-to-face meetings were held between February 2017 and February 2019&#44; and the document was edited over the course of several email reviews&#44; the last one in December 2020&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Other experts in both adult and paediatric airway management were also contacted for their opinion&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The different working subgroups searched the leading biomedical databases and metasearch engines&#58; Medline&#44; EMBASE&#44; CINAHL&#44; Scielo&#44; Web of Sicence&#44; Cochrane Library&#44; Cochrane plus&#44; TripDataBase&#44; Evidence Base Review and Clinical Evidence&#46; Search terms and keywords related to difficult airway&#44; unexpected difficult airway&#44; supraglottic devices&#44; new approaches in airway management&#44; surgical access&#44; airway rescue&#44; and video laryngoscopes were used&#46; Searches were limited to the paediatric population&#44; papers in English&#44; Italian&#44; French&#44; German and Spanish published after the date of publication of the previous algorithm<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Priority was given to randomised clinical trials&#44; systematic reviews&#44; observational clinical studies&#44; and clinical practice guidelines dealing with paediatric airway management&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">This consensus document does not put forward formal recommendations for clinical practice&#44; but rather a series of guidelines that can be applied based on the clinical situation&#44; the experience of the members of the working group&#44; and the most relevant scientific literature&#46; Following these guidelines does not guarantee a specific outcome&#44; nor does it override the individual responsibility of each anaesthesiologist to take the best decision for each patient&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pre-anaesthesia airway evaluation</span><p id="par0070" class="elsevierStylePara elsevierViewall">Identifying factors that can prevent the anaesthesiologist from securing an airway is a basic pillar of airway management&#44; and starts with the preoperative evaluation<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a>&#46; The paediatric pre-anaesthesia evaluation is challenging due to the lack of cooperation and constant changes found in these patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As a general rule&#44; the anaesthesiologist will need to take a detailed medical history that focusses on the birth history&#44; the perinatal period&#44; warning signs directly or indirectly related to the airway&#44; as well as previous difficulties in airway management<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The physical examination&#44; which should be performed from the front and side&#44; also has its limitations&#44; so clinical judgement and the experience of the examining anaesthesiologist play a crucial role&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The following risk factors for airway manipulation have been defined &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;7&#44;11</span></a>&#58;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Malformations of the pinna in school-age children is associated with greater laryngoscopy difficulty&#46; An incidence of up to 42&#37; has been reported in cases of bilateral microtia and 2&#37; in unilateral microtia<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The thyromental distance helps identify micrognathia and mandibular hypoplasia&#46; This is considered by most groups to be the most appropriate measurement method in children&#44; and the distance is normal when it is greater than 3 of the patient&#8217;s finger breadths<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11</span></a>&#46; Isolated measurements have not been shown to be as effective&#44; but the combination of tests such as the modified Mallampati test&#44; the forward protrusion of the mandible&#44; and the interincisor gap can correctly predict a difficult laryngoscopic view in school-age children with microtia<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;8&#44;9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;13&#8211;16</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The SCARTD has developed a mnemonic that combines a series of risk factors for difficult ventilation in children&#44; summarized in the acronym SMILE<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">S</span>AS &#40;obstructive sleep apnoea syndrome&#41; or <span class="elsevierStyleBold">s</span>noring&#58; tonsillar hypertrophy reduces the transverse diameter of the airway&#44; while mandibular hypoplasia and retrognathia reduce the anteroposterior diameter&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">M</span>asses&#58; space-occupying lesions&#44; including nasal obstruction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">BMI &#91;<span class="elsevierStyleBold"><span class="elsevierStyleItalic">I</span></span><span class="elsevierStyleItalic">MC</span> in Spanish&#93; &#40;body mass index&#41;&#58; obesity is defined as BMI above the 95th percentile in children aged over 2 years&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Tongue &#91;<span class="elsevierStyleBold"><span class="elsevierStyleItalic">L</span></span><span class="elsevierStyleItalic">engua</span> in Spanish&#93;&#58; macroglossia and glossoptosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Age &#91;<span class="elsevierStyleBold"><span class="elsevierStyleItalic">E</span></span><span class="elsevierStyleItalic">dad</span> in Spanish&#93;&#58; more frequent in neonates and infants&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Preparation</span><p id="par0130" class="elsevierStylePara elsevierViewall">Although the incidence of difficult airway in children is lower than in adults&#44; a greater number of adverse respiratory events &#40;as high as 10&#37; of all cases&#41; have been reported in the paediatric population<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;20</span></a>&#46; The evidence suggests that most of these events occur in paediatric and neonatal intensive care units and in the emergency room&#44; and involve patient-&#44; staff-&#44; and equipment-related factors<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;21</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In paediatric patients&#44; the number of attempts and the time taken for each attempt should be minimised due to their low tolerance to apnoea and high metabolic requirements&#46; Multiple intubation attempts can cause complications such as oedema&#44; bleeding&#44; or hypoxaemia&#44; among others<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#44;17&#44;22&#8211;24</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">For these reasons&#44; we have combined the priorities of paediatric airway management into the 5 P rule&#58;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025"><span class="elsevierStyleBold">1<span class="elsevierStyleSup">st</span> P&#58;</span> Anaesthesia <span class="elsevierStyleBold">P</span>lan and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">Prepare an anaesthesia plan to include an airway management strategy individualised for each patient and each hospital&#46; The patient and&#47;or their guardian must be advised of the individualized risks&#44; and informed consent must be obtained<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;11&#44;25</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Preoperative questions to consider when defining the plan&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Based on the patient&#8217;s characteristics&#44; the device available&#44; and my own experience&#44; will we be able to secure the airway while maintaining spontaneous ventilation&#63;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Will we be able to ventilate with a face mask&#63;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Will we need external devices to optimize face mask ventilation&#63;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Will we be able to insert a supraglottic airway device&#63;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Will we be able to perform direct laryngoscopy&#63;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Will we be able to insert an endotracheal tube&#63;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">What alternatives or rescue devices are available&#63;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">If necessary&#44; will we have access to the neck and trachea&#63; will we have a paediatric surgeon on hand&#63; and will the material be appropriate for the patient&#63;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;11&#44;12&#44;14</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030"><span class="elsevierStyleBold">2<span class="elsevierStyleSup">nd</span> P&#58;</span> Trained staff &#91;<span class="elsevierStyleItalic">personal</span>&#44; in Spanish&#93; and equipment in working order</span><p id="par0195" class="elsevierStylePara elsevierViewall">It is essential for staff to be familiar with the characteristics of the patient&#44; airway algorithms&#44; strategies&#44; devices&#44; and the language used during crisis management<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10&#44;14&#44;20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The Fourth National Audit Project &#40;NAP4&#41;&#44; a study on major complications in airway management conducted in the United Kingdom&#44; reported that human factors were involved in up to 40&#37; of adverse outcomes<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035"><span class="elsevierStyleBold">3<span class="elsevierStyleSup">rd</span> P&#58;</span> Position</span><p id="par0205" class="elsevierStylePara elsevierViewall">The position of the head and neck can lead to morphological changes in the upper airway&#46; Lateralization and deflection of the head can collapse the small&#44; elastic airway of very young children<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;30</span></a>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The best position for correct intubation varies according to age&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">In children under 2 years of age&#44; the head should be placed in a neutral position with the shoulders elevated to prevent flexion of the airway&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Between the ages of 2 and 8&#44; keep the head stabilized in a neutral position on a flat table&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">From the age of 8&#44; the sniffing position should be used&#44; as in adults&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040"><span class="elsevierStyleBold">4<span class="elsevierStyleSup">th</span> P&#58;</span> Preoxygenation</span><p id="par0230" class="elsevierStylePara elsevierViewall">Children have lower functional residual capacity and a higher O<span class="elsevierStyleInf">2</span> consumption rate than adults&#46; The younger the child&#44; the greater the risk of developing hypoxaemia when O<span class="elsevierStyleInf">2</span> delivery is interrupted&#44; such as during apnoea or airway obstruction&#46; Therefore&#44; manoeuvres should be optimized in order to prolong the safe apnoea time prior to induction and during airway management manoeuvres<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;14&#44;31</span></a>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Preoxygenation is a manoeuvre designed to increase the body&#8217;s oxygen stores and delay the onset of arterial haemoglobin desaturation during apnoea&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In most infants&#44; blood oxygen levels &#40;SaO<span class="elsevierStyleInf">2</span>&#41; fall to 90&#37; within 70&#8211;90 s of the onset of apnoea &#40;despite preoxygenation&#41;&#44; or even faster in the presence of upper respiratory tract infection&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Studies have shown that maximal preoxygenation &#40;end-tidal O<span class="elsevierStyleInf">2</span> &#91;EtO<span class="elsevierStyleInf">2</span>&#93; &#61; 90&#37;&#41;&#44; can be achieved in children more rapidly than in adults<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;32</span></a>&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The effectiveness of preoxygenation in children depends on their degree of cooperation&#46; In cooperating children&#44; standard &#40;100&#37; oxygen at tidal volume via a face mask&#41; or rapid &#40;100&#37; oxygen&#44; 4 breaths at maximum vital capacity&#41; pre-oxygenation is suitable&#44; and can achieve an EtO<span class="elsevierStyleInf">2</span> of 90&#37; within 100 s in almost all children&#44; and within 30 s with deep breathing&#46; Another option is passive administration of oxygen via the oral or nasal route during laryngoscopy or via Rapi-Fit adapters&#174; with tube exchangers or Frova introducers&#174;&#44; which reduces the need to interrupt airway manoeuvres and reoxygenate<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;23&#44;33&#44;34</span></a>&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Efficacy is shown in the increase in the fraction of alveolar oxygen&#44; in the partial pressure of oxygen&#44; and in the decrease in the fraction of alveolar nitrogen&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Several manoeuvres have been described&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Raising the head</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Apnoeic oxygenation</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Continuous positive airway pressure &#40;CPAP&#41;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Positive end expiratory pressure &#40;PEEP&#41;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Bilevel positive airway pressure</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Transnasal humidified rapid insufflation ventilatory exchange&#46;</p></li></ul></p><p id="par0295" class="elsevierStylePara elsevierViewall">The benefit of apnoeic oxygenation depends on the degree of airway patency and a high functional residual capacity&#47;body weight ratio&#46; There is no evidence of significant differences between low-flow systems &#40;0&#46;2 l&#47;kg&#47;min&#41; and high-flow systems&#44; and the latter are both more complex and costly&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">Fiadjoe et al&#46; suggest that apnoeic oxygenation techniques should be standardized in all anticipated and unanticipated intubation difficulties in paediatric patients<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23&#44;33&#8211;37</span></a>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045"><span class="elsevierStyleBold">5<span class="elsevierStyleSup">th</span> P&#58;</span> Adequate depth &#91;<span class="elsevierStyleItalic">profundidad</span>&#44; in Spanish&#93; of anaesthesia</span><p id="par0305" class="elsevierStylePara elsevierViewall">Children&#44; unlike adults&#44; are considered essentially &#8220;non-cooperative patients&#8221;&#44; meaning that airway management must be performed under anaesthesia<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15&#44;38</span></a>&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Before manipulating the airway&#44; sufficient depth of anaesthesia must be achieved to allow intubation without complications<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;25&#44;39</span></a>&#46; Muscle relaxants can improve conditions during intubation&#44; except in patients with anterior mediastinal masses&#44; mucopolysaccharidoses&#44; or external airway compression in which loss of tone could trigger irreversible obstruction<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;28&#44;39&#44;40</span></a>&#46; In these cases&#44; it is vital to maintain spontaneous ventilation<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;23&#44;31</span></a>&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Administration of anticholinergics may be indicated in certain cases to attenuate the reflex reactions triggered by airway manipulation or to reduce secretions&#44; but should not be given as routine practice<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;31</span></a>&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">The drugs administered will depend on the experience and knowledge of the clinician and the aim of the procedure&#46; Drugs such as dexmedetomidine could provide a safety margin when dealing with at-risk patients&#44; but there is insufficient evidence to recommend them<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;41</span></a>&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Airway management techniques</span><p id="par0325" class="elsevierStylePara elsevierViewall">The Anaesthesia PRactice In Children Observational Trial &#40;APRICOT&#41;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>&#44; a prospective observational multicentre study performed in 261 European hospitals between April 2014 and January 2015 to determine the incidence&#44; nature and consequences of critical events in children and to identify the triggering factors&#44; found a strong correlation between multiple attempts to secure the airway and critical respiratory events<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18&#44;26&#44;42</span></a>&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Patients under 1 year of age or with respiratory risk factors such as asthma&#44; upper respiratory tract infection&#44; snoring&#44; passive smoking&#44; and an inexperienced anaesthesiologist were significantly associated with critical respiratory events&#44; regardless of the device used&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Face mask ventilation and optimization manoeuvres</span><p id="par0335" class="elsevierStylePara elsevierViewall">Unanticipated difficulty during face mask ventilation is relatively uncommon &#40;2&#46;8&#37;&#8211;6&#46;6&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;16&#44;22</span></a>&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Many experts recommend confirming the feasibility of face mask ventilation before administering a neuromuscular blocking agent&#44; but there is no general consensus in this regard<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9&#44;21</span></a>&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">If ventilation difficulties are encountered&#44; the causes can be grouped into&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Obstructive&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0355" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anatomical</span>&#46; In these cases&#44; it is important to re-open the airway using manoeuvres such as oral opening and jaw thrust&#44; using an appropriately sized oro&#47;nasopharyngeal cannula&#44; four-hand ventilation&#44; maintaining the head in an optimal position and the airway clear of foreign bodies&#44; blood or secretions&#44; and by placing the fingers on the bony ridges to compressing the floor of the mouth<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;42&#44;43</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Functional</span>&#46; Caused by dynamic closure of the airway&#58; laryngospasm&#44; bronchospasm&#44; gastric hyperinflation and&#47;or rigid chest due to rapid infusion of opiates&#44; a situation that is generally resolved by achieving adequate depth of anaesthesia &#40;hypnosis&#47;muscle relaxation&#41;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;31&#44;40</span></a>&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Equipment&#47;respirator malfunction&#46; If this is suspected&#44; ventilate with a self-inflating bag or manual ventilation system&#44; such as a Mapleson system with oxygen supplied through the auxiliary outlet&#44; isolating the anaesthesia machine<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Tracheal intubation and optimization manoeuvres</span><p id="par0370" class="elsevierStylePara elsevierViewall">The incidence of anticipated difficult intubation is between 0&#46;06&#37; and 1&#46;34&#37;&#44; and nearly 5&#37; in children under 1 year of age&#46; Unanticipated difficulty occurs in 0&#46;24&#37; of children under 1 year of age and in 0&#46;07&#37; of children over 1 year of age<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#44;9&#44;16</span></a>&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">According to the APRICOT study&#44; more than 3 intubation attempts were required in 0&#46;9&#37; of children&#44; and the incidence of failed intubation was 0&#46;08&#37;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a>&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">The paediatric airway is particularly susceptible to oedema and bleeding&#44; so repeated intubation attempts should be avoided&#44; and various scientific societies recommend making no more than 3 attempts<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;45&#8211;47</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">Laryngoscopy optimization&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0390" class="elsevierStylePara elsevierViewall">Intubation position&#58; described in the preparation section&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0395" class="elsevierStylePara elsevierViewall">Appropriately sized blade for the age of the patient&#46; The straight Miller blade is best for neonates and infants because it allows the elongated epiglottis to be &#8220;lifted&#8221;&#46; In older children&#44; the curved Macintosh blade is used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Magill forceps&#46; These help advance the end of the tube toward the glottis during intubation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0405" class="elsevierStylePara elsevierViewall">BURP manoeuvre&#58; &#40;Backward&#44; Upward&#44; Rightward Pressure&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">OELM manoeuvre &#40;Optimal External Laryngeal Manipulation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">Use intubation guides and stylets only if glottic structures are visualized&#46;</p></li></ul></p><p id="par0420" class="elsevierStylePara elsevierViewall">There is growing consensus on the benefits of cuffed tubes&#44; provided a high volume&#44; low pressure cuff is used&#46; Cuff pressure should be continuously monitored to maintain it below 20&#8211;25 cmH<span class="elsevierStyleInf">2</span>O&#46; Cuffed tubes are not associated with an increase in morbidity&#44; they facilitate the use of closed circuit systems&#44; protect against aspiration&#44; and improve lung function monitoring<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;43&#44;48&#8211;50</span></a>&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">It is essential to routinely check the intubation status<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;47</span></a>&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Once the patient is intubated&#44; the incidence of ventilation difficulties is 0&#46;08&#37;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46; The most frequent causes are&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0435" class="elsevierStylePara elsevierViewall">Pneumothorax&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0440" class="elsevierStylePara elsevierViewall">Obstruction caused by secretions&#44; blood&#44; foreign body&#44; bronchospasm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0445" class="elsevierStylePara elsevierViewall">Displacement of the endotracheal tube&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0450" class="elsevierStylePara elsevierViewall">Equipment malfunction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0455" class="elsevierStylePara elsevierViewall">Intra-abdominal hypertension&#46;</p></li></ul></p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Rapid sequence induction and the Sellick manoeuvre</span><p id="par0460" class="elsevierStylePara elsevierViewall">Due to their particular characteristics&#44; rapid induction in young children or children at risk is performed in a &#8220;controlled&#8221; manner by maintaining ventilation with a minimum inspiratory pressure of &#60; 20 cmH<span class="elsevierStyleInf">2</span>O to secure oxygenation until intubation conditions are met&#46; The incidence of bronchial aspiration does not appear to increase significantly with this technique<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11&#44;51&#44;52</span></a>&#46;</p><p id="par0465" class="elsevierStylePara elsevierViewall">Cricoid pressure &#40;CP&#41; is a controversial topic&#46; Walker et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> found that the cricoid pressure required to compress the airways in children is 10&#46;5 Newton &#40;N&#41;&#44; and could be as low as 5 N in neonates and between 15 N and 25 N in adolescents&#46; The authors concluded that the force used in adults &#40;30 N&#41; is excessive in all paediatric patients&#44; and can compress and distort the child&#39;s airway&#46;</p><p id="par0470" class="elsevierStylePara elsevierViewall">Anaesthesia societies&#44; among them the German and French societies&#44; suggest that&#58; &#8220;Considering the side effects of CP and the lack of proven benefit&#44; it is not recommended in children&#46; It could be indicated in certain cases and when performed by experienced practitioners&#44; but pressure should be released when any difficulties arise&#8221;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;46&#44;53</span></a>&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Advanced airway management and optimization manoeuvres</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Fibreoptic bronchoscopy</span><p id="par0475" class="elsevierStylePara elsevierViewall">The technique of choice in anticipated difficult intubation in children continues to be fibreoptic intubation &#40;FOI&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;12&#44;21</span></a> particularly in patients with limited mouth opening&#46; However&#44; this technique requires special equipment&#44; longer preparation&#44; and has a steeper learning curve than other devices<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;23&#44;25&#44;46</span></a>&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Fibreoptic intubation optimization manoeuvres</span><p id="par1230" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0480" class="elsevierStylePara elsevierViewall">In the oral approach&#44; the fibrescope view can be improved if an assistant performs the mandibular subluxation manoeuvre and&#47;or pulls the tongue out&#44; thereby enlarging the posterior pharyngeal space&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0485" class="elsevierStylePara elsevierViewall">The topical administration of the vasoconstrictors oxymetazoline and phenylephrine reduces bleeding during nasal intubation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0490" class="elsevierStylePara elsevierViewall">A hydrophilic lubricant can help slide the endotracheal tube over the fibrescope and through the glottis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0495" class="elsevierStylePara elsevierViewall">Before intubation&#44; it is important to administer an antisialogogue and instil 1&#37;&#8211;2&#37; lidocaine through the working channel&#44; always in accordance with the recommended doses&#46; Transtracheal aspiration and nerve blocks are not recommended in paediatric patients because they are technically difficult and carry a risk of iatrogenic injury&#46;</p></li></ul></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Supraglottic airway devices</span><p id="par0500" class="elsevierStylePara elsevierViewall">These are currently the most commonly used and widely evaluated devices in children<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#8211;57</span></a>&#46; Second-generation supraglottic airways &#40;SGA&#41;&#44; such as the Ambu Aura-Gain&#174; laryngeal mask&#44; the I-gel&#174;&#44; and the Air-Q&#174;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;54&#44;60&#44;62</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a>&#44; provide better airway seals&#44; and can therefore deliver ventilation at higher inspiratory pressures when required&#46; They can also drain gastric content&#44; and are therefore considered more suitable and safer than first generation devices<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">58&#8211;60</span></a>&#46; SGAs are an important element in paediatric difficult airway algorithms&#44; in which they are used as a rescue technique to maintain oxygenation or as a guide for FOI <a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;20&#44;28&#44;47</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a>&#46;</p><p id="par0505" class="elsevierStylePara elsevierViewall">According to the APRICOT study&#44; more than 3 intubation attempts were required in 0&#46;9&#37; of children&#44; and the incidence of failed intubation was 0&#46;4&#37;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;42</span></a>&#46; Small SGAs need to be manoeuvred into place&#44; and are associated with a higher rate of displacement or mismatch<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#44;59</span></a>&#46;</p><p id="par0510" class="elsevierStylePara elsevierViewall">For some authors&#44; they are the technique of choice in the case of anticipated difficult intubation&#44; provided a thorough preoperative evaluation has ruled out limited mouth opening and infraglottic obstruction&#44; there is little risk of aspiration&#44; and the technique is performed by an experienced practitioner<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;54&#44;57&#44;60</span></a>&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Optimization manoeuvres for supraglottic devices</span><p id="par1235" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0515" class="elsevierStylePara elsevierViewall">Non-preformed SGAs should be inserted with the patient in the sniffing position&#46; Preformed SGAs can be inserted in the neutral position&#46; In patients with prominent or hypertrophic palatine tonsils&#44; the device might need to be rotated 90&#176; or even 180&#176; to advance past the tonsils&#44; and then rotated back again to place it in the correct position&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0520" class="elsevierStylePara elsevierViewall">If ventilation is inadequate with a second-generation SGA due to excessive leakage&#44; a half-number larger device should be used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0525" class="elsevierStylePara elsevierViewall">No more than 3 attempts should be made&#44; ideally by a more experienced practitioner<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;18&#44;46&#44;47</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0530" class="elsevierStylePara elsevierViewall">Clinical tests to verify correct positioning in children include insertion depth&#44; leak pressure&#44; inspection of chest excursion&#44; capnogram image&#44; and gastric drainage tube patency&#46;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0535" class="elsevierStylePara elsevierViewall">Cuff inflation&#58; inflate the minimum volume of air required to seal the airway&#44; never higher than 40 cmH<span class="elsevierStyleInf">2</span>O<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a>&#46; Over-inflating the cuff can cause dysphagia&#44; odynophagia&#44; ischaemic mucosal lesions&#44; and paresis or paralysis of the recurrent or hypoglossal nerves&#46;</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">&#8226;</span><p id="par0540" class="elsevierStylePara elsevierViewall">As the seal pressure of SGAs tends to increase if the head is rotated or placed in flexion&#44; these manoeuvres can be used to improve a suboptimal seal&#46; The head extension position increases the anteroposterior diameter of the hypopharyngeal space and moves the epiglottis away from the SGA cuff&#46; This manoeuvre facilitates FOI through the SGA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8226;</span><p id="par0545" class="elsevierStylePara elsevierViewall">Blind intubation through the SGA is not recommended due to the risk of injury&#44; dislocation of the epiglottis&#44; and injury to the periglottic tissue<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;46&#44;59</span></a>&#46;</p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Video laryngoscopes</span><p id="par0550" class="elsevierStylePara elsevierViewall">The introduction of the video laryngoscope &#40;VL&#41; has been the greatest advance in airway management in recent years<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;38&#44;43&#44;64&#8211;67</span></a>&#46; The VL has all the advantages of FOI and direct laryngoscopy &#40;DL&#41;&#44; but reduces the need for neck mobilization and the haemodynamic response to intubation&#44; and this has led some anaesthesiologists to use these devices as part of their routine practice<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;22&#44;25&#44;43</span></a>&#46;</p><p id="par0555" class="elsevierStylePara elsevierViewall">VLs can be grouped into hyperangulated or non-angulated blades<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;60&#44;66</span></a>&#44; the latter follow the design of the DL&#44; and the technique is called video-assisted direct laryngoscopy&#46; This technique allows external manoeuvres to be performed by a second operator&#44; confirms passage of the tube through the glottis&#44; and is used as a teaching aid&#46; Hyperangulated blades improve glottic vision in difficult cases&#44; and some designs include a channel through which the endotracheal tube &#40;ETT&#41; can be introduced into the trachea<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;21&#44;31&#44;67&#8211;72</span></a>&#46;</p><p id="par0560" class="elsevierStylePara elsevierViewall">Various VLs are available&#44; but no particular device has been shown to be superior to any other<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;23&#44;70</span></a>&#46;</p><p id="par0565" class="elsevierStylePara elsevierViewall">The current guidelines of the American Society of Anesthesiologists &#40;ASA&#41; recommend considering the use of VLs in high-risk patients &#40;with anticipated or unanticipated difficult intubation&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0570" class="elsevierStylePara elsevierViewall">Many authors and guidelines mention VLs&#44; if available&#44; as a second-line option to improve laryngeal view in the context of unanticipated difficulty in tracheal intubation&#44; provided the operator is familiar with the technique&#44; since a good glottic view does not always guarantee passage of the tube through the trachea<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;60&#44;61&#44;65&#8211;68</span></a>&#46;</p><p id="par0575" class="elsevierStylePara elsevierViewall">Some comparative studies have reported a high first-attempt success rate with VLs&#59; however&#44; the technique is more time consuming&#44; and some high-risk patients desaturate rapidly<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">66&#8211;68&#44;70&#8211;73</span></a>&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Video laryngoscopy optimization manoeuvres</span><p id="par1240" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8226;</span><p id="par0580" class="elsevierStylePara elsevierViewall">The most common error is inserting the VL too deep in the trachea&#46; This makes it difficult to insert the ETT&#44; usually because it collides with the right arytenoid&#46; In this case&#44; the VL should be withdrawn slightly and the ETT advanced using a slight counterclockwise rotation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8226;</span><p id="par0585" class="elsevierStylePara elsevierViewall">In channelled VLs&#44; it is advisable to lubricate the area around the cuff&#44; which must be deflated to prevent it from breaking when the tube slides through the channel&#46;</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">&#8226;</span><p id="par0590" class="elsevierStylePara elsevierViewall">In non-channelled VLs&#44; it is advisable to maintain the intubation guide or stylet at the same angle as the blade<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a>&#46; Some authors recommend preforming the stylet in the shape of a hockey stick and performing a retromolar approach<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a>&#46;</p></li></ul></p><p id="par0595" class="elsevierStylePara elsevierViewall">In complex cases&#44; combined techniques&#44; such as VL &#43; FOI or SGA &#43; FOI&#44; can minimise risks while maximising the advantages of each device&#46; The combination used will depend on the patient&#8217;s clinical status&#44; the experience of the operator&#44; and the availability of each device<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;19&#44;23&#44;34</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">74&#8211;76</span></a>&#46;</p><p id="par0600" class="elsevierStylePara elsevierViewall">The safest combination is SGA &#43; FOI<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75&#44;76</span></a>&#46; This strategy&#44; which is included in rescue algorithms&#44; is associated with a higher success rate&#44; because oxygenation can be maintained during intubation&#44; thus reducing the risk of hypoxaemia&#44; particularly in at-risk patients<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;56</span></a>&#46;</p><p id="par0605" class="elsevierStylePara elsevierViewall">The combination of VL &#43; FOI can displace soft tissues to improve the field of vision&#46; This makes it easier to advance the fiberscope and introduce the ETT in the trachea if it requires a change in angle&#46; In this case&#44; several operators are required to perform the different manoeuvres&#46;</p><p id="par0610" class="elsevierStylePara elsevierViewall">ETT insertion can also be facilitated by combining a VL with a rigid stylet to which an adaptor can be attached to allowed oxygen delivery during the intubation manoeuvres<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Rescue technique&#58; front of neck access</span><p id="par0615" class="elsevierStylePara elsevierViewall">There are few studies and little evidence related to the performance of an emergency surgical airway in a cannot intubate&#44; cannot ventilate &#40;CICV&#41; situation in paediatric patients<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;43&#44;61&#44;77&#8211;81</span></a>&#46;</p><p id="par0620" class="elsevierStylePara elsevierViewall">A series of risk factors that can precipitate this situation have been described&#44; such as<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;10&#44;12&#44;13</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a>&#58;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">&#8226;</span><p id="par0625" class="elsevierStylePara elsevierViewall">More than 3 intubation attempts&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8226;</span><p id="par0630" class="elsevierStylePara elsevierViewall">Patients weighing less than 10 kg&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">&#8226;</span><p id="par0635" class="elsevierStylePara elsevierViewall">Presence of micrognathia&#46;</p></li></ul></p><p id="par0640" class="elsevierStylePara elsevierViewall">In more recent articles&#44; the surgical airway is called the Front of Neck Access &#40;FONA&#41; technique&#44; a terms that encompasses all techniques that include cannulas or rescue devices inserted via the cricothyroid membrane &#40;CTM&#41; or the anterior wall of the trachea<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#8211;79&#44;81</span></a>&#46; FONA should not be delayed once indicated<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0645" class="elsevierStylePara elsevierViewall">Four types of FONA have been described<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#58;<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">1</span><p id="par0650" class="elsevierStylePara elsevierViewall">Needle cricothyroidotomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">2</span><p id="par0655" class="elsevierStylePara elsevierViewall">Surgical cricothyroidotomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">3</span><p id="par0660" class="elsevierStylePara elsevierViewall">Retrograde intubation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">4</span><p id="par0665" class="elsevierStylePara elsevierViewall">Tracheostomy&#46;</p></li></ul></p><p id="par0670" class="elsevierStylePara elsevierViewall">All these techniques are associated with a high rate of complications&#44; in which equipment availability and operator experience play an important role<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;78</span></a>&#46;</p><p id="par0675" class="elsevierStylePara elsevierViewall">The trachea of young children is elastic&#44; flaccid&#44; mobile&#44; and difficult to locate&#44; particularly in neonates and infants&#46; The cricoid and thyroid cartilages are more prominent than the thyroid&#44; and the laryngeal structures are located at a higher level&#44; making it difficult to achieve the optimal angle needed for safe FONA<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;31</span></a>&#46; The CTM in neonates is very small &#40;2&#46;6&#8722;3 mm &#215; 3 mm&#41;&#44; and it is hard to find devices that fit this size<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;79</span></a>&#46;</p><p id="par0680" class="elsevierStylePara elsevierViewall">Some authors have described inserting transcutaneous tracheal catheters into the oesophagus&#44; due to the tendency of the laryngeal structures to collapse<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; Neck extension increases the sagittal diameter of the CTM and reduces the risk of this complication&#46; Other reported complications include fracture of the cricoid cartilage&#44; cervical haematoma&#44; injury to the vocal cords&#44; and catheter malpositioning<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;77</span></a>&#46;</p><p id="par0685" class="elsevierStylePara elsevierViewall">Cannula-based techniques&#44; where a small catheter is inserted through the CTM or trachea&#44; are preferred in young children or neonates<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#46;</p><p id="par0690" class="elsevierStylePara elsevierViewall">If the CTM is palpable and a 45&#176; angle can be achieved&#44; it is preferable to perform FONA at this level&#46;</p><p id="par0695" class="elsevierStylePara elsevierViewall">Surgical techniques&#44; such as Seldinger &#40;using the Melker cricothyroidotomy set&#44; for example&#41;&#44; require more time&#44; but provide better oxygenation<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;79</span></a>&#46;</p><p id="par0700" class="elsevierStylePara elsevierViewall">Most recommendations are derived from animal models and expert opinion&#46; The Difficult Airway Society &#40;DAS&#41; recommends that&#44; if a surgeon is not available&#44; the technique of choice should be insertion of an angiocatheter&#44; as described in their algorithm&#46; In the absence of evidence to the contrary&#44; this technique should also be used in children because it is less likely to cause injury compared to other methods<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#46;</p><p id="par0705" class="elsevierStylePara elsevierViewall">According to Weiss et al&#46;&#44; cannula and introducer techniques should be used in children over 8 years of age&#44; as well as in adults<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0710" class="elsevierStylePara elsevierViewall">If it is not possible to identify the structures in the anterior wall of the neck&#44; other authors suggest making a vertical incision in the neck&#44; identifying the tracheal cartilages&#44; inserting a guidewire or stylet&#44; and then&#44; using the Seldinger technique and an introducer&#44; insert a tube or a device that permits oxygenation<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#44;78&#44;80</span></a>&#46; The NAP4 study recommends this technique unless the operator has more experience in another of the techniques described<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#46;</p><p id="par0715" class="elsevierStylePara elsevierViewall">Elective tracheostomy should be considered the first option in cases where FOI is expected to be very difficult or impossible&#44; need for tracheostomy is anticipated in the postoperative period&#44; or in patients with severe laryngotracheal injuries<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;43&#44;78</span></a>&#46;</p><p id="par0720" class="elsevierStylePara elsevierViewall">According to the latest studies&#44; experts agree that surgical tracheotomy performed by an ENT specialist or a paediatric surgeon is the technique of choice in a CICV situation<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;43&#44;47&#44;61</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#44;81</span></a>&#46;</p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Oxygenation methods</span><p id="par0725" class="elsevierStylePara elsevierViewall">Ventilation through an angiocatheter is frequently insufficient&#44; so it should be considered merely a temporary measure<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;79&#44;82&#44;83</span></a>&#46;</p><p id="par0730" class="elsevierStylePara elsevierViewall">Catheter-over-needle techniques are faster&#44; but do not allow adequate flow&#44; and it is important to ensure an adequate expiratory pause to avoid barotrauma&#46;</p><p id="par0735" class="elsevierStylePara elsevierViewall">If specific cricothyroidotomy or tracheostomy cannulas or catheters are used&#44; the patient can be ventilated using a self-inflating bag or Mapleson breathing system&#46;</p><p id="par0740" class="elsevierStylePara elsevierViewall">Other more complex systems are also available&#58;<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">&#8226;</span><p id="par0745" class="elsevierStylePara elsevierViewall">Manujet&#174;&#58; associated with multiple barotrauma-related complications<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">87&#44;88</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#8226;</span><p id="par0750" class="elsevierStylePara elsevierViewall">Ventrain &#40;Dolphys medical BV&#174;&#41;&#58; creates active expiration&#44; which reduces the risk of barotrauma<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84&#8211;89</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">&#8226;</span><p id="par0755" class="elsevierStylePara elsevierViewall">Enk oxygen flow modulator &#40;Cook&#174; medical&#41;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8226;</span><p id="par0760" class="elsevierStylePara elsevierViewall">Rapid-O2&#8482; oxygen insufflation device &#40;Meditech&#44; UK&#41;&#46;</p></li></ul></p><p id="par0765" class="elsevierStylePara elsevierViewall">The last 3 devices allow better expiratory flow than the Manujet&#174;&#46;</p><p id="par0770" class="elsevierStylePara elsevierViewall">Ultrasound is considered an extremely useful&#44; non-invasive technique for evaluating the airway&#46; It allows the operator to<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82&#8211;86</span></a>&#58;<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#8226;</span><p id="par0775" class="elsevierStylePara elsevierViewall">Measure the airway&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">&#8226;</span><p id="par0780" class="elsevierStylePara elsevierViewall">Predict which size instruments will be needed</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">&#8226;</span><p id="par0785" class="elsevierStylePara elsevierViewall">Locate the CTM in FONA and identify the tracheal rings to guide tracheotomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">&#8226;</span><p id="par0790" class="elsevierStylePara elsevierViewall">Identify the vocal cords and assess their function before anaesthesia induction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">&#8226;</span><p id="par0795" class="elsevierStylePara elsevierViewall">Determine the depth of the tube in neonates&#46;</p></li></ul></p><p id="par0800" class="elsevierStylePara elsevierViewall">There is insufficient evidence to support any particular technique&#44; but according to recommendations&#44; airway management specialists should receive the training required to perform percutaneous cricothyrotomy&#44; and thus be capable of responding to emergency airway situations<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;77&#44;78</span></a>&#46;</p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Proposed paediatric difficult intubation algorithm</span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Anticipated difficult intubation</span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Prevention</span><p id="par0805" class="elsevierStylePara elsevierViewall">The core strategy is prevention&#44; which involves detecting patients with a difficult airway in order to develop a plan&#44; and defining WHO will secure the airway&#44; and HOW AND WHERE the technique will be performed<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;21&#44;25&#44;26</span></a>&#46;</p><p id="par0810" class="elsevierStylePara elsevierViewall">In the case of anticipated intubation difficulty &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; it is advisable for each hospital to draw up its own check list based on the resources available&#46; The checklist should include all the information related to the procedure&#44; the planned strategy&#44; the need for informed consent&#44; and the steps required to verify that the basic material&#44; rescue devices&#44; monitoring equipment&#44; and oxygenation systems needed are present and in working order<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; It is advisable to identify and mark the CTM using ultrasound<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">83&#44;86</span></a>&#46; The team in charge must define their roles before the start of the procedure<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;39</span></a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">PLAN A&#58; planned intubation</span><p id="par0815" class="elsevierStylePara elsevierViewall">It is important to check whether face mask ventilation will be possible&#44; as this will determine whether the airway will be secured under spontaneous ventilation or in apnoea<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9&#44;21&#44;45</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;71</span></a>&#46;</p><p id="par0820" class="elsevierStylePara elsevierViewall">In case of doubt&#44; intubation should be performed under spontaneous ventilation&#44; and the following aspects must be clearly defined&#58;<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">&#8226;</span><p id="par0825" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Who</span> will secure the airway&#63;</p></li></ul></p><p id="par0830" class="elsevierStylePara elsevierViewall">This will be the most experienced anaesthesiologist&#44; who will work with a multidisciplinary team&#46;<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">&#8226;</span><p id="par0835" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">How</span> will intubation be performed&#63;</p></li></ul></p><p id="par0840" class="elsevierStylePara elsevierViewall">It is important to decide on the most appropriate anaesthesia technique based on the characteristics of the child&#44; their baseline status&#44; the risk of desaturation or bronchial aspiration&#44; and the surgical indication<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;43</span></a>&#44; and to select the first-choice device &#40;FOI&#44; VL&#44; SGA&#44; or direct laryngoscopy&#41;&#46; If there is a risk of hypoxaemia&#44; it is preferable to prioritise an SGA over a VL<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;57</span></a>&#46; Rescue devices should be available&#46;<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">&#8226;</span><p id="par0845" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Where</span> will these patients be intubated&#63;</p></li></ul></p><p id="par0850" class="elsevierStylePara elsevierViewall">In the interests of patient safety&#44; intubation should be performed in hospitals specialized in the care of paediatric patients<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;11&#44;85</span></a>&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">PLAN B</span><p id="par0855" class="elsevierStylePara elsevierViewall">Scheduled tracheostomy as the initial surgical access in certain cases<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Unanticipated difficult intubation</span><p id="par0860" class="elsevierStylePara elsevierViewall">An algorithm has been developed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; grouping the difficulties encountered in both ventilation and intubation&#44; why these difficulties arise&#44; and how to resolve them&#46; The colours denote the seriousness of the situation and the scope of action available&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0865" class="elsevierStylePara elsevierViewall">In all situations&#44; the operator will be able to move to the safety zone &#40;green&#41;&#44; in which oxygenation is correct and the airway stable&#44; which should be the main objective&#46;</p><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">PLAN A</span><p id="par0870" class="elsevierStylePara elsevierViewall">The aim must be to perform the best possible technique from the first attempt&#58; adequate anaesthesia plan&#44; age-appropriate position&#44; oxygenation&#44; monitoring&#44; minimum attempts at both face mask ventilation and direct laryngoscopy<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;23&#8211;26&#44;43&#44;45&#8211;47&#44;61&#44;77</span></a>&#46;</p><p id="par0875" class="elsevierStylePara elsevierViewall">Depending on the characteristics of the patient&#44; the surgery&#44; and the experience of the anaesthesiologist&#44; the team will decide whether the initial approach should be intubation or insertion of an SGA&#46;</p><p id="par0880" class="elsevierStylePara elsevierViewall">In the event of any difficulty&#44; the team must ask for help&#44; bring in the difficult intubation cart&#44; and start administering oxygen at the highest concentration permissible for each particular child&#46;</p><p id="par0885" class="elsevierStylePara elsevierViewall">If the difficulty involves face mask ventilation&#44; once the patient is correctly repositioned&#44; opening manoeuvres such as jaw thrust and suction of secretions should be performed&#44; and if these are ineffective&#44; an oro&#47;nasopharyngeal cannula should be inserted and four-hand ventilation started<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#46;</p><p id="par0890" class="elsevierStylePara elsevierViewall">Functional obstruction of the airway can be reversed by deepening anaesthesia and&#47;or administering muscle relaxants<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a>&#46;</p><p id="par0895" class="elsevierStylePara elsevierViewall">If the difficulty arises during intubation&#44; the first step is to perform optimization manoeuvres&#44; such as&#58; age-appropriate positioning&#44; using guidewires or stylets when the glottic structures are visible&#44; even only partially&#44; mobilising the larynx using manoeuvres such as OELM or BURP&#44; which often facilitate intubation&#46;</p><p id="par0900" class="elsevierStylePara elsevierViewall">Video laryngoscopy is a useful alternative if the operator is experienced in this technique&#46; No more than 3 attempts&#44; including VL&#44; should be made over a period not exceeding 10 min&#46;</p><p id="par0905" class="elsevierStylePara elsevierViewall">If it is not possible to insert the ETT&#44; but ventilation with a face mask is achieved&#44; the situation will be non-urgent&#58; can&#8217;t intubate-can oxygenate&#44; at which time different alternatives will be considered depending on the needs of each patient and the urgency of the intervention&#44; such as performing the intervention with the face mask&#44; FOI through the SGA&#44; which allows simultaneous ventilation&#44; waking the patient and rescheduling as an anticipated difficult intubation&#44; or moving on to plan B&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">PLAN B</span><p id="par0910" class="elsevierStylePara elsevierViewall">This is a situation in which intubation is impossible and face mask ventilation is unstable&#46;</p><p id="par0915" class="elsevierStylePara elsevierViewall">The first option is to insert a second generation SGA&#46;</p><p id="par0920" class="elsevierStylePara elsevierViewall">If this is successful&#44; there will be time to stop&#44; think&#44; and consider the options available&#44; such as&#58;<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">&#8226;</span><p id="par0925" class="elsevierStylePara elsevierViewall">Attempting FOI through the SGA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">&#8226;</span><p id="par0930" class="elsevierStylePara elsevierViewall">Continue the procedure with an SGA if ventilation is adequate and the intervention cannot be postponed<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;47</span></a>&#46;</p></li></ul></p><p id="par0935" class="elsevierStylePara elsevierViewall">If the foregoing fails&#44; the following options are available&#58;<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">&#8226;</span><p id="par0940" class="elsevierStylePara elsevierViewall">Wake the patient and restore spontaneous ventilation if SpO<span class="elsevierStyleInf">2</span> &#62; 80&#37; and the situation allows it&#44; using antagonists to reverse the drugs administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">&#8226;</span><p id="par0945" class="elsevierStylePara elsevierViewall">If deterioration is progressive&#44; muscle relaxants &#40;MR&#41; can be administered if not previously used and not contraindicated<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>&#46;</p></li></ul></p><p id="par0950" class="elsevierStylePara elsevierViewall">If face-mask and SGA oxygenation is precarious and the patient cannot be woken up&#44; the team must declare an emergency so that they can rapidly prepare for an emergency surgical airway&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">PLAN C&#58; cannot intubate&#47;cannot ventilate</span><p id="par0955" class="elsevierStylePara elsevierViewall">The team must continue with their efforts to maintain oxygenation to optimise the patient while FONA is performed<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;47</span></a>&#46;</p><p id="par0960" class="elsevierStylePara elsevierViewall">After reviewing the literature and seeking the opinion of experts in paediatric airway management&#44; such as anaesthesiologists&#44; surgeons&#44; and paediatric ENT specialists&#44; the SCARTD reached the following consensus on the performance of FONA in a CICV situation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0965" class="elsevierStylePara elsevierViewall">Earlier guidelines established an age limit&#44; but there is no consensus on age in the latest articles&#46; Given the lack of standardisation with regard to emergency teams&#44; the keys steps in this protocol are the availability of tracheostomy sets and the palpation and identification of the laryngeal structures&#46;</p></span></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Extubation of a difficult airway</span><p id="par0970" class="elsevierStylePara elsevierViewall">According to the NAP4 study&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a third of all airway-related problems in paediatrics occur during extubation&#46; This is probably due to the following factors&#58; inadequate airway management strategy&#44; inadequate risk assessment&#44; and lack of planning&#46;</p><p id="par0975" class="elsevierStylePara elsevierViewall">It is important to define the strategy to be followed at the start of the intervention&#44; and to ensure that the patient will be able to maintain adequate gas exchange and airway patency once ventilatory support has been withdrawn&#44; bearing in mind that extubation is an elective procedure<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">91&#8211;93</span></a>&#46;</p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">STAGES</span><p id="par0980" class="elsevierStylePara elsevierViewall">Draw up a plan&#46; Stratify patients as&#58;<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">&#8226;</span><p id="par0985" class="elsevierStylePara elsevierViewall">Low risk&#58; routine intubation&#44; with no intraoperative complications or risk factors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">&#8226;</span><p id="par0990" class="elsevierStylePara elsevierViewall">High risk&#58; anticipated difficult intubation&#44; perioperative airway compromise and&#47;or restricted airway access&#46;</p></li></ul></p><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Prepare for extubation&#58; teamwork</span><p id="par0995" class="elsevierStylePara elsevierViewall">Reassess the patient&#8217;s general status and the patency of the airway&#46;</p><p id="par1000" class="elsevierStylePara elsevierViewall">In high-risk cases&#44; it is advisable to perform extubation with the patient awake and under spontaneous ventilation in order to ensure adequate oxygenation&#46;</p><p id="par1005" class="elsevierStylePara elsevierViewall">Extubation under deep sedation is not recommended in high-risk patients<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;91</span></a>&#46;</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Perform the extubation</span><p id="par1010" class="elsevierStylePara elsevierViewall">Ensure adequate oxygenation during the procedure&#46;</p><p id="par1015" class="elsevierStylePara elsevierViewall">Make sure an airway crash cart is available&#44; and prepare the necessary material in advance&#46;</p><p id="par1020" class="elsevierStylePara elsevierViewall">Extubation must be performed by an expert practitioner who is capable of responding if rescue techniques are required&#46;</p><p id="par1025" class="elsevierStylePara elsevierViewall">The team leader and a well-organised&#44; flexible sequence of events must be clearly defined&#46;</p><p id="par1030" class="elsevierStylePara elsevierViewall">Several extubation techniques have been described&#58;<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">&#8226;</span><p id="par1035" class="elsevierStylePara elsevierViewall">Direct &#40;recommended in low-risk patients&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">&#8226;</span><p id="par1040" class="elsevierStylePara elsevierViewall">Through devices such as the face mask or SGA&#44; which may require deep sedation for tolerance&#46; This option is rarely used in children&#46;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">&#8226;</span><p id="par1045" class="elsevierStylePara elsevierViewall">Use of guidewires or airway exchange catheters&#46; These will facilitate reintubation using the Seldinger technique&#46; Some exchange catheters allow jet ventilation through the Rapi-Fit system&#174;&#46;</p></li></ul></p><p id="par1050" class="elsevierStylePara elsevierViewall">According to Jagannathan et al&#46;&#44; direct intubation without adjuvants was performed in 95&#37; of cases in a tertiary hospital&#44; and only 5&#37; of patients required reintubation<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a>&#46;</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Post-extubation care</span><p id="par1055" class="elsevierStylePara elsevierViewall">It is important to maintain oxygen delivery and monitoring after extubation&#46; The ideal period has not been established and must be decided on a case-by-case basis&#44; depending on the patient&#39;s status and stratification&#46;</p></span></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Materials</span><p id="par1060" class="elsevierStylePara elsevierViewall">The contents of the airway crash cart will depend on the materials available&#44; so each hospital must stock the cart according to the type of patients treated and the level of experience of the surgical team<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;19&#44;23&#44;40</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a>&#46;</p><p id="par1065" class="elsevierStylePara elsevierViewall">The cart must be easily and rapidly accessible&#44; and the material and airway devices must be checked frequently to ensure they are in working order&#46;</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Documentation</span><p id="par1070" class="elsevierStylePara elsevierViewall">Both the family and the patient should receive information about the procedure&#44; the techniques used&#44; and the complications that may arise&#46; It is also advisable to evaluate and follow-up high-risk patients&#46;</p><p id="par1075" class="elsevierStylePara elsevierViewall">Hospitals must create electronic alert systems for patients with a history of difficult intubation&#46;</p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Training</span><p id="par1080" class="elsevierStylePara elsevierViewall">In addition to creating algorithms based on the resources available in each hospital&#44; clinicians also need to receive conventional and simulation-based training to update their theoretical knowledge and practical skills in airway management to prepare them to deal with emergency situations<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;77</span></a>&#46;</p><p id="par1085" class="elsevierStylePara elsevierViewall">Four basic visual aids are used for airway management training and decision making in both simulation and real life scenarios<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#58;<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">1</span><p id="par1090" class="elsevierStylePara elsevierViewall">Universal algorithms&#58; ASA<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">2</span><p id="par1095" class="elsevierStylePara elsevierViewall">Local or specific algorithms&#58; DAS<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;47</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">3</span><p id="par1100" class="elsevierStylePara elsevierViewall">Concept-based cognitive aids&#58; Vortex<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">4</span><p id="par1105" class="elsevierStylePara elsevierViewall">Check lists&#44; which emphasise the need to plan carefully before administering anaesthesia&#46;</p></li></ul></p><p id="par1110" class="elsevierStylePara elsevierViewall">Complex algorithms&#44; such as those developed by the ASA&#44; are useful for teaching&#44; while simple diagrams like the Vortex&#44; can help with decision making under stress<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par1115" class="elsevierStylePara elsevierViewall">The DAS guidelines group possible airway problems on a single page&#46; Each situation is colour-coded according to severity&#44; and different optimization options are provided for each technique<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#46;</p><p id="par1120" class="elsevierStylePara elsevierViewall">Despite the growing number of studies&#44; the paediatric airway algorithms designed by various scientific societies &#40;Polish Society<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a>&#44; <span class="elsevierStyleItalic">Soci&#233;t&#233; Fran&#231;aise d&#39;Anesth&#233;sie et de R&#233;animation</span> &#91;SFAR&#93;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a>&#44; DAS<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#44; <span class="elsevierStyleItalic">All India Difficult Airway Association</span> &#91;AIDAA&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> still focus on strategies for managing unanticipated intubation difficulties&#46; These aids are crowded with information&#44; so they should be studied in advance to prepare clinicians to act in stressful situations in which a combination of factors can undermine their ability to respond&#46;</p><p id="par1125" class="elsevierStylePara elsevierViewall">With the Vortex Approach<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#44; Chrimes has developed a simple cognitive aid for use in real time during an emergency airway management situation&#46; The Vortex promotes teamwork with a clear&#44; easily understood diagram that shows how communication&#44; continuous reassessment&#44; and pauses to think and redirect the situation can make a difference&#46;</p><p id="par1130" class="elsevierStylePara elsevierViewall">The key is to make the best effort to achieve the planned technique - face mask ventilation&#44; an SGA&#44; or intubation - minimise the number of attempts&#44; optimise tissue oxygenation&#44; and keep the patient in the green safety zone&#46; If a particular strategy fails&#44; there are always other rescue alternatives available&#46;</p><p id="par1135" class="elsevierStylePara elsevierViewall">All these algorithms recommend limiting the number of intubation attempts&#44; regardless of the device used&#44; and stress the importance of identifying potential problems and planning accordingly&#44; and referring difficult cases to specialized centres&#46;</p><p id="par1140" class="elsevierStylePara elsevierViewall">Another important aspect is the creation and promotion of centres specialising in difficult airway management&#44; a strategy that will<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10&#44;90</span></a>&#58;<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">&#8226;</span><p id="par1145" class="elsevierStylePara elsevierViewall">Improve paediatric care by identifying high risk patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">&#8226;</span><p id="par1150" class="elsevierStylePara elsevierViewall">Reduce the incidence of preventable airway management complications by creating multidisciplinary teams to carefully select and prepare patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">&#8226;</span><p id="par1155" class="elsevierStylePara elsevierViewall">Provide centres with the basic and advanced material needed for patient care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">&#8226;</span><p id="par1160" class="elsevierStylePara elsevierViewall">Provide surgical teams with training and continuous professional development courses in technical and non-technical skills related to teamwork&#44; decision-making in routine situations&#44; and crisis management and resolution strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">&#8226;</span><p id="par1165" class="elsevierStylePara elsevierViewall">Allow centres to monitor high-risk patients and create reliable evaluation methods that will improve the quality of care provided by airway management teams by detecting weaknesses and building on strengths&#46;</p></li></ul></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Conclusions</span><p id="par1245" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">&#8226;</span><p id="par1170" class="elsevierStylePara elsevierViewall">Paediatric patients differ from adults not only in terms of weight and size&#44; but also in terms of psychology&#44; physiology and anatomy&#46; All these factors must be understood by clinicians treating these patients in both routine interventions and critical situations&#46; These skills are the key to reducing the incidence of complications&#46;</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">&#8226;</span><p id="par1175" class="elsevierStylePara elsevierViewall">Direct laryngoscopy and basic face mask ventilation will always be pivotal airway management skills&#46;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">&#8226;</span><p id="par1180" class="elsevierStylePara elsevierViewall">The manoeuvres required to secure the airway must be performed quickly &#8211; due to the limited safe apnoea window &#8211; and carefully&#44; by minimizing the number of intubation attempts&#44; regardless of the device used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">&#8226;</span><p id="par1185" class="elsevierStylePara elsevierViewall">The evidence suggests that most adverse intubation-related events occur in paediatric and neonatal intensive care units and emergency rooms&#44; where the number of factors involved could be reduced by creating crisis care circuits&#44; promoting the acquisition of technical skills&#44; and facilitating communication between the different teams involved&#46;</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">&#8226;</span><p id="par1190" class="elsevierStylePara elsevierViewall">All clinicians should be familiar with at least one alternative technique to direct laryngoscopy&#44; since the basis for success is operator experience&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">&#8226;</span><p id="par1195" class="elsevierStylePara elsevierViewall">In the case of anticipated difficult intubation&#44; clinicians should run through a check list that includes ultrasound identification and marking of the CTM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">&#8226;</span><p id="par1200" class="elsevierStylePara elsevierViewall">Anticipation and planning is paramount&#46; In the case of anticipated difficult intubation&#44; anaesthesia must be administered in a tertiary hospital by an expert anaesthesiologist using specific material&#44; regardless of the procedure or intervention planned&#46;</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">&#8226;</span><p id="par1205" class="elsevierStylePara elsevierViewall">In complex cases&#44; combined techniques&#44; such as VL &#43; FOI or SGA &#43; FOI can minimise risks while making use of the advantages of each device&#46; The combination used will depend on the patient&#8217;s clinical status&#44; the experience of the operator&#44; and the availability of each device&#46;</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">&#8226;</span><p id="par1210" class="elsevierStylePara elsevierViewall">The creation of specialized teams could help improve practice and reduce the morbidity associated with paediatric airway management&#46;</p></li></ul></p><p id="par1215" class="elsevierStylePara elsevierViewall">The recommendations must be applied in each hospital according to the resources available&#46; It is important to bear in mind that even the most straightforward intubation can go wrong&#44; so rescue alternatives must always be available in order to avoid the appearance of complications and irreversible sequelae&#46;</p></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Conflict of interests</span><p id="par1220" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:19 [
        0 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        1 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Methodology"
        ]
        2 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Pre-anaesthesia airway evaluation"
        ]
        3 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Preparation"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "1 P&#58; Anaesthesia Plan and informed consent"
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "2 P&#58; Trained staff &#91;personal&#44; in Spanish&#93; and equipment in working order"
            ]
            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "3 P&#58; Position"
            ]
            3 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "4 P&#58; Preoxygenation"
            ]
            4 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "5 P&#58; Adequate depth &#91;profundidad&#44; in Spanish&#93; of anaesthesia"
            ]
          ]
        ]
        4 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Airway management techniques"
        ]
        5 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Face mask ventilation and optimization manoeuvres"
        ]
        6 => array:3 [
          "identificador" => "sec0060"
          "titulo" => "Tracheal intubation and optimization manoeuvres"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Rapid sequence induction and the Sellick manoeuvre"
            ]
          ]
        ]
        7 => array:3 [
          "identificador" => "sec0070"
          "titulo" => "Advanced airway management and optimization manoeuvres"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Fibreoptic bronchoscopy"
            ]
            1 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Fibreoptic intubation optimization manoeuvres"
            ]
            2 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Supraglottic airway devices"
            ]
            3 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Optimization manoeuvres for supraglottic devices"
            ]
            4 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Video laryngoscopes"
            ]
            5 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Video laryngoscopy optimization manoeuvres"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0105"
          "titulo" => "Rescue technique&#58; front of neck access"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Oxygenation methods"
            ]
          ]
        ]
        9 => array:3 [
          "identificador" => "sec0115"
          "titulo" => "Proposed paediatric difficult intubation algorithm"
          "secciones" => array:2 [
            0 => array:3 [
              "identificador" => "sec0120"
              "titulo" => "Anticipated difficult intubation"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0125"
                  "titulo" => "Prevention"
                ]
                1 => array:2 [
                  "identificador" => "sec0130"
                  "titulo" => "PLAN A&#58; planned intubation"
                ]
                2 => array:2 [
                  "identificador" => "sec0135"
                  "titulo" => "PLAN B"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "sec0140"
              "titulo" => "Unanticipated difficult intubation"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0145"
                  "titulo" => "PLAN A"
                ]
                1 => array:2 [
                  "identificador" => "sec0150"
                  "titulo" => "PLAN B"
                ]
                2 => array:2 [
                  "identificador" => "sec0155"
                  "titulo" => "PLAN C&#58; cannot intubate&#47;cannot ventilate"
                ]
              ]
            ]
          ]
        ]
        10 => array:2 [
          "identificador" => "sec0160"
          "titulo" => "Extubation of a difficult airway"
        ]
        11 => array:3 [
          "identificador" => "sec0165"
          "titulo" => "STAGES"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0170"
              "titulo" => "Prepare for extubation&#58; teamwork"
            ]
            1 => array:2 [
              "identificador" => "sec0175"
              "titulo" => "Perform the extubation"
            ]
            2 => array:2 [
              "identificador" => "sec0180"
              "titulo" => "Post-extubation care"
            ]
          ]
        ]
        12 => array:2 [
          "identificador" => "sec0185"
          "titulo" => "Materials"
        ]
        13 => array:2 [
          "identificador" => "sec0190"
          "titulo" => "Documentation"
        ]
        14 => array:2 [
          "identificador" => "sec0195"
          "titulo" => "Training"
        ]
        15 => array:2 [
          "identificador" => "sec0200"
          "titulo" => "Conclusions"
        ]
        16 => array:2 [
          "identificador" => "sec0205"
          "titulo" => "Conflict of interests"
        ]
        17 => array:2 [
          "identificador" => "xack627842"
          "titulo" => "Acknowledgements"
        ]
        18 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-10-16"
    "fechaAceptado" => "2021-05-25"
    "multimedia" => array:5 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2862
            "Ancho" => 2918
            "Tamanyo" => 392128
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0090"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Paediatric anticipated difficult intubation management algorithm&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CTM&#58; cricothyroid membrane&#59; SGD&#58; supraglottic device&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1639
            "Ancho" => 3175
            "Tamanyo" => 628946
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0095"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">SCARTD paediatric unanticipated difficult intubation management algorithm&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">2nd G&#58; second generation&#59; CICV&#58; cannot intubate&#47;cannot ventilate&#59; CTM&#58; cricothyroid membrane&#59; FiO2&#58; fraction of inspired oxygen&#59; FM&#58; face mask&#59; MR&#58; muscle relaxant&#59; SCARTD&#58; Catalan Society of Anaesthesiology&#44; Resuscitation and Pain Management&#59; SGA&#58; supraglottic airway&#59; VDL&#58; video laryngoscope&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 972
            "Ancho" => 3175
            "Tamanyo" => 263995
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0100"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">SCARTD recommendations for paediatric unanticipated difficult intubation&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CICV&#58; cannot intubate&#47;cannot ventilate&#59; CTM&#58; cricothyroid membrane&#46; SCARTD&#58; Catalan Society of Anesthesiology&#44; Resuscitation and Pain Therapy&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0105"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Adapted from&#58; Andreu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Congenital malformations&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Skull abnormalities&#58; Apert syndrome&#44; Crouzon syndrome&#44; hydrocephalus&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mandibular hypoplasia&#58; Pierre-Robin&#44; Treacher-Collins&#44; Goldenhar&#44; Apert syndromes&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal neck movement&#58; Klippel-Feil syndrome&#44; Down syndrome&#44; mucopolysaccharidosis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Limited mouth opening&#58; Freeman-Sheldon&#44; Hallermann-Strieff&#44; epidermolysis bullosa syndromes&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Small oral cavity&#58; Pierre-Robin&#44; Treacher-Collins&#44; high-arched palate and&#47;or cleft palate syndromes&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Macroglossia&#58; hypothyroidism&#44; Beckwith-Wiedeman syndrome&#44; Down syndrome&#44; mucopolysaccharidosis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cervical spine mass&#58; cystic hygroma&#44; teratomas&#44; hemangiomas&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laryngeal and subglottic anomalies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Acquired abnormalities&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infections&#58; retropharyngeal and peritonsillar abscess&#44; epiglottitis&#44; croup and tracheitis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anaphylaxis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Facial injuries and&#47;or burns&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Foreign bodies&#58; common in preschool children&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other causes&#58; tumuors&#44; anterior mediastinal mass&#44; previous surgery&#44; radiotherapy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Pathologies or syndromes associated with paediatric anticipated difficult intubation&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0110"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; American Society of Anesthesiologists&#59; BMI&#58; body mass index&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MATERIAL&#58; Inadequate equipment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TEAM&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unfamiliarity with the characteristics of the paediatric patient and intubation algorithms&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poor technique&#58; face mask ventilation&#44; Sellick manoeuver&#44; placement of oro&#47;nasopharyngeal cannulas&#44; or intubation manoeuvres&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PATIENT&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Improper positioning of the head and neck&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inadequate depth of anaesthesia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">hyperinflation and gastric distension&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Muscle stiffness from rapid injection of opiates&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASA III-IV&#44; Mallampati III-IV&#44; obesity &#40;BMI &#62; 35&#41; and children scheduled for cardiac or maxillofacial surgery<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;11</span></a>&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Risk factors in airway manipulation&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:93 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence of intraoperative hypoxemia in children in relation to age"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1213/ANE.0b013e31829332b5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "2013"
                        "volumen" => "117"
                        "paginaInicial" => "169"
                        "paginaFinal" => "175"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Major complications of airway management in the UK&#58; results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society&#46; Part 1&#58; anaesthesia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aer058"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2011"
                        "volumen" => "106"
                        "paginaInicial" => "617"
                        "paginaFinal" => "631"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Proposal for the management of the unexpected difficult pediatric airway"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1460-9592.2010.03284.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2010"
                        "volumen" => "20"
                        "paginaInicial" => "454"
                        "paginaFinal" => "464"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence and predictors of difficult laryngoscopy in 11&#44;219 pediatric anesthesia procedures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1460-9592.2012.03813.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2012"
                        "volumen" => "22"
                        "paginaInicial" => "729"
                        "paginaFinal" => "736"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Description and function of a difficult airway service"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13783"
                      "Revista" => array:5 [
                        "tituloSerie" => "Pediatr Anesth"
                        "fecha" => "2020"
                        "volumen" => "30"
                        "paginaInicial" => "375"
                        "paginaFinal" => "382"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Paediatric difficult airway management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Update Anaesth"
                        "fecha" => "2015"
                        "volumen" => "30"
                        "paginaInicial" => "116"
                        "paginaFinal" => "122"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation &#40;PeDI&#41; registry&#58; a prospective cohort analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S2213-2600(15)00508-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Respir Med"
                        "fecha" => "2016"
                        "volumen" => "4"
                        "paginaInicial" => "37"
                        "paginaFinal" => "48"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Algorithm for pediatric difficult airway&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0034-9356(11)70066-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Anestesiol Reanim"
                        "fecha" => "2011"
                        "volumen" => "58"
                        "paginaInicial" => "304"
                        "paginaFinal" => "311"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controversies in pediatric perioperative airways"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1155/2015/368761"
                      "Revista" => array:4 [
                        "tituloSerie" => "Biomed Res Int"
                        "fecha" => "2015"
                        "volumen" => "2015"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric airway management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/2229-5151.128015"
                      "Revista" => array:4 [
                        "tituloSerie" => "Int J Crit Illness Inj Sci"
                        "fecha" => "2014"
                        "volumen" => "4"
                        "paginaInicial" => "65"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An update on airway management in infants and children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Anaesth Pain Intensive Care"
                        "fecha" => "2019"
                        "volumen" => "18"
                        "paginaInicial" => "85"
                        "paginaFinal" => "96"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The paediatric airway&#58; basic principles and current developments"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/EJA.0000000000000023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Anaesthesiol"
                        "fecha" => "2014"
                        "volumen" => "31"
                        "paginaInicial" => "293"
                        "paginaFinal" => "299"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Microtia and difficult airway&#58; how to manage&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.23736/S0375-9393.20.14429-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Minerva Anestesiol"
                        "fecha" => "2020"
                        "volumen" => "86"
                        "paginaInicial" => "365"
                        "paginaFinal" => "367"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prediction of difficult laryngoscopy in school-aged patients with microtia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.23736/S0375-9393.19.13895-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Minerva Anestesiol"
                        "fecha" => "2020"
                        "volumen" => "86"
                        "paginaInicial" => "387"
                        "paginaFinal" => "393"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Visual aids for pediatric airway management"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13789"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2020"
                        "volumen" => "30"
                        "paginaInicial" => "371"
                        "paginaFinal" => "374"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Expected difficult airway in children"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ACO.0000000000000198"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Anaesthesiol"
                        "fecha" => "2015"
                        "volumen" => "28"
                        "paginaInicial" => "321"
                        "paginaFinal" => "326"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Approach to the paediatric difficultairway in a high- versus low-resource setting&#58; a comparison of algorithms and difficult airway trolleys"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Anaesthesia"
                        "fecha" => "2019"
                        "volumen" => "399"
                        "paginaInicial" => "1"
                        "paginaFinal" => "11"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Normal and difficult airways in children&#58; &#8220;What&#8217;s New&#8221;&#8212;current evidence"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13798"
                      "Revista" => array:5 [
                        "tituloSerie" => "Pediatr Anesth"
                        "fecha" => "2020"
                        "volumen" => "30"
                        "paginaInicial" => "257"
                        "paginaFinal" => "263"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practice guidelines for management of the difficult airway&#58; an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ALN.0b013e31827773b2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2013"
                        "volumen" => "118"
                        "paginaInicial" => "251"
                        "paginaFinal" => "270"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence&#44; impact and indicators of difficult intubations in the neonatal intensive care unit&#58; a report from the National Emergency Airway Registry for Neonates"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/archdischild-2018-316336"
                      "Revista" => array:3 [
                        "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed"
                        "fecha" => "2019"
                        "volumen" => "104"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Emerging trends&#44; techniques&#44; and equipment for airway management in pediatric patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13814"
                      "Revista" => array:5 [
                        "tituloSerie" => "Pediatr Anesth"
                        "fecha" => "2020"
                        "volumen" => "30"
                        "paginaInicial" => "269"
                        "paginaFinal" => "279"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric airway management&#58; current practices and future directions"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12013"
                      "Revista" => array:5 [
                        "tituloSerie" => "Pediatr Anesth"
                        "fecha" => "2012"
                        "volumen" => "22"
                        "paginaInicial" => "1008"
                        "paginaFinal" => "1015"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A framework for the management of the pediatric airway"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13716"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2019"
                        "volumen" => "29"
                        "paginaInicial" => "985"
                        "paginaFinal" => "992"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The number of tracheal intubation attempts matters&#33; A prospective multi-institutional pediatric observational study"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s12887-016-0593-y"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Pediatr"
                        "fecha" => "2016"
                        "volumen" => "16"
                        "paginaInicial" => "58"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Vortex&#58; a universal &#8216;high-acuity implementation tool&#8217; for emergency airway management"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aew175"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2016"
                        "volumen" => "117"
                        "paginaInicial" => "i20"
                        "paginaFinal" => "7"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Advances in emergent airway management in pediatrics"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.emc.2019.03.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Emerg Med Clin North Am"
                        "fecha" => "2019"
                        "volumen" => "37"
                        "paginaInicial" => "473"
                        "paginaFinal" => "491"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Airway management"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "edicion" => "4th edition"
                        "fecha" => "2020"
                        "editorial" => "Elsevier"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s13049-019-0666-7"
                      "Revista" => array:5 [
                        "tituloSerie" => "Scand J Trauma Resusc Emerg Med"
                        "fecha" => "2019"
                        "volumen" => "27"
                        "paginaInicial" => "87"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Upper airway modifications in head extension during development"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.accpm.2016.04.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesth Crit Care Pain Med"
                        "fecha" => "2017"
                        "volumen" => "36"
                        "paginaInicial" => "285"
                        "paginaFinal" => "290"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Paediatric difficult airway management&#58; what every anaesthetist should know&#33;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aew054"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2016"
                        "volumen" => "117 Suppl 1"
                        "paginaInicial" => "i3"
                        "paginaFinal" => "5"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Paediatric airway management&#58; what is new&#63;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/0019-5049.103959"
                      "Revista" => array:5 [
                        "tituloSerie" => "Indian J Anaesth"
                        "fecha" => "2012"
                        "volumen" => "56"
                        "paginaInicial" => "448"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preoxygenation&#58; physiologic basis&#44; benefits&#44; and potential risks"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1213/ANE.0000000000001589"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "2017"
                        "volumen" => "124"
                        "paginaInicial" => "507"
                        "paginaFinal" => "517"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Apneic oxygenation as a standard of care in children&#58; how do we get there&#63;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1213/ANE.0000000000004483"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "2020"
                        "volumen" => "130"
                        "paginaInicial" => "828"
                        "paginaFinal" => "830"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A narrative review of oxygenation during pediatric intubation and airway procedures"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1213/ANE.0000000000004403"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "2020"
                        "volumen" => "130"
                        "paginaInicial" => "831"
                        "paginaFinal" => "840"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of age and increasing head-up tilt on pre-oxygenation times in children&#58; a randomised exploratory study"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/anae.13379"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesthesia"
                        "fecha" => "2016"
                        "volumen" => "71"
                        "paginaInicial" => "429"
                        "paginaFinal" => "436"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxygen supplementation during prolonged tracheal intubation should be the standard of care"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aew303"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2016"
                        "volumen" => "117"
                        "paginaInicial" => "417"
                        "paginaFinal" => "418"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nasal high-flow oxygen delivery in children with abnormal airways"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13151"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2017"
                        "volumen" => "27"
                        "paginaInicial" => "616"
                        "paginaFinal" => "620"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implementation of NAP4 emergency airway management recommendations in a quaternary-level pediatric hospital"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13128"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2017"
                        "volumen" => "27"
                        "paginaInicial" => "451"
                        "paginaFinal" => "460"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cannot ventilate--paralyze&#33;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12054"
                      "Revista" => array:7 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2012"
                        "volumen" => "22"
                        "paginaInicial" => "1147"
                        "paginaFinal" => "1149"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of the difficult airway in the pediatric patient"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-0038-1624576"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr Intensive Care"
                        "fecha" => "2018"
                        "volumen" => "7"
                        "paginaInicial" => "115"
                        "paginaFinal" => "125"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Induction of anesthesia with dexmedetomidine and sevoflurane for a pediatric difficult airway"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/0366-6999.211883"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chin Med J"
                        "fecha" => "2017"
                        "volumen" => "130"
                        "paginaInicial" => "1997"
                        "paginaFinal" => "1998"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Airway management in paediatric anaesthesia in Europe-insights from APRICOT &#40;Anaesthesia Practice In Children Observational Trial&#41;&#58; a prospective multicentre observational study in 261 hospitals in Europe"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.bja.2018.04.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2018"
                        "volumen" => "121"
                        "paginaInicial" => "66"
                        "paginaFinal" => "75"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Airway management"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2020"
                        "editorial" => "StatPearls Publishing"
                        "editorialLocalizacion" => "StatPearls&#44; Treasure Island &#40;FL&#41;"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mapleson&#8217;s breathing systems"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/0019-5049.120148"
                      "Revista" => array:6 [
                        "tituloSerie" => "Indian J Anaesth"
                        "fecha" => "2013"
                        "volumen" => "57"
                        "paginaInicial" => "507"
                        "paginaFinal" => "515"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in Paediatrics"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/0019-5049.195483"
                      "Revista" => array:6 [
                        "tituloSerie" => "Indian J Anaesth"
                        "fecha" => "2016"
                        "volumen" => "60"
                        "paginaInicial" => "906"
                        "paginaFinal" => "914"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of the child&#8217;s airway under anaesthesia&#58; the French guidelines"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.accpm.2019.02.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesth Crit Care Pain Med"
                        "fecha" => "2019"
                        "volumen" => "38"
                        "paginaInicial" => "681"
                        "paginaFinal" => "693"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development of a guideline for the management of the unanticipated difficult airway in pediatric practice"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12615"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2015"
                        "volumen" => "25"
                        "paginaInicial" => "346"
                        "paginaFinal" => "362"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cuffed versus uncuffed endotracheal tubes for general anaesthesia in children aged eight years and under"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD011954.pub2"
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2017"
                        "volumen" => "11"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric cuffed endotracheal tubes"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/0970-9185.105786"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anaesthesiol Clin Pharmacol"
                        "fecha" => "2013"
                        "volumen" => "29"
                        "paginaInicial" => "13"
                        "paginaFinal" => "18"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endotracheal tubes and the cricoid&#58; is there a good fit&#63;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijporl.2016.03.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Pediatr Otorhinolaryngol"
                        "fecha" => "2016"
                        "volumen" => "85"
                        "paginaInicial" => "8"
                        "paginaFinal" => "11"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of cricoid force on airway calibre in children&#58; a bronchoscopic assessment"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aep337"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2010"
                        "volumen" => "104"
                        "paginaInicial" => "71"
                        "paginaFinal" => "74"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cricoid pressure controversies narrative review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ALN.0000000000001489"
                      "Revista" => array:7 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2017"
                        "volumen" => "126"
                        "paginaInicial" => "738"
                        "paginaFinal" => "752"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Place of rapid sequence induction in paediatric anaesthesia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bjaceaccp/mkv024"
                      "Revista" => array:5 [
                        "tituloSerie" => "BJA Educ"
                        "fecha" => "2016"
                        "volumen" => "16"
                        "paginaInicial" => "120"
                        "paginaFinal" => "123"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is it safe to use supraglottic airway in children with difficult airways&#63;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aeu005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2014"
                        "volumen" => "112"
                        "paginaInicial" => "620"
                        "paginaFinal" => "622"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Time to abandon the &#8216;vintage&#8217; laryngeal mask airway and adopt second-generation supraglottic airway devices as first choice"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aev156"
                      "Revista" => array:7 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2015"
                        "volumen" => "115"
                        "paginaInicial" => "497"
                        "paginaFinal" => "499"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Supraglottic airway devices vs tracheal intubation in children&#58; a quantitative meta-analysis of respiratory complications"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12495"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2014"
                        "volumen" => "24"
                        "paginaInicial" => "1088"
                        "paginaFinal" => "1098"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Elective use of supraglottic airway devices for primary airway management in children with difficult airways"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aet411"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2014"
                        "volumen" => "112"
                        "paginaInicial" => "742"
                        "paginaFinal" => "748"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric supraglottic airway devices in clinical practice&#58; a prospective observational study"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s12871-017-0403-6"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Anesthesiol"
                        "fecha" => "2017"
                        "volumen" => "17"
                        "paginaInicial" => "119"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Advances in supraglottic airway devices for the management of difficult airways in children"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1586/17434440.2016.1136210"
                      "Revista" => array:6 [
                        "tituloSerie" => "Expert Rev Med Devices"
                        "fecha" => "2016"
                        "volumen" => "13"
                        "paginaInicial" => "157"
                        "paginaFinal" => "169"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Update on airway devices"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s40140-015-0100-2"
                      "Revista" => array:5 [
                        "tituloSerie" => "Curr Anesthesiol Rep"
                        "fecha" => "2015"
                        "volumen" => "5"
                        "paginaInicial" => "147"
                        "paginaFinal" => "155"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Unanticipated difficult airway management in children - the consensus statement of the Paediatric Anaesthesiology and Intensive Care Section and the Airway Management Section of the Polish Society of Anaesthesiology and Intensive Therapy and the Polish So"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5603/AIT.2017.0079"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesthesiol Intensive Ther"
                        "fecha" => "2017"
                        "volumen" => "49"
                        "paginaInicial" => "336"
                        "paginaFinal" => "349"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Performance and skill retention of five supraglottic airway devices for the pediatric difficult airway in a manikin"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00431-018-3134-x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Pediatr"
                        "fecha" => "2018"
                        "volumen" => "177"
                        "paginaInicial" => "871"
                        "paginaFinal" => "878"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of blind intubation with different supraglottic airway devices by inexperienced physicians in several airway scenarios&#58; a manikin study"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00431-019-03345-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Pediatr"
                        "fecha" => "2019"
                        "volumen" => "178"
                        "paginaInicial" => "871"
                        "paginaFinal" => "882"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized equivalence trial of the King Vision aBlade videolaryngoscope with the Miller direct laryngoscope for routine tracheal intubation in children &#60;2 yr of age"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aex073"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2017"
                        "volumen" => "118"
                        "paginaInicial" => "932"
                        "paginaFinal" => "937"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Videolaryngoscopes in paediatric anaesthesia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s40746-014-0007-z"
                      "Revista" => array:5 [
                        "tituloSerie" => "Curr Treat Options Peds"
                        "fecha" => "2015"
                        "volumen" => "1"
                        "paginaInicial" => "25"
                        "paginaFinal" => "37"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Videolaryngoscopy&#8212;is there a role in paediatric airway management&#63;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Minerva Anestesiol"
                        "fecha" => "2013"
                        "volumen" => "79"
                        "paginaInicial" => "1326"
                        "paginaFinal" => "1328"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The difficult pediatric airway&#8212;a review of new devices for indirect laryngoscopy in children younger than two years of age"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1460-9592.2010.03487.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2011"
                        "volumen" => "21"
                        "paginaInicial" => "98"
                        "paginaFinal" => "103"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The efficacy of GlideScope&#174; videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate&#58; an analysis from the paediatric difficult intubation registry"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aex344"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2017"
                        "volumen" => "119"
                        "paginaInicial" => "984"
                        "paginaFinal" => "992"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neonatal airway management"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.clp.2019.08.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Perinatol"
                        "fecha" => "2019"
                        "volumen" => "46"
                        "paginaInicial" => "745"
                        "paginaFinal" => "763"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric video laryngoscope versus direct laryngoscope&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12458"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2014"
                        "volumen" => "24"
                        "paginaInicial" => "1056"
                        "paginaFinal" => "1065"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Difficult airway management of neonates&#44; infants&#44; and children with syndromes involving the airway"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/978-3-030-04600-2_7"
                      "Revista" => array:4 [
                        "tituloSerie" => "Springer Nat"
                        "fecha" => "2019"
                        "paginaInicial" => "67"
                        "paginaFinal" => "75"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD009975.pub2"
                      "Revista" => array:2 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2015"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Children with challenging airways&#58; what about GlideScope&#174; video-laryngoscopy&#63;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.accpm.2016.10.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesth Crit Care Pain Med"
                        "fecha" => "2017"
                        "volumen" => "36"
                        "paginaInicial" => "267"
                        "paginaFinal" => "271"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Videolaryngoscopy versus fiber-optic intubation through a supraglottic airway in children with a difficult airway&#58; an analysis from the multicenter pediatric difficult intubation registry"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ALN.0000000000001758"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2017"
                        "volumen" => "127"
                        "paginaInicial" => "432"
                        "paginaFinal" => "440"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous ventilation during flexible fiberscopic-assisted intubation via supraglottic airways"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12863"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2016"
                        "volumen" => "26"
                        "paginaInicial" => "457"
                        "paginaFinal" => "458"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized comparison between the i-gelTM and the air-QTM supraglottic airways when used by anesthesiology trainees as conduits for tracheal intubation in children"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12630-014-0304-9"
                      "Revista" => array:5 [
                        "tituloSerie" => "Can J Anesth&#47;J Can Anesth"
                        "fecha" => "2015"
                        "volumen" => "62"
                        "paginaInicial" => "587"
                        "paginaFinal" => "594"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0385"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An institutional approach to the management of the &#8216;Can&#8217;t Intubate&#44; Can&#8217;t Oxygenate&#8217; emergency in children"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12926"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Anesth"
                        "fecha" => "2016"
                        "volumen" => "26"
                        "paginaInicial" => "784"
                        "paginaFinal" => "793"
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0390"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The emergency paediatric surgical airway&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/EJA.0000000000000813"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Anaesthesiol"
                        "fecha" => "2018"
                        "volumen" => "35"
                        "paginaInicial" => "558"
                        "paginaFinal" => "565"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0395"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The &#8220;Can&#8217;t intubate can&#8217;t oxygenate&#8221; scenario in pediatric anesthesia&#58; a comparison of the Melker cricothyroidotomy kit with a scalpel bougie technique"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12565"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2015"
                        "volumen" => "25"
                        "paginaInicial" => "400"
                        "paginaFinal" => "404"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0400"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of pediatric &#8220;cannot intubate&#44; cannot oxygenate&#8221;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ams2.305"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acute Med Surg"
                        "fecha" => "2017"
                        "volumen" => "4"
                        "paginaInicial" => "462"
                        "paginaFinal" => "466"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Front of neck access to the airway&#58; a narrative review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.tacc.2018.06.001"
                      "Revista" => array:2 [
                        "tituloSerie" => "Trends Anaesth Crit Care"
                        "fecha" => "2018"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13220"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2017"
                        "volumen" => "27"
                        "paginaInicial" => "1015"
                        "paginaFinal" => "1020"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Usefulness of ultrasound-guided measurement of minimal transverse diameter of subglottic airway in determining the endotracheal tube size in children with congenital heart disease&#58; a prospective observational study"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4103/aca.ACA_220_17"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Card Anaesth"
                        "fecha" => "2018"
                        "volumen" => "21"
                        "paginaInicial" => "382"
                        "paginaFinal" => "387"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib0420"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Realtime ultrasound guided percutaneous tracheostomy in emergency setting&#58; the glass ceiling has been broken"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s40696-017-0035-x"
                      "Revista" => array:5 [
                        "tituloSerie" => "Disaster Mil Med"
                        "fecha" => "2017"
                        "volumen" => "3"
                        "paginaInicial" => "7"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib0425"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Accuracy of identifying the cricothyroid membrane in children using palpation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00540-018-2538-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anesth"
                        "fecha" => "2018"
                        "volumen" => "32"
                        "paginaInicial" => "768"
                        "paginaFinal" => "773"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib0430"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Point-of-care ultrasound in pediatric anesthesia&#58; perioperative considerations"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ACO.0000000000000852"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Anaesthesiol"
                        "fecha" => "2020"
                        "volumen" => "33"
                        "paginaInicial" => "343"
                        "paginaFinal" => "353"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib0435"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Transtracheal jet oxygenation&#58; Comparing the efficacy and safety of two self-made Y-connector devices with the ENK oxygen flow modulatorTM in an infant animal model"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.13687"
                      "Revista" => array:5 [
                        "tituloSerie" => "Pediatr Anesth"
                        "fecha" => "2019"
                        "volumen" => "29"
                        "paginaInicial" => "799"
                        "paginaFinal" => "807"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib0440"
              "etiqueta" => "88"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Transtracheal jet ventilation in the &#8220;can&#8217;t intubate can&#8217;t oxygenate&#8221; emergency&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aew192"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2016"
                        "volumen" => "117 Suppl 1"
                        "paginaInicial" => "i28"
                        "paginaFinal" => "38"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            88 => array:3 [
              "identificador" => "bib0445"
              "etiqueta" => "89"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Emergency ventilation of infant subglottic stenosis through small-gauge lumen using the ventrain&#58; a case report"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1213/XAA.0000000000000657"
                      "Revista" => array:7 [
                        "tituloSerie" => "A A Pract"
                        "fecha" => "2018"
                        "volumen" => "10"
                        "paginaInicial" => "136"
                        "paginaFinal" => "138"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib0450"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Difficult airway consultation service for children&#58; steps to implement and preliminary results"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12625"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2015"
                        "volumen" => "25"
                        "paginaInicial" => "363"
                        "paginaFinal" => "371"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            90 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "91"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tracheal extubation in children with difficult airways&#58; a descriptive cohort analysis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pan.12837"
                      "Revista" => array:6 [
                        "tituloSerie" => "Paediatr Anaesth"
                        "fecha" => "2016"
                        "volumen" => "26"
                        "paginaInicial" => "372"
                        "paginaFinal" => "377"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            91 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "92"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "DAS Extubation Guidelines&#46; Difficult Airway Society&#46; 2020&#46; Available from&#58; <a target="_blank" href="https://das.uk.com/content/das-extubation-guidelines">https&#58;&#47;&#47;das&#46;uk&#46;com&#47;content&#47;das-extubation-guidelines</a>&#46; &#91;Accessed 3 August 2020&#93;&#46;"
                ]
              ]
            ]
            92 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "93"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Difficult Airway Society Guidelines for the management of tracheal extubation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2044.2012.07075.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesthesia"
                        "fecha" => "2012"
                        "volumen" => "67"
                        "paginaInicial" => "318"
                        "paginaFinal" => "340"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack627842"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par1225" class="elsevierStylePara elsevierViewall">We would like to thank Dr&#46; Ricard Valero&#44; Dr&#46; Anna Lopez&#44; Dr&#46; Silvia Bermejo&#44; Dr&#46; Rosa Villalonga&#44; and Dr&#46; Nuria Montferrer for their valuable contributions and for their help in preparing this manuscript&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/23411929/0000006900000008/v1_202209300620/S2341192922001317/v1_202209300620/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "47200"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Special article"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006900000008/v1_202209300620/S2341192922001317/v1_202209300620/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922001317?idApp=UINPBA00004N"
]
Indexed in:

Follow us:

Subscribe:

Article

Indexed in:

Follow us:

Subscribe:

Article

Subscribe to our newsletter
