Thomas Riva

Background: Trauma is a leading cause of death in children. Paediatric patients comprise only a small fraction of HEMS missions. Little is known about the diagnostic accuracy of prehospital and in-hospital diagnoses in a large physician-staffed HEMS. Methods: This observational multicentre study included paediatric trauma patients ≤ 16 years treated by the Swiss Air-Rescue between 28/10/2021 and 20/08/2024. We included all primary missions with a National Advisory Committee for Aeronautics (NACA) score of ≥ 3 (i.e. moderate to severe trauma) transported to three paediatric trauma centres or declared dead on-scene. Data were obtained from the HEMS database and the hospital discharge report. The primary outcome was diagnostic accuracy between the prehospital and in-hospital diagnoses, measured with Cohen’s kappa. Secondary outcomes included patient characteristics, interventions, and survival. Results: We screened 1,531 eligible missions, of which 282 met inclusion criteria. Median age was 8.3 [IQR 3.5–12.1] years, and 163 (57.8%) were male. Most missions had a NACA score of 3 [IQR 3–4] and were during the daytime (90.4%). Ten patients were declared dead on-scene. Tracheal intubation was performed in 7.5% of the patients. Cohen’s kappa of the diagnostic accuracy between prehospital and in-hospital diagnoses was 0.64 (95%CI 0.58–0.70). Polytrauma was underdiagnosed; in contrast, injuries to the extremity, pelvis and traumatic brain injury were overdiagnosed. Overall survival to hospital discharge and at 1 year after trauma was 92.2%. Conclusions: Paediatric trauma in this cohort was characterised by a high incidence of high-velocity injuries. The prehospital diagnosis correlated substantially with the in-hospital diagnosis, supporting the clinical value of HEMS physicians to correctly triage paediatric patients. Documentation of vital signs was heterogeneous. Hospital survival and 1-year survival were high in this cohort. However, polytrauma remained underdiagnosed and should be targeted to improve prehospital care for paediatric trauma. Trial registration: N/A.

Background: Neuromuscular blocking agents are recommended by the European Society of Anaesthesiology and Intensive Care (ESAIC) and European Society of Paediatric Anaesthesia (ESPA) for facilitating tracheal intubation in children. Despite these recommendations, real‐world data on how neuromuscular blocking agents are used, monitored, and reversed remain scarce. Aims: To identify and characterize self‐reported neuromuscular blocking agent practice patterns across European and non‐European countries, in the period preceding publication of the joint ESAIC and ESPA guidelines. Methods: We conducted an anonymous, cross‐sectional survey between 12 November and 12 December 2025, targeting members of the ESAIC, ESPA, and the French and Spanish national pediatric anesthesiology societies involved in pediatric airway management across 43 countries. Results: The survey was accessed by 904 persons, and 874 responses were included in the analysis. Most participants were from Europe (83.5%) and worked in mixed pediatric anesthesia and intensive care settings (71.2%). Rocuronium was the most frequently used neuromuscular blocking agent for both routine tracheal intubation (68%; 95% CI 65%–71%) and rapid sequence intubation (67%; 95% CI 64%–70%). Neuromuscular blocking agents were used “always” or “mostly” before routine intubation in 47% of neonates (≤ 30 days) and 50% of infants (< 1 year), whereas “rarely” or “never” use was reported in 30% and 24%, respectively. Most respondents (56%) assessed adequacy of neuromuscular block using a fixed time interval after neuromuscular blocking agent administration. Reversal was administered “always” before extubation by 27% of respondents, while 9.3% reported “rarely” and 2.9% “never.” Only half of participants used quantitative neuromuscular monitoring to guide reversal. Sugammadex was used by 47%. Conclusions: Self‐reported clinical practice regarding neuromuscular blocking agent use in pediatric patients remains heterogeneous. Children are frequently intubated without neuromuscular blocking agents and extubated without consistent reversal. Quantitative neuromuscular monitoring remains uncommon. These practice patterns raise concerns for patient safety.

Purpose of review: Airway management in paediatric patients carries a high risk of respiratory complications, particularly in neonates and infants. The role of neuromuscular blocking agents (NMBAs) has evolved substantially, with increasing evidence supporting their use to optimise facemask ventilation and tracheal intubation when spontaneous breathing is not required. This review is timely as new pharmacological options and monitoring strategies have emerged to improve safety in this vulnerable population. Recent findings: Evidence from randomised trials, observational studies, and international guidelines suggests that NMBAs improve first-attempt intubation success, suppress airway reactivity, and reduce perioperative respiratory adverse events. In neonates and infants, rocuronium improves intubation conditions, and the recent approval by the Food and Drug Administration of sugammadex for use in children below two years of age expands reversal options and enhances patient safety. Despite this, residual neuromuscular block remains common, especially in the absence of objective monitoring. Quantitative neuromuscular monitoring provides superior detection of incomplete recovery compared with clinical or qualitative methods. Summary: NMBAs are a key component of paediatric airway management when spontaneous ventilation is unnecessary. Routine integration of quantitative monitoring and appropriate pharmacological reversal is essential to reduce residual block and improve patient safety.

Background: Although clinical trials are fundamental to advancing evidence‐based practice, significant heterogeneity in outcome reporting poses a considerable challenge to the validity of systematic reviews. This inconsistency impedes the ability to compare, synthesise and interpret research findings effectively. In the field of paediatric airway management, this issue is particularly relevant because of the low incidence of critical events and the related high morbidity and mortality. The issue of inadequate and variable outcome reporting in clinical trials has been widely acknowledged, necessitating initiatives to enhance the quality of future research. Objective: This protocol delineates the methodology used for the development of standardised, consensus‐based outcome definitions and reporting items specifically tailored to paediatric airway management trials. The goal is to create guidance that will serve as an extension to the established SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) frameworks, leading to enhanced trial reproducibility and transparency and ultimately improve pediatric airway research, systematic reviews and advance patient care and safety. Methods: This project will adhere to the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network's framework for guideline development. The methodology will be structured into four distinct phases: (1) a scoping review to comprehensively identify outcomes and variables currently reported in paediatric airway management trials; (2) a three‐round Delphi process involving a multidisciplinary panel of experts to prioritise and refine outcomes and variables; (3) a consensus meeting to achieve agreement on the final set of reporting items, which will then be prepared for publication and (4) dissemination. Conclusions: The finalised outcome reporting guidelines, in the form of SPIRIT and CONSORT extensions for paediatric airway management, will be disseminated through various channels to maximise their reach and impact. These include publication in peer‐reviewed journals, presentation at major international conferences and submission to relevant international reporting registries, such as the EQUATOR, SPIRIT and CONSORT registries. Active engagement with key stakeholders, including journal editors, research funders, regulatory bodies and clinician networks and national and international societies, will be a crucial component of the dissemination strategy.

Summary: Introduction: larynGuide™ is a novel assistive software integrated with the C‐MAC ^® videolaryngoscope, which provides guidance during laryngoscopy and advises on tracheal tube position. This first in‐human study evaluated the accuracy and reliability of larynGuide compared with the judgment of the airway operator. Methods: This prospective, single‐centre, investigator‐initiated, observational study included adult patients undergoing elective surgery requiring general anaesthesia with tracheal intubation. After informed consent and standardised induction of anaesthesia, laryngoscopy and tracheal intubation were performed with a C‐MAC ^® videolaryngoscope with a Macintosh blade by a board‐certified anaesthetist. larynGuide ran on a second screen, visible only to the study team but blinded to the airway operator. After tracheal intubation attempts, the airway operator confirmed tracheal tube placement visually and with capnography. The primary outcome was the real‐time accuracy of larynGuide in identifying correct tracheal tube placement. Results: We enrolled 132 patients, of whom 110 were analysed. Of 108 patients with correctly placed tracheal tubes, larynGuide identified 102 (sensitivity 0.94, 95%CI 0.88–0.98). In six patients, the software misclassified tracheal tube position: two false negatives (i.e. the software advised a failed tracheal intubation despite correct placement); and four patients with no feedback. Among two patients with unsuccessful tracheal intubation due to oesophageal tube placement at the first attempt, larynGuide detected one. Discussion: This first in‐human study has established the feasibility of AI‐guided real‐time tracheal intubation using larynGuide. The software showed promising sensitivity, while specificity was limited. Videolaryngoscopy image quality issues, including fogging and poor visibility, impaired the performance of the software.

Background: High‐flow oxygen in children prolongs the apnea time. The exact mechanism remains unclear. Aims: This study investigated whether low‐ and high‐flow nasal oxygen are non‐inferior to very high‐flow oxygen in preventing lung volume loss during apnoea in children under general anesthesia. We also examined whether early onset oxygen using the Optiflow Switch cannula reduces lung volume loss compared to conventional late‐onset application. Finally, we assessed the timing and regional distribution of lung volume changes using electrical impedance tomography (EIT). Methods: We conducted a single center randomized controlled non‐inferiority trial. After Ethics Committee approval and informed consent, we recruited 108 children (ASA1 and 2, 10–20 kg) undergoing elective general anesthesia. The primary endpoint was the normalized reduction in lung volume in relation to body weight (mL kg ⁻¹ ) after termination of facemask ventilation from start to end of apnoea measured with EIT. After induction of anesthesia and neuromuscular blockade, patients were left apnoeic for 5 min receiving humidified and heated oxygen with a high‐flow system at different flow rates: (1) Low‐flow 0.2 L min ⁻¹ kg ⁻¹ ; (2) High‐flow 2 L min ⁻¹ kg ⁻¹ ; (3) Very high‐flow 4 L min ⁻¹ kg ⁻¹ (control group); (4) Early onset of high‐flow 2 L min ⁻¹ kg ⁻¹ with Optiflow Switch. Normalization of impedance change to 6–8 mL kg ⁻¹ in relation to body weight and changes in lung volume from start to end of apnoea were measured. Results: 89/108 children were analyzed (low‐flow n = 20, high‐flow n = 24, very high‐flow n = 21 and early onset high‐flow n = 24.). The estimated mean (95% CI) reduction in lung volume was: low‐flow 5.9 (5.3–7.8) mL kg ⁻¹ , high‐flow 6.5 (5.3–7.8) mL kg ⁻¹ , very high‐flow (control) 5.7 (4.4–7.0) mL kg ⁻¹ , and early onset high‐flow 6.7 (5.5–7.9) mL kg ⁻¹ . Non‐inferiority could be demonstrated only for the low‐flow group compared to the control group. Conclusions: Apnoeic oxygenation with low‐flow is non‐inferior to very high‐flow regarding lung volume loss in children. An early onset of apnoeic oxygenation after facemask ventilation may delay lung volume loss during apnoea.