- Design
- Multicentre retrospective registry cohort with propensity weighting
- Population
- 4,878 anaesthetics in children with airway hyperresponsiveness at 12 centres
- Primary outcome
- Respiratory adverse events during induction-phase airway management
- Effect
- Adjusted RR 0.41 (0.19-0.62) for supraglottic airway vs intubation
A retrospective registry analysis from 12 Japanese tertiary centres (BJA, 29 September 2026) studied 4,878 general anaesthetics in children with an active or recent (within 14 days) upper respiratory infection, an asthma exacerbation or household smoke exposure. 38% had a supraglottic airway and 62% tracheal intubation at induction.
After inverse probability weighting, supraglottic airway use was associated with fewer respiratory adverse events (adjusted RR 0.41, 95% CI 0.19-0.62), fewer airway management-related events (0.32, 0.19-0.45) and less severe desaturation (0.47, 0.19-0.75).
These are the children in whom perioperative respiratory events most often occur, and instrumenting the trachea is a strong trigger for laryngospasm and bronchospasm. The finding fits that logic and earlier work in other paediatric groups. It is observational, so children who were intubated may have had operations or features that made them riskier, but the size of the association is large.
Where the procedure allows, these data support a supraglottic airway as the default for a child with a recent cold or reactive airways, with intubation kept for the cases that need it.
- Consider a supraglottic airway first for children with a recent cold, asthma exacerbation or smoke exposure
- Keep tracheal intubation for procedures or patients that clearly need it
- Have an experienced paediatric anaesthetist manage the airway in these children
- Prepare for laryngospasm and bronchospasm whatever device is used
Why it matters
It gives large-scale support for an airway choice that can reduce the commonest serious paediatric anaesthetic complication.
Don't overread it
Observational registry data - residual confounding by case type is possible.
The statistics, in plain English
An adjusted RR of 0.41 means respiratory events were about 60% less frequent. Weighting balances the measured differences between groups, but cannot account for reasons not recorded in the registry for choosing intubation.
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