We thank Dr. Horvath for his correspondence1  regarding our study of the association between infant laryngoscopy attempts and hypoxemia.2  We agree that infants experience higher risks of respiratory adverse events during tracheal intubation than adults. Although the American Society of Anesthesiologists (Schaumburg, Illinois; ASA) provides definitions and clinical examples to guide the use of the ASA Physical Status system, Dr. Horvath states correctly that a patient’s age is not considered.3  Dr. Horvath’s suggestion of updating the definitions for the ASA Physical Status system for pediatric patients is worthy of discussion. Assigning ASA Physical Status II to healthy infants because of higher rates of adverse events during tracheal intubation might be problematic. First, the purpose of the ASA Physical Status classification system is to communicate the patient’s medical comorbidities, not their anesthetic risk. Second, if age were considered a comorbidity then one would have to assign a higher status for patients at both extremes of age, not just infants. Finally, a rapid sequence induction in a child increases the risk of hypoxemia during laryngoscopy, yet ASA Physical Status is not typically adjusted because of a plan for rapid sequence induction. There are many clinical scenarios wherein infants may be classified appropriately as ASA Physical Status I, such as a 3-month-old patient undergoing a circumcision. Although direct laryngoscopy can be challenging in infants, there are alternatives for establishing an airway, including supraglottic airways and video laryngoscopy, that may be less challenging than direct laryngoscopy.

In summary, we share Dr. Horvath’s concerns about the need to document and communicate the higher incidence of adverse events in infants; however, we do not feel that ASA Physical Status is the right tool. We welcome further ideas to address this in the future.

Dr. Fiadjoe discloses funding from The Anesthesia Patient Safety Foundation (Rochester, Minnesota). The other authors declare no competing interests.

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