Search

Summary: While videolaryngoscopy has resulted in better overall success rates of tracheal intubation, airway assessment is still an important prerequisite for safe airway management. This study aimed to create an artificial intelligence model to identify difficult videolaryngoscopy using a neural network. Baseline characteristics, medical history, bedside examination and seven facial images were included as predictor variables. ResNet‐18 was introduced to recognise images and extract features. Different machine learning algorithms were utilised to develop predictive models. A videolaryngoscopy view of Cormack‐Lehane grade of 1 or 2 was classified as 'non‐difficult', while grade 3 or 4 was classified as 'difficult'. A total of 5849 patients were included, of whom 5335 had non‐difficult and 514 had difficult videolaryngoscopy. The facial model (only including facial images) using the Light Gradient Boosting Machine algorithm showed the highest area under the curve (95%CI) of 0.779 (0.733–0.825) with a sensitivity (95%CI) of 0.757 (0.650–0.845) and specificity (95%CI) of 0.721 (0.626–0.794) in the test set. Compared with bedside examination and multivariate scores (El‐Ganzouri and Wilson), the facial model had significantly higher predictive performance (p < 0.001). Artificial intelligence‐based facial analysis is a feasible technique for predicting difficulty during videolaryngoscopy, and the model developed using neural networks has higher predictive performance than traditional methods. [ABSTRACT FROM AUTHOR]

Summary: Children with difficult tracheal intubation are at increased risk of severe complications, including hypoxaemia and cardiac arrest. Increasing experience with the simultaneous use of videolaryngoscopy and flexible bronchoscopy (hybrid) in adults led us to hypothesise that this hybrid technique could be used safely and effectively in children under general anaesthesia. We reviewed observational data from the international Pediatric Difficult Intubation Registry from 2017 to 2021 to assess the safety and efficacy of hybrid tracheal intubation approaches in paediatric patients. In total, 140 patients who underwent 180 attempts at tracheal intubation with the hybrid technique were propensity score‐matched 4:1 with 560 patients who underwent 800 attempts with a flexible bronchoscope. In the hybrid group, first attempt success was 70% (98/140) compared with 63% (352/560) in the flexible bronchoscope group (odds ratio (95%CI) 1.4 (0.9–2.1), p = 0.1). Eventual success rates in the matched groups were 90% (126/140) for hybrid vs. 89% (499/560) for flexible bronchoscope (1.1 (0.6–2.1), p = 0.8). Complication rates were similar in both groups (15% (28 complications in 182 attempts) hybrid; 13% (102 complications in 800 attempts) flexible bronchoscope, p = 0.3). The hybrid technique was more likely than flexible bronchoscopy to be used as a rescue technique following the failure of another technique (39% (55/140) vs. 25% (138/560), 2.1 (1.4–3.2) p < 0.001). While technically challenging, the hybrid technique has success rates similar to other advanced airway techniques, few complications and may be considered an alternative technique when developing an airway plan for paediatric patients whose tracheas are difficult to intubate under general anaesthesia. [ABSTRACT FROM AUTHOR]

Summary: In thyroid surgery, intra‐operative neuromonitoring signals of the recurrent laryngeal nerve can be detected by surface electrodes on a tracheal tube positioned at the vocal fold level. The incidence of difficult tracheal intubation in patients undergoing thyroidectomy for nodular goitre ranges from 5.3% to 20.5%. The aim of this study was to compare videolaryngoscopy with conventional direct laryngoscopy as methods for proper placement of the surface electrode to prevent insufficient intra‐operative nerve signal quality. In this prospective randomised trial, adult patients requiring tracheal intubation during thyroid surgery were randomly allocated to two groups of C‐MAC® (Macintosh style blade) videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. Primary outcome was the incidence of insufficient signal electromyogram amplitude level (< 500 μV) after successful tracheal intubation. A total of 260 (130 per group) participants were analysed. An insufficient signal was more frequent with direct laryngoscopy (35/130, 27%), compared with C‐MAC (12/130, 9%, p < 0.001). First‐pass tracheal intubation success rate was lower with direct laryngoscopy (86/130 (66%)) compared with the C‐MAC (125/130 (96%)) (p < 0.0001). Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (16/130 (12%)), compared with the C‐MAC (0/130, (0%)) (p < 0.0001). The results suggest that videolaryngoscopy has an impact on the quality of the initial intra‐operative neuromonitoring signal in patients undergoing thyroid surgery, and this technique can provide optimised surface electrode positioning. [ABSTRACT FROM AUTHOR]

Summary: We conducted a narrative review in six areas of obstetric emergencies: category‐1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high‐flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest. [ABSTRACT FROM AUTHOR]

Difficult airway management continues to adversely affect patient care and clinical outcomes and is poorly predicted. Previous difficult airway management is the most accurate predictor of future difficulty. The Difficult Airway Society initiated a national airway database to allow clinicians to access details of previous difficult airway episodes in patients issued with a difficult airway alert card. We aimed to analyse this database, reporting patient characteristics, airway management and patient outcomes. We included all living adult patients reported in the first 5 years of the database (n = 675). Clinical airway assessment was reported in 634 (94%) patients, with three or more parameters assessed in 488 (72%). A history of difficult airway was known in 136 (20%) patients and difficult airway management was anticipated in 391 (58%). In all, 75 (11%) patients had an airway-related critical incident, with 1 in 29 being awoken from anaesthesia, 1 in 34 requiring unplanned or prolonged stay in the intensive care unit and 1 in 225 needing an emergency front-of-neck airway or had a cardiac arrest/peri-arrest episode. Airway-related critical incidents were associated with out-of-hours airway management, but no other associations were apparent. Our data report the first analysis of a national difficult airway database, finding that unanticipated difficult airway management continues to occur despite airway assessment, and the rate of critical incidents in this cohort of patients is high. This database has the potential to improve airway management for patients in the future. [ABSTRACT FROM AUTHOR]

In anaesthetised patients, Barker et al. used a fibreoptic laryngoscope and found the angle formed by the vocal cords decreased after induction of anaesthesia with both thiopentone and propofol before neuromuscular blockade [20]. Furthermore, patients with a predicted difficult airway were excluded, and hence, the findings are not generalisable beyond the study population, although there is no reason to believe that the vocal cords would react differently to neuromuscular blockade in these patients. Keywords: airway management; difficult airway; facemask ventilation; neuromuscular blockade; vocal cords EN airway management difficult airway facemask ventilation neuromuscular blockade vocal cords 949 952 4 08/04/22 20220901 NES 220901 Facemask ventilation is the cornerstone of airway management, and establishing its adequacy represents a critical decision branch-point in difficult airway algorithms. [Extracted from the article]

Summary: We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high‐flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management. [ABSTRACT FROM AUTHOR]

Summary: Obesity is an increasingly prevalent comorbidity within the UK population. The aim of this study was to determine the proportion of obese patients in an elective surgical population. The second aim was to determine the choice of airway equipment and incidence of airway events in obese vs. non‐obese patients. We conducted a cross‐sectional observational study over two 24‐h periods in March 2018 across 39 hospitals in the greater London area. Data were collected regarding 1874 patients. The incidence of obesity was 32% in the study population compared with 26% in the general UK population (p < 0.0001). Minor airway events were defined as: desaturation to SpO2 < 90%; failed mask ventilation; supraglottic airway device problem; aspiration; airway trauma and difficult intubation; or recognised oesophageal intubation. Major airway events were defined as: unrecognised oesophageal intubation; a 'cannot intubate cannot oxygenate' emergency; the need for unplanned front‐of‐neck airway; cardiac arrest; or unplanned intensive care unit admission due to an airway event. In total, 89 minor and two major airway events were recorded. Obese patients were more likely to experience a minor airway event (RR 2.39, 95%CI 1.60–3.57), the most common being desaturation (SpO2 < 90%). The use of a supraglottic airway device in obese vs. non‐obese patients was associated with increased airway events (RR 3.46 [1.88–6.40]). Tracheal intubation vs. supraglottic airway device use increased with obesity class but was not associated with a decrease in airway events (RR 0.90 [0.53–1.55]). Our data suggest that obesity is more common in the elective surgical vs. general population and minor airway events are more common in obese vs. non‐obese elective patients. [ABSTRACT FROM AUTHOR]

Keywords: airway management; difficult airway; guidelines; tracheal intubation EN airway management difficult airway guidelines tracheal intubation 991 994 4 06/05/21 20210701 NES 210701 It could not be timelier to reflect on the Difficult Airway Society (DAS) 2004 difficult airway guidelines - or as they were back then, simply "The DAS Guidelines" [1]. This structure for airway trolleys was extended further in the 2015 DAS guidelines [15], with specifically designed trolley drawer signs included in the supplementary information and on the DAS website. Several years later, during the review process of the 4th National Audit Project (NAP4) of the RCoA and DAS [7,8], Adrian Pearce was the main voice emphasising time and again that good airway management was founded on an airway strategy rather than a plan. It is perhaps a recognition of both how far DAS has progressed, and the acceptance of the value of its guidelines, that at the start of the COVID-19 pandemic in 2020, it was to DAS that the anaesthetic and critical care organisations turned for rapid delivery of pandemic-specific airway management guidelines [22-24]. [Extracted from the article]

Summary: Transnasal humidified rapid insufflation ventilatory exchange prolongs safe apnoeic oxygenation time in children. In adults, transnasal humidified rapid insufflation ventilatory exchange is reported to have a ventilatory effect with PaCO2 levels increasing less rapidly than without it. This ventilatory effect has yet to be reproduced in children. In this non‐inferiority study, we tested the hypothesis that children weighing 10–15 kg exhibit no difference in carbon dioxide clearance when comparing two different high‐flow nasal therapy flow rates during a 10‐min apnoea period. Following standardised induction of anaesthesia including neuromuscular blockade, patients were randomly allocated to high‐flow nasal therapy of 100% oxygen at 2 or 4 l.kg−1.min−1. Airway patency was ensured by continuous jaw thrust. The study intervention was terminated for safety reasons when SpO2 values dropped < 95%, or transcutaneous carbon dioxide levels rose > 9.3 kPa, or near‐infrared spectroscopy values dropped > 20% from their baseline values, or after an apnoeic period of 10 min. Fifteen patients were included in each group. In the 2 l.kg−1.min−1 group, mean (SD) transcutaneous carbon dioxide increase was 0.46 (0.11) kPa.min−1, while in the 4 l.kg−1.min−1 group it was 0.46 (0.12) kPa.min−1. The upper limit of a one‐sided 95%CI for the difference between groups was 0.07 kPa.min−1, lower than the predefined non‐inferiority margin of 0.147 kPa.min−1 (p = 0.001). The lower flow rate of 2 l.kg−1.min−1 was non‐inferior to 4 l.kg−1.min−1 relative to the transcutaneous carbon dioxide increase. In conclusion, an additional ventilatory effect of either 2 or 4 l.kg−1.min−1 high‐flow nasal therapy in apnoeic children weighing 10–15 kg appears to be absent. [ABSTRACT FROM AUTHOR]

Summary: Transnasal humidified rapid insufflation ventilatory exchange prolongs safe apnoeic oxygenation time in children. In adults, transnasal humidified rapid insufflation ventilatory exchange is reported to have a ventilatory effect with PaCO2 levels increasing less rapidly than without it. This ventilatory effect has yet to be reproduced in children. In this non‐inferiority study, we tested the hypothesis that children weighing 10–15 kg exhibit no difference in carbon dioxide clearance when comparing two different high‐flow nasal therapy flow rates during a 10‐min apnoea period. Following standardised induction of anaesthesia including neuromuscular blockade, patients were randomly allocated to high‐flow nasal therapy of 100% oxygen at 2 or 4 l.kg−1.min−1. Airway patency was ensured by continuous jaw thrust. The study intervention was terminated for safety reasons when SpO2 values dropped < 95%, or transcutaneous carbon dioxide levels rose > 9.3 kPa, or near‐infrared spectroscopy values dropped > 20% from their baseline values, or after an apnoeic period of 10 min. Fifteen patients were included in each group. In the 2 l.kg−1.min−1 group, mean (SD) transcutaneous carbon dioxide increase was 0.46 (0.11) kPa.min−1, while in the 4 l.kg−1.min−1 group it was 0.46 (0.12) kPa.min−1. The upper limit of a one‐sided 95%CI for the difference between groups was 0.07 kPa.min−1, lower than the predefined non‐inferiority margin of 0.147 kPa.min−1 (p = 0.001). The lower flow rate of 2 l.kg−1.min−1 was non‐inferior to 4 l.kg−1.min−1 relative to the transcutaneous carbon dioxide increase. In conclusion, an additional ventilatory effect of either 2 or 4 l.kg−1.min−1 high‐flow nasal therapy in apnoeic children weighing 10–15 kg appears to be absent. [ABSTRACT FROM AUTHOR]

We reviewed the literature on management of general and regional anaesthesia in pregnant women with anticipated airway difficulty. We identified 138 publications comprising 158 cases; these either described equipment or techniques for the provision of general anaesthesia, or the management of women with regional analgesia or anaesthesia, with the aim of avoiding general anaesthesia. Most of the former group described women requiring caesarean section alone, or in combination with other surgery, which was sometimes airway-related. Management techniques were largely similar to those in non-obstetric patients requiring surgery who have airway difficulties, although suggested differences related to physiological changes of pregnancy and avoidance of nasal intubation. In the reports discussing regional anaesthesia, consideration was often given to the possible requirement for urgent out-of-hours anaesthetic intervention, and the predicted difficulty of management of general anaesthesia should it be required. In a number of reported cases, multidisciplinary planning led to the conclusion that elective caesarean section should be performed in order to avoid emergency airway management. Based on this literature review, we advise antenatal planning that includes: assessment of the patient's clinical characteristics; consideration of the equipment and personnel available to provide safe airway management out-of-hours; and elective caesarean section should these be lacking. If general anaesthesia is required, a risk assessment must be made as to the probability of safe airway management after the induction of anaesthesia, and awake tracheal intubation should be used if this cannot be assured. Decision aids are provided to illustrate these points. Online appendices include a comprehensive compendium of case reports on the management of a number of rare syndromes and airway conditions. [ABSTRACT FROM AUTHOR]

Severe acute respiratory syndrome-corona virus-2, which causes coronavirus disease 2019 (COVID-19), is highly contagious. Airway management of patients with COVID-19 is high risk to staff and patients. We aimed to develop principles for airway management of patients with COVID-19 to encourage safe, accurate and swift performance. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID-19, drawing on published literature and immediately available information from clinicians and experts. Recommendations on the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required and the selection of equipment are discussed. The fundamental principles of airway management in these settings are described for: emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. We provide figures to support clinicians in safe airway management of patients with COVID-19. The advice in this document is designed to be adapted in line with local workplace policies. [ABSTRACT FROM AUTHOR]

Newer modalities for asleep airway management such as videolaryngoscopes and supraglottic airway devices have further advanced safe airway management but have not replaced awake tracheal intubation. However, time itself should not be the determining factor in cases where awake tracheal intubation is considered the safest approach, and the alternative, tracheal intubation attempt after induction of anaesthesia in a predicted difficult airway patient may well take longer, and bears the concomitant increased risk of having to revert to emergency front-of-neck access. It seems prudent to consider the nature of the pathology in these patients and come to a reassurance that asleep airway management is safe before induction of anaesthesia, and if not, then choose awake tracheal intubation. Yes, awake tracheal intubation with FB or VL may be difficult, or impossible, in the bleeding patient, but if the airway examination indicates an anatomically difficult airway then an awake approach, either awake tracheal intubation or awake front-of-neck access, is definitively as indicated as it would have been had the airway not been bleeding - or even more so [13]. [Extracted from the article]

The article focuses on the difficulty associated with airway assessment in an operation theatre in the field of medical care. It talks about the importance of screening for airway assessment during surgeries in hospitals . It tells about the airway assessment being done in patient undergoing general anaesthesia inorder to manage the airway passage and gas exchange during sedation.

Although bedside screening tests are routinely used to identify people at high risk of having a difficult airway, their clinical utility is unclear. We estimated the diagnostic accuracy of commonly used bedside examination tests for assessing the airway in adult patients without apparent anatomical abnormalities scheduled to undergo general anaesthesia. We searched for studies that reported our pre-specified bedside index screening tests against a reference standard, published in any language, from date of inception to 16 December 2016, in seven bibliographic databases. We included 133 studies (127 cohort type and 6 case-control) involving 844,206 participants. Overall, their methodological quality (according to QUADAS-2, a standard tool for assessing quality of diagnostic accuracy studies) was moderate to high. Our pre-specified tests were: the Mallampati test (6 studies); modified Mallampati test (105 studies); Wilson risk score (6 studies); thyromental distance (52 studies); sternomental distance (18 studies); mouth opening test (34 studies); and the upper lip bite test (30 studies). Difficult facemask ventilation, difficult laryngoscopy, difficult intubation and failed intubation were the reference standards in seven, 92, 50 and two studies, respectively. Across all reference standards, we found all index tests had relatively low sensitivities, with high variability, but specificities were consistently and markedly higher than sensitivities. For difficult laryngoscopy, the sensitivity and specificity (95%CI) of the upper lip bite test were 0.67 (0.45-0.83) and 0.92 (0.86-0.95), respectively; upper lip bite test sensitivity (95%CI) was significantly higher than that for the mouth opening test (0.22, 0.13-0.33; p < 0.001). For difficult tracheal intubation, the modified Mallampati test had a significantly higher sensitivity (95%CI) at 0.51 (0.40-0.61) compared with mouth opening (0.27, 0.16-0.41; p < 0.001) and thyromental distance (0.24, 0.12-0.43; p < 0.001). Although the upper lip bite test showed the most favourable diagnostic test accuracy properties, none of the common bedside screening tests is well suited for detecting unanticipated difficult airways, as many of them are missed. [ABSTRACT FROM AUTHOR]

An editorial is presented on the impact of human factors on clinical performance during airway emergencies. Topics discussed include limiting devices strategy which involves the elimination of devices with same functions that reduces clutter and make the items more readily visible; and the importance of structured layout airway trolley and the integration of cognitive aids in it.

Recent controversy regarding the ethics of conducting airway research in patients led to disagreements concerning the value and frequency of manikin-based investigation. However, no formal examination of the methodology of airway research has been undertaken. We, therefore, performed a systematic bibliometric review of airway management research to describe the conduct, quantify the subjects (patient vs. manikin vs. other), assess the reported outcomes and map global trends. We retrieved 1505 relevant studies published between 2006 and 2017, together recruiting 359,648 subjects, of which 341,233 were patients, the remaining being volunteers or subjects managing manikins, human cadavers, animals or bench models. There were 701 randomised controlled clinical trials (46.6%), 83 non-randomised experimental clinical trials (5.5%), 298 observational studies (19.8%) and 423 non-patient studies (28.1%). A total of 1082 studies (71.9%) were patient studies and 322 were manikin studies (21.4%). The total annual number of airway management studies increased over time, as did the annual number of patient studies, but there was no significant increase in the annual number of manikin studies over time. Of the patient studies, subject baseline characteristics were most likely to be ASA status 1-2 (n = 531, 49.1%), populations were most often elective surgical patients (n = 918, 84.8%) and the most common interventions studied were tracheal intubation (n = 820, 54.4%) or supraglottic airway device insertion (n = 257, 17.1%). There was a total of 77 different primary outcomes used in the included studies, the most commonly reported being success rate and procedure time. By understanding how and what has been previously studied these data can be used to form the basis for future priority setting exercises, core outcome set development, and could inform strategy on the future directions of airway management research. [ABSTRACT FROM AUTHOR]

In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management. [ABSTRACT FROM AUTHOR]

The authors discuss practice implications of Difficult Airway Society (DAS) guidelines for airway management in critical illness. Topics discussed include the emphasis of the guidelines that the target group of patients is those who are "critically ill," barrier to strategic planning for airway management, and the focus of DAS on the development and investigation of devices.

The article focuses on the concept of visualisation and documentation of laryngeal anatomy related to tracheal intubation. It mentions that airway devices refer to the laryngeal view that can be obtained as an indicator of intubation difficulty. It focuses on anaesthetic chart as an indicator of future laryngeal views.

Despite being infrequent, complications of airway management remain an important contributor to morbidity and mortality during anaesthesia and care of the critically ill. Developments in the last three decades have made anaesthesia safer, and this has been mirrored in the equipment and techniques available for airway management. Modern technology including novel oxygenation modalities, widespread availability of capnography, second-generation supraglottic airway devices and videolaryngoscopy provide the tools to make airway management safer still. However, technology will only take safety so far, and non-technical aspects of airway management are critically important for communication and decision making during airway crises, acknowledging a 'cannot intubate, cannot oxygenate' situation and transitioning to emergency front of neck airway. Randomised controlled trials provide little useful information about safety in this setting, and data from registries and databases are likely to be of more value. This narrative review focuses on recent evidence in this area. [ABSTRACT FROM AUTHOR]

The authors comment on a prospective cohort study of awake fiberoptic intubation (AFOI) at a tertiary centre. They cite the challenge of acquiring and maintaining expertise to effectively manage AFOI. They also present an overview of the major findings of the study including various complications that were identified, the wide use of sedation during AFOI, and maintenance of exygenation during airway management.

Transnasal humidified rapid insufflation ventilatory exchange prolongs safe apnoeic oxygenation time in children. In adults, transnasal humidified rapid insufflation ventilatory exchange is reported to have a ventilatory effect with PaCO 2 levels increasing less rapidly than without it. This ventilatory effect has yet to be reproduced in children. In this non-inferiority study, we tested the hypothesis that children weighing 10-15 kg exhibit no difference in carbon dioxide clearance when comparing two different high-flow nasal therapy flow rates during a 10-min apnoea period. Following standardised induction of anaesthesia including neuromuscular blockade, patients were randomly allocated to high-flow nasal therapy of 100% oxygen at 2 or 4 l.kg -1 .min -1 . Airway patency was ensured by continuous jaw thrust. The study intervention was terminated for safety reasons when SpO 2 values dropped < 95%, or transcutaneous carbon dioxide levels rose > 9.3 kPa, or near-infrared spectroscopy values dropped > 20% from their baseline values, or after an apnoeic period of 10 min. Fifteen patients were included in each group. In the 2 l.kg -1 .min -1 group, mean (SD) transcutaneous carbon dioxide increase was 0.46 (0.11) kPa.min -1 , while in the 4 l.kg -1 .min -1 group it was 0.46 (0.12) kPa.min -1 . The upper limit of a one-sided 95%CI for the difference between groups was 0.07 kPa.min -1 , lower than the predefined non-inferiority margin of 0.147 kPa.min -1 (p = 0.001). The lower flow rate of 2 l.kg -1 .min -1 was non-inferior to 4 l.kg -1 .min -1 relative to the transcutaneous carbon dioxide increase. In conclusion, an additional ventilatory effect of either 2 or 4 l.kg -1 .min -1 high-flow nasal therapy in apnoeic children weighing 10-15 kg appears to be absent., (© 2020 Association of Anaesthetists.)

The occurrence of a thyroid gland superficially placed on the pharyngeal portion of the tongue is rare, but poses problems to the patient and anaesthetist. This report describes a patient with a lingual thyroid and a history of problems associated with it that resulted in admission to the ICU and warnings about future intubation of the larynx. The patient underwent awake tracheal intubation using a standard fibreoptic assisted technique, and was advised that she purchase an appropriate Medic-Alert bracelet. [ABSTRACT FROM AUTHOR]