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To prospectively identify complications related to airway management in children before pediatric intensive care unit (ICU) admission.A descriptive, prospective study covering an 18-month period. A survey was completed at the time of admission to obtain demographic data, reason for endotracheal (ET) intubation, medications administered, location of and personnel responsible for ET intubation, and major/minor variances associated with airway management. Major variances were defined as technical problems resulting in a significant risk for airway trauma and increased morbidity. Minor variances were problems that should be avoided, but which do not significantly increase the immediate risk to the patient. Additional information obtained included whether a chest radiograph (CXR) was obtained and if postextubation problems occurred, such as stridor requiring treatment or reintubation.Community hospitals, emergency rooms, children’s hospital emergency roomsAll children ≤18 yrs of age receiving ET intubation before admission to the pediatric ICU, except those in cardiovascular arrest.Data were collected on 250 consecutive patients. Major or minor variances were noted in 135 (54%) patients and in 66% of patients ≤1 yr of age (p = .02865; odds ratio, 2.0). Twenty-six percent of patients ≤1 yr of age received an anticholinergic agent before ET intubation compared with 40% of older patients (p = .04343; odds ratio, 0.504). Eleven patients received a neuromuscular blocking agent (NMBA) without a sedative/analgesic agent. Major variances occurred in 54% of patients who did not receive a NMBA and in 27% of patients who received a NMBA (p = .00002; odds ratio, 0.307). Forty-one patients (16%) were intubated with an inappropriately sized ET tube. Postintubation CXRs were obtained in 65% of patients managed outside of a children’s hospital and in 93% of patients in a children’s hospital emergency room (p < .00001; odds ratio, 7.199). Variances detectable by CXR went unrecognized in 40% of patients, despite obtaining a CXR.Emergency airway management in children can be fraught with problems. Most variances could be avoided by improved education regarding appropriate ET tube size, appropriate medication use, and improved training for evaluation of ET tube placement.