- Design
- multicentre retrospective registry cohort with propensity score-based inverse probability of treatment weighting
- Population
- 4,878 weighted encounters in children under 18 with airway hyperresponsiveness, from 27,844 registry encounters at 12 Japanese centres
- Primary outcome
- respiratory adverse events during induction-phase airway management
- Effect
- adjusted risk ratio 0.41 (95% CI 0.19-0.62); airway-management events 0.32 (0.19-0.45); severe desaturation 0.47 (0.19-0.75)
Twelve Japanese tertiary centres contributed to a paediatric difficult airway registry between July 2022 and February 2025. From 27,844 encounters, 4,878 children under 18 met the definition of airway hyperresponsiveness — an active upper respiratory tract infection, one within the preceding 14 days, an asthma exacerbation, or household smoking exposure. Of these, 3,005 (61.6%) were managed at induction with tracheal intubation and 1,873 (38.4%) with a supraglottic airway device. Propensity score-based inverse probability of treatment weighting was used to balance the groups.
After adjustment, supraglottic airway placement was associated with substantially fewer respiratory adverse events: adjusted risk ratio 0.41 (95% CI 0.19-0.62). Airway management-related adverse events gave 0.32 (0.19-0.45) and severe oxygen desaturation 0.47 (0.19-0.75). All three intervals sit well below 1.0.
The child with a runny nose on the morning of surgery is one of the most common decisions in paediatric anaesthesia, and it is usually framed as proceed or postpone. This reframes part of it: where the case can be done with a supraglottic airway, the device choice is itself a way of reducing risk in a child you have decided to proceed with. That is a more useful lever than the cancellation decision, because it is available on the day and costs nothing.
The limits are real and the authors state them. This is observational — anaesthetists chose the device, and the reasons they chose intubation for a particular child are exactly the reasons that child might have had a worse respiratory course. Weighting cannot remove that. Nor does this say a supraglottic airway is appropriate where the surgery demands intubation. What it supports is choosing the device when the case genuinely allows either.
- Where the procedure allows either, favour a supraglottic airway at induction in a child with a recent upper respiratory infection, asthma exacerbation or household smoke exposure
- Include household smoking exposure in the assessment of airway hyperresponsiveness, not only recent infection
- Do not use this to justify a supraglottic airway where the surgical position, duration or shared airway requires intubation
- Frame the on-the-day decision as device choice as well as proceed or postpone
- Keep the usual precautions — deep plane at placement, avoiding airway instrumentation at a light depth — which this study does not replace
Why it matters
The device decision is available on the day of surgery in a way the cancellation decision often is not.
Don't overread it
The anaesthetist chose the device, so children judged higher risk were more likely to be intubated — the real effect is probably smaller than this estimate.
The statistics, in plain English
An adjusted risk ratio of 0.41 with an interval from 0.19 to 0.62 sits entirely below 1.0, so the association is secure in direction and large in size. Inverse probability of treatment weighting balances the characteristics that were recorded, which is the best available tool here, but it cannot balance the clinical judgement that led an anaesthetist to intubate a particular child — and that judgement is likely to have tracked risk. That is residual confounding by indication, and it would bias the result in exactly the direction seen, so the true effect is probably smaller than 0.41.
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