Search

The selection of different examination sequences of painless gastroscopy in patients with difficult airway risk was explored in this study. A total of 45 patients undergoing painless gastroscopy with Mallampati airway score of III-IV were randomly assigned into two groups (A group and B group) according to the sequence of colonoscopy and gastroscopy. Group A was first examined by gastroscopy after anesthesia, and then by colonoscopy. Group B was examined in the opposite order, first by colonoscopy, and then by gastroscopy. Ramsay Sedation scores were evaluated every five minutes when gastroscopy was performed in the two groups. The dosage of propofol, blood pressure, heart rate, blood oxygen saturation, recovery time, hospital leaving time, and adverse reactions after induction and endoscopy were recorded. The dosage of propofol and change of vital signs in B group was less than that in A group. Operation time, recovery time, hospital leaving time and postoperative adverse reactions have no significant difference between two groups. For patients at risk of difficult airway, colonoscopy followed by gastroscopy has more stable intraoperative vital signs and less propofol consumption. [ABSTRACT FROM AUTHOR]

Background: Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. Methods: This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. Results: Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). Conclusions: Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. Trial registration: The study was registered in the German Register for Clinical Studies (number DRKS00028068). [ABSTRACT FROM AUTHOR]

Background: The definition of patients with special needs (SNs) is used in the literature to refer to individuals with mental and physical disorders for whom the usual perioperative pathways are not applicable due to lack of cooperation, regardless of age. Studies in the literature recognize the appropriateness of general anesthesia for performing day surgery dental care in this type of patient. Objectives: The main objective was to assess the possible incidence of difficult airway management, understood as difficulty ventilating and/or intubating the patient. A secondary objective was to highlight the influence of general anesthesia on patient outcomes by testing the incidence of perioperative complications. Methods: The present retrospective, single-center, observational study involved 41 uncooperative patients aged between 3 and 17 undergoing dental surgery under general anesthesia. Data relating to airway management and general anesthesia present in the medical records were analyzed. Results: Tracheal intubation was successfully completed in all of the patients considered, and in no case did the patient have to be woken up because of difficulty in airway management. No perioperative complications attributable to anesthesia were found in any patients. Conclusions: From the present experience, it can be concluded that general anesthesia is a suitable option for performing dental care in pediatric subjects with special needs, and that although the peculiar perioperative management of these patients might increase the risk of possible anesthesia-related side effects, no complications have been encountered in any case. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to undertake an anthropometric assessment and to compare the muscular strength of elite athletes with that of a control group to predict Mallampati classification. Material and Method: The study group consisted of elite track athletes, and the control group consisted of volunteers with similar characteristics. Anthropometric measurements of the hand, fingers, and wrist were made; handgrip strength and the pinch strength of the fingers were also measured. A serum biochemical analysis was then performed. Participants were divided into two groups: those with Modified Mallampati Scores (MMS) I and II, and those with III and IV. A partial correlation test was used to examine the correlations of the variables according to the MMS groups. Results: The study included 32 elite athletes and 42 volunteer participants. Serum Na level, fingertip to root digit 3 (FTR3), and FTR4 were significantly lower in males in MMS groups 3-4. Among all cases, wrist extension angle (WEA) was found to be significantly lower in MMS group 3-4. However, hand breadth at thumb (HBT), hand depth radial (HDR), breadth at the first joint of digit 2 (BFJD2), pinch strength of thumb (PST), and PSLF were significantly higher in MMS groups 3-4. Among these variables, HBT, BFJD2, PST, and PSLF were significantly higher in elite athletes, but HDR was similar between the study groups. MMS groups showed the highest correlation with the pinch strength of the thumb. Conclusion: The pinch strength of the thumb and little finger was determined as the most important predictors for the MMS group rather than the handgrip strength (HGS). [ABSTRACT FROM AUTHOR]

Difficult airway is a major life-threatening complication during induction of general anesthesia. In thyroid surgery, intubation could be complicated by airway distortion because of the enlarged thyroid gland. Recently, ultrasonography has been proposed as a potential modality for airway assessment and management. The aim of the study is to evaluate ultrasound-based measurement of airway parameters in 13 selected patients with compressive goiter and tracheal deviation scheduled for thyroidectomy before induction of general anesthesia. Specifically, we detected the distance between the skin and retro-isthmic trachea (DSRIT) and the distance between the sub isthmic trachea and the carotid artery (DCSIT) at the side of the dominant lobe. We compared ultrasound measures before intubation with Cormack-Lehane laryngoscopes grades recorded during tracheal intubation. [ABSTRACT FROM AUTHOR]

Abstract Background Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. Methods This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. Results Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). Conclusions Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. Trial registration The study was registered in the German Register for Clinical Studies (number DRKS00028068).

Arnold Chiari Malformation (ACM) is a group of deformities of the cranium and hindbrain, where there is herniation of cerebellar tonsils through the foramen magnum. Based on the morphology and degree of anatomic defects, Chiari malformations are categorised as type 1, 2, and 3, usually through imaging. While type 2 and 3 are more prevalent and occur in younger age groups, being present from birth, type 1 Chiari is the least severe and is more frequently found in adults. Numerous deformities, including spinal deformity, encephalocele, hydrocephalus, syrinx, and elevated intracranial pressure, are associated with it. Additionally, there are autonomic disturbances associated with it as well. As a result of all these factors, anaesthesiologists face significant challenges. Hereby, the authors present a case report of 52-year-old male patient of ACM type 1 associated with bony deformity at the craniovertebral junction and syrinx, who underwent cervical decompression with C1-C2 fixation. This patient had a tingling sensation and numbness in the left upper limb, with power in the left upper limb being 1/5 and progressive gait abnormalities. Additionally, the present patient had his right upper limb amputated below the elbow joint after a road traffic accident 10 years ago, which imposed more challenges regarding intravenous access. A well-thought-out, multidisciplinary approach is needed for its management. The management of adequate intraoperative anaesthesia in such cases will have an impact on the recovery after surgery of patients with ACM type 1.

Obesity is characterised by a body weight that surpasses the expected or ideal weight by over 10%, considering factors such as height, age, body build, and sex. Another way to define obesity is based on body fat content: a male is considered obese if body fat exceeds 25% of his total weight, while a female is considered obese if body fat exceeds 30%. Abdominal obesity, prevalent in 40% of women in India, poses significant challenges in the realm of anaesthesia, particularly during laparoscopic abdominal surgeries. The co-existence of morbid obesity, hypothyroidism, and hypertension present intricate medical conditions that demand precise management. During the surgical procedure, issues related to large intraabdominal tumours and airway maintenance impact respiratory and circulatory dynamics. Notably, intraoperative challenges, including bronchospasm, hypotension, and respiratory acidosis, were addressed to ensure the patient's well-being and a successful surgical outcome. The present case report provides insights into the comprehensive management of high-risk patients undergoing laparoscopic abdominal surgery. It underscores the significance of tailored anaesthesia strategies to mitigate complications and ensure a favourable postoperative recovery. This report presents the case of a 59-year-old female with obesity (BMI: 39.6 kg/m2), hypothyroidism, and hypertension who underwent laparoscopic abdominal surgery and discusses managing intraoperative challenges, such as bronchospasm, hypotension, and respiratory acidosis, and the postoperative care for successful patient recovery.

Abstract Background This systematic review aims to assist clinical decision-making in selecting appropriate preoperative prediction methods for difficult tracheal intubation by identifying and synthesizing literature on these methods in adult patients undergoing all types of surgery. Methods A systematic review and meta-analysis were conducted following PRISMA guidelines. Comprehensive electronic searches across multiple databases were completed on March 28, 2023. Two researchers independently screened, selected studies, and extracted data. A total of 227 articles representing 526 studies were included and evaluated for bias using the QUADAS-2 tool. Meta-Disc software computed pooled sensitivity (SEN), specificity (SPC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). Heterogeneity was assessed using the Spearman correlation coefficient, Cochran’s-Q, and I2 index, with meta-regression exploring sources of heterogeneity. Publication bias was evaluated using Deeks’ funnel plot. Results Out of 2906 articles retrieved, 227 met the inclusion criteria, encompassing a total of 686,089 patients. The review examined 11 methods for predicting difficult tracheal intubation, categorized into physical examination, multivariate scoring system, and imaging test. The modified Mallampati test (MMT) showed a SEN of 0.39 and SPC of 0.86, while the thyromental distance (TMD) had a SEN of 0.38 and SPC of 0.83. The upper lip bite test (ULBT) presented a SEN of 0.52 and SPC of 0.84. Multivariate scoring systems like LEMON and Wilson’s risk score demonstrated moderate sensitivity and specificity. Imaging tests, particularly ultrasound-based methods such as the distance from the skin to the epiglottis (US-DSE), exhibited higher sensitivity (0.80) and specificity (0.77). Significant heterogeneity was identified across studies, influenced by factors such as sample size and study design. Conclusion No single preoperative prediction method shows clear superiority for predicting difficult tracheal intubation. The evidence supports a combined approach using multiple methods tailored to specific patient demographics and clinical contexts. Future research should focus on integrating advanced technologies like artificial intelligence and deep learning to improve predictive models. Standardizing testing procedures and establishing clear cut-off values are essential for enhancing prediction reliability and accuracy. Implementing a multi-modal predictive approach may reduce unanticipated difficult intubations, improving patient safety and outcomes.

Abstract Background The aim of this study was to establish a consensus among experts in prehospital work regarding the management of difficult airways in prehospital care in Sweden. The results were subsequently used to develop an algorithm for handling difficult airway in prehospital care, as there was none available in Sweden prior to this study. Methods This two-round Delphi study was conducted by forming an expert panel comprising anesthesiologists and anesthesia nurses working in prehospital setting in Sweden. The expert panel responded digital forms with questions and statements related to airway management. The study continued until consensus was reached, defined as more than 70% agreement. The study took place from December 4, 2021, to May 15, 2022. Results In the first round, 74 participants took part, while the second round involved 37 participants. Consensus was reached in 16 out of 17 statements. 92% of the participants agreed that an airway algorithm adapted for prehospital use is necessary. Conclusions The capacity to adapt the approach to airway management based on specific pre-hospital circumstances is crucial. It holds significance to establish a uniform framework that is applicable across various airway management scenarios. Consequently, the airway management algorithm that has been devised should be regarded as a recommendation, allowing for flexibility rather than being interpreted as a rigid course of action. This represents the inaugural nationwide algorithm for airway management designed exclusively for pre-hospital operations in Sweden. The algorithm is the result of a consensus reached by experts in pre-hospital care.

Background: This systematic review aims to assist clinical decision-making in selecting appropriate preoperative prediction methods for difficult tracheal intubation by identifying and synthesizing literature on these methods in adult patients undergoing all types of surgery. Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. Comprehensive electronic searches across multiple databases were completed on March 28, 2023. Two researchers independently screened, selected studies, and extracted data. A total of 227 articles representing 526 studies were included and evaluated for bias using the QUADAS-2 tool. Meta-Disc software computed pooled sensitivity (SEN), specificity (SPC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). Heterogeneity was assessed using the Spearman correlation coefficient, Cochran's-Q, and I2 index, with meta-regression exploring sources of heterogeneity. Publication bias was evaluated using Deeks' funnel plot. Results: Out of 2906 articles retrieved, 227 met the inclusion criteria, encompassing a total of 686,089 patients. The review examined 11 methods for predicting difficult tracheal intubation, categorized into physical examination, multivariate scoring system, and imaging test. The modified Mallampati test (MMT) showed a SEN of 0.39 and SPC of 0.86, while the thyromental distance (TMD) had a SEN of 0.38 and SPC of 0.83. The upper lip bite test (ULBT) presented a SEN of 0.52 and SPC of 0.84. Multivariate scoring systems like LEMON and Wilson's risk score demonstrated moderate sensitivity and specificity. Imaging tests, particularly ultrasound-based methods such as the distance from the skin to the epiglottis (US-DSE), exhibited higher sensitivity (0.80) and specificity (0.77). Significant heterogeneity was identified across studies, influenced by factors such as sample size and study design. Conclusion: No single preoperative prediction method shows clear superiority for predicting difficult tracheal intubation. The evidence supports a combined approach using multiple methods tailored to specific patient demographics and clinical contexts. Future research should focus on integrating advanced technologies like artificial intelligence and deep learning to improve predictive models. Standardizing testing procedures and establishing clear cut-off values are essential for enhancing prediction reliability and accuracy. Implementing a multi-modal predictive approach may reduce unanticipated difficult intubations, improving patient safety and outcomes. [ABSTRACT FROM AUTHOR]

The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery. [ABSTRACT FROM AUTHOR]

The lightwand is a valuable device for managing the airways of patients with neck immobilization due to its ease of minimal neck movement. For lightwand intubation, adopting a face-to-face technique offers the potential for improved accessibility and reduced risk of injury associated with blind scooping maneuvers. In this study, we compared the initial success rate of the face-to-face approach with the conventional method as the primary endpoint and their complications as the second endpoint, including postoperative sore throat, the incidence of bleeding and hoarseness in neckimmobilized patients. Our findings indicate that the initial success rate was 84.1% for the face-to-face approach and 88.6% for the conventional approach (p = 0.381). The intubation times for the face-to-face approach and conventional approach were 12.0 and 14.0 seconds, respectively (p = 0.704). Furthermore, there were no statistically significant inter-group differences observed in the overall incidence of postoperative complications, including sore throat, bleeding and hoarseness. In summary, our study shows that the face-to-face approach in lightwand intubation for neck-immobilized patients could be suggested as one of the alternatives, yielding outcomes similar to the conventional lightwand technique. [ABSTRACT FROM AUTHOR]

Forestier syndrome, also known as Diffuse Idiopathic Skeletal Hyperostosis (DISH), is characterized by typical findings of ossification and calcification primarily of the anterior longitudinal ligament, which result in osteophyte formation. This is a rare condition and is rarely associated with systemic diseases such as diabetes mellitus and obesity. It occurs mostly in the fifth and sixth decades of life and predominantly in males. This report describes a case of a 68-year-old man with DISH syndrome, who experienced a difficult airway and a serious complication during intubation. [ABSTRACT FROM AUTHOR]

Background: The main clinical manifestations of patients with Pierre Robin sequence (PRS) include micrognathia, the glossoptosis and dyspnoea. The difficulty of tracheal intubation (TI) in such patients is increased. Objective: The purpose of the study was to evaluate the reliability and efficacy of the PRS simulator. Methods: A PRS simulator was developed by using 3-dimensional (3D) printing technology under computer-aided design. A total of 12 anaesthesiologists each trained 5 times for TI on the PRS Training Simulator-1 and recorded the simulation time. After the training, they were randomly divided into three groups with a total of 12 nontrained anaesthesiologists, and the simulation was completed on PRS Simulator-2, 3 and 4. The simulation time was recorded, and the performance was evaluated by three chief anaesthesiologists. Then, all 24 anaesthesiologists completed the questionnaire. Results: A PRS simulator developed by 3D printing was used to simulate the important aspects of TI. The average number of years worked was 6.3 ± 3.1 years, and 66.7% were female. The time for the 12 anaesthesiologists to complete the training gradually decreased (p < 0.01). Compared with the trained anaesthesiologists, the simulation time of TI in the nontrained anaesthesiologists was much longer (all p < 0.01). In addition, the simulation performance of the trained anaesthesiologists was relatively better (all p < 0.01). Conclusion: The reliability and efficacy of the PRS simulator is herein preliminarily validated, and it has potential to become a teaching and training tool for anaesthesiologists. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Airway management in Duchenne patients can be challenging. We present a case of an anticipated difficult airway in a 24-year-old Duchenne patient that was managed by planning different suitable strategies based on the unanticipated difficult airway algorithm of the Difficult Airway Society (DAS). Case presentation: The patient initially presented with appendicitis, requiring a laparoscopic appendectomy within 6 h. Due to the underlying condition and a known difficult airway, we anticipated potential airway problems and successfully managed the "can ventilate but cannot intubate" situation using the algorithm. The difficult airway was attributed to reduced mandibular mobility, limited inclination or reclination, a large tongue, prominent incisors, and a posteriorly positioned epiglottis. Despite thorough preparation and team briefing, we experienced three failed intubation attempts. Considering limited nighttime resources, the urgency of the surgery, the need for a tube for laparoscopy, and the risk of exacerbating airway issues, we made the decision to awaken the patient and wait for a second attempt after the epiglottis swelling had subsided. We used reversible, short-acting agents for induction, enabling us to continue with the algorithm within the allotted timeframe. In a second stage, we successfully performed fiberoptic-guided intubation via a supraglottic airway device using the Aintree intubation catheter, utilizing more favorable resources. Conclusions: For a patient with Duchenne muscular dystrophy and a difficult airway, advanced expertise is critical. Detailed anesthesia planning, clear team communication, and the use of reversible, short-acting agents are crucial. Adherence to the Difficult Airway Society guidelines is essential for safe airway management. [ABSTRACT FROM AUTHOR]

Patients with head and neck cancer are at an increased risk of airway complications, not only because of the tumor itself and the need for a shared airway, but also the treatment of cancer (including surgery, radiotherapy, and chemotherapy) poses major challenges in airway management. The perioperative assessment, therefore, needs to be comprehensive to allow us to predict possible airway difficulty. Moreover, the suitability and feasibility of primary and rescue plans are needed to be assessed for each individual patient. In this case report, we describe a case of a patient, with recurrent tongue cancer with prior history of surgery and radiotherapy to the head and neck region. The difficulty in managing the airway in this case was anticipated correctly and subsequently encountered in almost every step, including bag-mask ventilation, video-laryngoscopy, and laryngeal mask airway (LMA) insertion in a patient. Despite the presence of visual aids and algorithms for the management of a difficult airway, a premeditated airway management plan, and the availability of all necessary equipment and expertise, a break in structure and sequence was encountered, which was quickly corrected and saved the patient from any harm. [ABSTRACT FROM AUTHOR]

Laryngoscopy for tracheal intubation has been developed for many decades. Among various conventional laryngoscopes, videolaryngoscopes (VLs) have been applied in different patient populations, including difficult airways. The safety and effectiveness of VLs have been repeatedly studied in both normal and difficult airways. The superiority of VLs then has been observed and is advocated as the standard of care. In contrast to laryngoscopy, the development of video-assisted intubating stylet (VS, also named as styletubation) was noticed two decades ago. Since then, sporadic clinical experiences of use have appeared in the literature. In this review article, we presented our vast use experiences of the styletubation (more than 55,000 patients since 2016). We found this technique to be swift (the time to intubate from 3 s to 10 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction and fast learning curve for the novice trainees) in both normal and difficult airway scenarios. We, therefore, propose that the styletubation technique can be feasibly applied as universal routine use for tracheal intubation. [ABSTRACT FROM AUTHOR]

Background and Objectives: Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life‐threatening situation known as "Can't Intubate, Can't Oxygenate". This situation requires immediate recognition, advanced airway management, and ultimately emergency front‐of‐neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front‐of‐neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front‐of‐neck access in children. Methods: A comprehensive literature was performed the use of emergency front‐of‐neck access (eFONA) in infants and children. Results: Eighty‐six papers were deemed relevant by abstract. Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported. Conclusion: Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to establish a consensus among experts in prehospital work regarding the management of difficult airways in prehospital care in Sweden. The results were subsequently used to develop an algorithm for handling difficult airway in prehospital care, as there was none available in Sweden prior to this study. Methods: This two-round Delphi study was conducted by forming an expert panel comprising anesthesiologists and anesthesia nurses working in prehospital setting in Sweden. The expert panel responded digital forms with questions and statements related to airway management. The study continued until consensus was reached, defined as more than 70% agreement. The study took place from December 4, 2021, to May 15, 2022. Results: In the first round, 74 participants took part, while the second round involved 37 participants. Consensus was reached in 16 out of 17 statements. 92% of the participants agreed that an airway algorithm adapted for prehospital use is necessary. Conclusions: The capacity to adapt the approach to airway management based on specific pre-hospital circumstances is crucial. It holds significance to establish a uniform framework that is applicable across various airway management scenarios. Consequently, the airway management algorithm that has been devised should be regarded as a recommendation, allowing for flexibility rather than being interpreted as a rigid course of action. This represents the inaugural nationwide algorithm for airway management designed exclusively for pre-hospital operations in Sweden. The algorithm is the result of a consensus reached by experts in pre-hospital care. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis aimed to compare the efficacy of dynamic versus standard bougies to achieve tracheal intubation. We searched MEDLINE, Embase, CENTRAL, Web of Science, Scopus and Google Scholar on 10 October 2023. We included clinical trials comparing both devices. The primary outcome was the first-attempt intubation success rate. The secondary outcome was the time required for tracheal intubation. Eighteen studies were included. Dynamic bougies do not increase first-attempt success rate (RR 1.11; p = 0.06) or shorten tracheal intubation time (MD −0.30 sec; p = 0.84) in clinical trials in humans. In difficult airways, first-attempt success intubation rate was greater for dynamic bougies (RR 1.17; p = 0.002); Additionally, they reduced the time required for intubation (MD −4.80 sec; p = 0.001). First-attempt intubation success rate was higher (RR 1.15; p = 0.01) and time to achieve intubation was shorter when using Macintosh blades combined with dynamic bougies (MD −5.38 sec; p < 0.00001). Heterogeneity was high. Dynamic bougies do not increase the overall first-pass success rate or shorten tracheal intubation time. However, dynamic bougies seem to improve first-attempt tracheal intubation rate in patients with difficult airways and in those intubated with a Macintosh blade. Further research is needed for definitive conclusions. CRD42023472122 [ABSTRACT FROM AUTHOR]

Obesity is characterised by a body weight that surpasses the expected or ideal weight by over 10%, considering factors such as height, age, body build, and sex. Another way to define obesity is based on body fat content: a male is considered obese if body fat exceeds 25% of his total weight, while a female is considered obese if body fat exceeds 30%. Abdominal obesity, prevalent in 40% of women in India, poses significant challenges in the realm of anaesthesia, particularly during laparoscopic abdominal surgeries. The co-existence of morbid obesity, hypothyroidism, and hypertension present intricate medical conditions that demand precise management. During the surgical procedure, issues related to large intraabdominal tumours and airway maintenance impact respiratory and circulatory dynamics. Notably, intraoperative challenges, including bronchospasm, hypotension, and respiratory acidosis, were addressed to ensure the patient's well-being and a successful surgical outcome. The present case report provides insights into the comprehensive management of high-risk patients undergoing laparoscopic abdominal surgery. It underscores the significance of tailored anaesthesia strategies to mitigate complications and ensure a favourable postoperative recovery. This report presents the case of a 59-year-old female with obesity (BMI: 39.6 kg/m2), hypothyroidism, and hypertension who underwent laparoscopic abdominal surgery and discusses managing intraoperative challenges, such as bronchospasm, hypotension, and respiratory acidosis, and the postoperative care for successful patient recovery. [ABSTRACT FROM AUTHOR]

Supraglottic masses can be an anaesthesiologist’s nightmare due to the difficult airway scenario and bleeding risk during airway manipulation. Awake fibreoptic intubation is the primary method to secure the airway in such cases. However, most practising anaesthesiologists are not experts at handling the fibreoptic scope, especially in cases with a floppy supraglottic mass where it becomes difficult to displace the mask with the thin flexible bronchoscope. A hybrid technique of intubation in supraglottic masses using Bonfils rigid scope and C-MAC is often described but frequently not available. Here we describe a case of an elderly patient in their 80s presenting with a floppy supraglottic mass where an awake fibreoptic bronchoscope failed to secure the airway. Without access to a rigid Bonfils scope, we intuitively used a C-MAC to visualize the larynx and a yankauer suction catheter to displace the mass and perform a bougie-guided endotracheal intubation.

Abstract A difficult airway is a situation in which an anesthesiologist with more than 5 years of experience encounters difficulty with intubation or mask ventilation. According to the 2022 American Society of Anesthesiologists Practice Guidelines for the Management of Difficult Airway, difficult airways are subdivided into seven detailed categories. This condition can lead to serious adverse events and therefore must be diagnosed accurately and quickly. In this review, we comprehensively summarize and discuss the different methods used in clinical practice and research to assess difficult airways, including medical history, simple bedside assessment, comprehensive assessment of indicators, preoperative endoscopic airway examination, imaging, computer-assisted airway reconstruction, and 3D-printing techniques. We also discuss in detail the latest trends in difficult airway assessment through mathematical methods and artificial intelligence. With the continuous development of artificial intelligence and other technologies, in the near future, we will be able to predict whether a patient has a difficult airway simply by taking an image of the patient's face through a cell phone program. Artificial intelligence and other technologies will bring great changes to the development of airway assessment, and at the same time raise some new questions that we should think about.

Abstract Background Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation. Method This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model’s performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset’s instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden’s J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined. Results The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH 0.9, and 121 (57.9%) had pH

Objectives: The study's primary goal was to assess the feasibility of the cricothyroidotomy technique (CTT) in cats and evaluate its success rate (i.e., secure airway access). Secondary outcomes were the assessment of the subjective difficulty of airway access based on body score condition and weight. Further secondary outcomes consisted of procedural time and scoring of associated complications. The current study hypothesized that the CTT procedure would provide secure airway access with a reasonable success rate. Materials and methods: A prospective experimental study assessing the performance of CTT and associated complications was conducted on 30 feline cadavers. A procedural datasheet was completed to subjectively grade difficulty of landmark palpation, guide placement and tube placement and expected success of the procedure. A dissection was then performed post-procedure by a blinded observer to evaluate for any associated damages. Results: CTT was successful in securing an airway in 100% of the cats. The time to completion of the CTT was rapid, with a median time of 49 s (ranging from 31 to 90 s) for securing an airway. Of importance, this procedure was judged to be overall easy (median "ease of procedure score" of 7/10; ranging from 3 to 10) by the experimenters. The post-procedural lesion rate was elevated (76.7%) in this population of cats, though based on the lesion scores, was deemed mild in 73.9% of the cases. Clinical significance: CTT warrants consideration as the primary option for emergency front-of-neck airway access for cats although further studies are necessary. [ABSTRACT FROM AUTHOR]

Tracheal intubation is the gold standard for airway management in emergency medicine, but more difficult to apply for inexperienced individuals than laryngeal mask airway (LMA). The aim of our study was to investigate if inexperienced individuals are able to secure the airway with the help of LMA after a short introduction. A second aim was to evaluate Thiel-fixed specimens against unfixed ones. In a body donor model, LMA application was evaluated between medical students without previous airway experience and anesthesiologists by comparing the sealing of the larynx using a water column applied to the esophagus. LMAs were successfully applied in 46 out of 55 (83.6%) attempts by medical students and in 30 out of 39 (76.9%) attempts by anesthesiologists. Among medical students, 14.1% of all LMA applications were primarily leaky, compared with 18.8% in anesthesiologists. Esophageal sealing was better in Thiel-fixed specimens (leakage 10.9%) compared with unfixed specimens (leakage 22.9%). Our data showed no significant difference between anesthesiologists and medical students in terms of sealing of LMA. Therefore, we conclude that medical students without previous airway experience can quickly learn to apply LMA sufficiently and thus, achieve aspiration protection similar to anesthesiologists. Medical students without previous airway experience can successfully insert LMAs after a short introduction. Thiel-fixed specimens are suitable for studies as well as for training in LMA application. [ABSTRACT FROM AUTHOR]

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]

Background: Ultrasonographic imaging has been recently become simple portable and non-invasive adjuvant for bedside assessment of anterior neck soft tissue thickness which when measured at different levels showed to have significant role in predicting difficult laryngoscopy. Aims and Objectives: Primary objective was Ultrasonographic measurement of anterior neck soft tissue thickness at 3 levels -Distance from skin to hyoid bone (DSHB) -Distance from skin to thyrohyoid membrane (DSTM) -Distance from skin to anterior commissure of vocal cord(DSAC) and to compare and correlate the findings with Cooks modification of Cormack-Lehane score in predicting difficult laryngoscopy .Secondary objective was to compare and correlate the ultrasonographic measurements with conventional airway assessment methods. Materials and Methods: After obtaining approval from the ethical committee, 90 Patients with BMI above 25 kg /m2 was enrolled for the study. A day before the surgery a thorough Preanaesthetic evaluation and assessment of the airway is done using conventional methods. Then on the day of surgery ultrasonographic measurement of anterior neck at 3 levels was done and after inducing the patients laryngoscopy was done and Cooks modification of Cormack-Lehane score assessed. Results: The optimal cut off values to predict difficult laryngoscopy was 1.26, 2 and 1.2 cms for DSHB,DSTM and DSAC respectively, and among the three skin to anterior commissure of vocal cord was observed to be best USG parameter with more area under the ROC curve. Conclusion: USG measurement of anterior neck soft tissue thickness can be useful in predicting difficult laryngoscopy in overweight and obese patients also it had more diagnostic accuracy than conventional methods like MMS in predicting difficult laryngoscopy. [ABSTRACT FROM AUTHOR]

The principle of general anesthesia is a free airway during anesthesia-surgery. A female patient age 55 year, who has morbid obesity with body mass index/BMI 38.6, and suffered from hypertension, diabetes mellitus, and giant struma was having struma-lifting surgery in Melinda 2 Hospital Bandung-Indonesia. The patient was assumed to have difficulties in performing intubation, therefore it was decided to do awake tracheal intubation (ATI) for the general anesthesia facility. Patient was positioned in a Ramped position, she was given monitor standard, was given binasal oxygen, and several medicine which combination of lidocaine spray, lidocaine, fentanyl, midazolam, and dexmedetomidine intravenous. Intubation was done with direct laryngoscopy. After the endotracheal tube (ETT) was entered, which was confirmed by the balloon movement of the anesthesia machine, the patient was given propofol, additional fentanyl, and muscle paralyzed atracurium and dexmedetomidine was stopped. Anesthesia maintenance was N2O/O2, sevoflurane. Bleeding amount was 1200 mL and the fluid given was ringer laktat 1000 mL and gelofusin 1000 mL. During the surgery there was severely decreasing blood tension which needed efedrin, then it was replaced with norepinefrin bitartrate monohydrate (vascon) and finally the combination of vascon and dobutamine. At the end of the surgery, after the patient could open her eyes, spontaneous respiration and extubation were given. The post-surgery patient then was taken care of in a high-care unit for four days before she was moved to the ward. [ABSTRACT FROM AUTHOR]

Practitioners can face significant challenges when managing the airways of infants and neonates because of their unique anatomical and physiological features. The requirement for emergency airway management in this age group is rare. Details of emergency airway techniques in paediatric practice guidelines are missing or lack consensus, and it is known that outcomes for affected children can be poor. Ideally, these children should be managed by experienced paediatric airway practitioners working in a team. However, situations can arise where practitioners, unfamiliar and inexperienced with infants, find themselves in charge. So, what happens when such a practitioner encounters this life-or-death scenario and feels ill-equipped to act? The ethical and legal issues surrounding the management of this emergency are clearly defined, but they can be unknown or misunderstood by doctors. Compounding the extreme stress of the scenario is the moral and ethical dilemma of whether to act or not. The following discussion explores these issues and examines the philosophical and psychological perspectives. [ABSTRACT FROM AUTHOR]

Audience: This airway trainer modification is designed to instruct all levels of training in emergency medicine in order to familiarize trainees with airway anatomy and obtain superior views of the glottic inlet. Introduction: During intubation with a standard geometry laryngoscope, such as the Macintosh blade, placement of the distal end of the blade within the vallecula and engagement of the median glossoepiglottic fold, also referred to as the midline vallecular fold (MVF), has long been championed by experts in airway management for its ability to improve glottic inlet visualization. This notion was further supported by the recent publication of a retrospective video review by Driver et al. Unfortunately, airway anatomy, including engagement of the MVF, does not receive the emphasis it deserves during intubation training of emergency medicine residents. Emergency physicians often have limited time to perform complete airway examinations, but a sound recognition and appreciation of the laryngeal inlet can serve as a roadmap to optimal laryngoscopy. Recent advancements in airway education emphasize visualization of airway anatomy with review of video laryngoscopy (VL) recordings to identify routine VL errors in vallecula manipulation, such as failure to engage the MVF. Simulation can continue to play an essential role in enhancing trainees’ airway skills. Current airway trainers lack functional fidelity components, such an engageable MVF, resulting in a missed opportunity to teach airway skills and anatomy in a safe and controlled setting. To address these concerns, we modified an existing airway task trainer with the addition of a simulated MVF to expose trainees to airway anatomy and adequate MVF engagement resulting in epiglottic elevation. Educational Objectives: By the end of this education session, participants should be able to: 1. Identify relevant airway anatomy during intubation, including base of the tongue, epiglottis, midline vallecular fold, anterior arytenoids. 2. Appreciate the value of a stepwise anatomically guided approach to intubation. 3. Become familiar with the midline vallecular fold and underlying anatomy, including the hyoepiglottic ligament, and how proper placement of the laryngoscope can result in improved glottic visualization. Educational Methods: The TrueCorp AirSim airway task trainer was modified with the addition of a simulated MVF. Prior to the modification described here, there were no dynamic trainers with the functional fidelity needed to teach trainees how to engage the MVF with proper placement of the distal tip of the laryngoscope. Once the trainer was created, learners are introduced to relevant anatomy through the initial lecture to unsure baseline knowledge. During the lecture, videos and images are reviewed to demonstrate the importance of an anatomical roadmap to successful intubation. Learners then practiced with the modified task trainer to gain hands-on experience with laryngoscope placement and improved glottic visualization. A short verbal debriefing was performed at the end of the skills session to address any remaining questions. Research Methods: Pre- and post-simulation surveys were completed by attendees of a weekly didactic session, ranging from medical students, PGY 1-4 emergency medicine residents, and emergency medicine attending physicians. Pre- and post-simulation familiarity with airway anatomy and comfortability with MVF engagement was assessed using a 5-point Likert scale Results: Twenty-six participants ranging from medical students to attending physicians completed a pre- and post-simulation survey. Overall, feedback from leaners was positive. Learners were excited to learn new airway management techniques and requested an expansion of current airway curriculum based on the success of this implementation. Discussion: This modified task trainer places an emphasis on teaching airway anatomy to trainees with the addition of functional fidelity by adding an engageable element providing the trainee with feedback on successful placement of the laryngoscope. This simple and cost-effective modification can add value to existing airway management curriculums by serving as a visual cue of airway anatomy and instructing trainees on proper placement of the laryngoscope. Our results showed participants experienced increased comfort with airway anatomy recognition and engagement of MVF for difficult intubations. Participants found the trainer effective with the simulated MVF resulting in glottic elevation and recommended this for future simulation. Participants were eager to learn additional airway techniques to improve their laryngoscopy skills, suggesting an area of growth for emergency medicine didactic curriculums. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: Endotracheal intubation is essential for emergency airway management, assisting ventilation and oxygenation by allowing airway patency. As an alternative to direct laryngoscopy (DL), the use of video laryngoscopy (VL) is now advocated by many operators, especially to manage the difficult airway (DA). This study aimed to compare DL and Scoper® VL in normal and DAs. Materials and Methods: We conducted a crossover trial comparing DL and VL in difficult and normal airway (NA). Twenty volunteer medical students from the University of Health Sciences Türkiye Hamidiye Faculty of Medicine who had not received intubation training before enrolled. After the training sessions, the volunteers performed at four different independent stations (DL on normal and DA scenarios, VL on normal and DA scenarios) in a completely randomized manner on the next day. The primary outcome was the first-pass success rate, with secondary outcomes of time to intubation, number of intubation attempts, user satisfaction, and procedural difficulty by visual analog scale. Results: Twenty volunteers were included in the study. When the first-pass success rate was examined, the highest success rates were found with VL. No statistically significant difference was detected in terms of time to intubation, user satisfaction with the intervention, or procedural difficulty. No other statistically significant differences were found between the four scenarios in other pairwise comparisons (p<0.05). Conclusion: Although the first-pass success rates were better with VL, it was not superior to DL. Further studies should be planned involving Scoper® in conjunction with other video laryngoscopes to evaluate efficacy. [ABSTRACT FROM AUTHOR]

Airway management is a vital part of anesthesia practices, intensive care units, and emergency departments, and a proper pre-operative assessment can guide clinicians' plans for securing an airway. Complex airway assessment has recently been at the forefront of anesthesia research, with a substantial increase in annual publications during the last 20 years. In this paper, we provide an extensive overview of the literature connected with pre-operative airway evaluation procedures, ranging from essential bedside physical examinations to advanced imaging techniques such as ultrasound (US), radiography, computed tomography (CT), and magnetic resonance imaging (MRI). We discuss transnasal endoscopy, virtual endoscopy, 3D reconstruction-based technologies, and artificial intelligence (AI) as emerging airway evaluation techniques. The management of distorted upper airways associated with head and neck pathology can be challenging due to the intricate anatomy. We present and discuss the role of recent technological advancements in recognizing difficult airways and assisting clinical decision making while highlighting current limitations and pinpointing future research directions. [ABSTRACT FROM AUTHOR]

A difficult airway is a situation in which an anesthesiologist with more than 5 years of experience encounters difficulty with intubation or mask ventilation. According to the 2022 American Society of Anesthesiologists Practice Guidelines for the Management of Difficult Airway, difficult airways are subdivided into seven detailed categories. This condition can lead to serious adverse events and therefore must be diagnosed accurately and quickly. In this review, we comprehensively summarize and discuss the different methods used in clinical practice and research to assess difficult airways, including medical history, simple bedside assessment, comprehensive assessment of indicators, preoperative endoscopic airway examination, imaging, computer-assisted airway reconstruction, and 3D-printing techniques. We also discuss in detail the latest trends in difficult airway assessment through mathematical methods and artificial intelligence. With the continuous development of artificial intelligence and other technologies, in the near future, we will be able to predict whether a patient has a difficult airway simply by taking an image of the patient's face through a cell phone program. Artificial intelligence and other technologies will bring great changes to the development of airway assessment, and at the same time raise some new questions that we should think about. [ABSTRACT FROM AUTHOR]

Background: Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation. Method: This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined. Results: The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%. Conclusion: DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration. [ABSTRACT FROM AUTHOR]

Innovations and challenges for lung separation or isolation have evolved during the last few years. In this chapter, we present the up-to-date, robust evidence available during the previous five years supporting the positions of the different devices, techniques, and tricks for their use in adult and pediatric patients undergoing various thoracic surgical interventions. Additionally, we presented an update on lung isolation in patients with airway difficulty and the suggested training level to master these techniques. [ABSTRACT FROM AUTHOR]

Background: Foreign Body Aspiration (FBA) is one of the paediatric emergencies which require timely diagnosis and management. The inherent tendency of children to explore small objects with their mouths often prove to be fatal as they are difficult to remove once aspirated. Case Report: We present the case of a 5-year-old boy who presented with dyspnea and vomiting following the aspiration of a pen cap. Chest radiograph and Rigid Bronchoscopy helped to identify the foreign body but it couldn't be removed by Rigid Bronchoscopy alone due it's wedge-shaped nature. Hence, an unconventional method of foreign body removal was performed by making a tracheostoma, pushing the foreign body to the level of tracheostoma and thereby taking it out from the tracheostoma under strict monitoring of anesthesia team. Conclusion: Alternative approaches like this are required for prompt intervention in a difficult case as it helps to reduce complications produced by repeated failed attempts. [ABSTRACT FROM AUTHOR]

Background: Mallampati grading (MPG) classification in a sitting position is the most commonly used method for airway assessment. The study aimed to compare the predictive value of MPG in the sitting and supine positions to predict difficult tracheal intubation (DTI). Patients and Methods: The present study was a prospective, blinded, and observational study. Three hundred nine patients aged 18–60 years, scheduled for surgery requiring orotracheal intubation, were included. Airway assessment was performed preoperatively, including sitting MPG with and without phonation. Supine MPG with and without phonation was noted in the operation theater. The ease of bag-mask ventilation (BMV) and laryngoscopy view were graded according to the Han scale and the Cormack and Lehane scores, respectively. A receiver operating characteristic curve was used to assess the cutoff point, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of MPG, and body mass index for predicting DTI. Results: Difficult BMV, DTI, and both (difficult BMV and DTI) were observed in 22.7%, 12.9%, and 5.2% of patients, respectively. MPG in the sitting position without phonation yielded the highest diagnostic accuracy (76.38%), specificity (79.55%), and PPV (28.6%), with good sensitivity (55%) and NPV (92.2%). Supine MPG without phonation showed comparable results. Conclusion: Sitting position MPG without phonation is the best predictor of DTI, followed by supine MPG without phonation. Therefore, supine MPG without phonation is equivalent to sitting without phonation MPG and can be used for predicting DTI whenever the patient cannot be made upright.

Difficult airway is a serious condition that can be fatal and is frequently encountered during general anesthesia applications. Tracheobronkopathy osteochondroplasty (TBO) is a rare benign disease that is one of the causes of unpredictable difficult airway. A 45-year-old male patient with no comorbidities was transferred to the operating room for elective cholecystectomy. He couldn’t be intubated after standard monitoring and induction of anesthesia. The patient, who had papillomatous lesions in the trachea detected by bronchoscopy, was awakened to be scheduled for rigid bronchoscopy. TBO was detected in pathological examination of the samples taken in rigid bronchoscopy. TBO is a rare benign disease. Its etiology is unknown. It may be asymptomatic or may present with persistent dry cough, hemoptysis, dyspnea, recurrent lower respiratory tract infection, atelectasis and difficult intubation. Some patients may be diagnosed for the first time in the operating room due to difficult intubation.In cases with advanced tracheal stenosis, invasive airway intervention may be required or it may have a fatal course. The use of a laryngeal mask in the perioperative period may be an ideal option in a patient known to have TBO before. Unexpected difficult airway management in the operating room is important for anesthesiologists. According to the difficult airway society algorithm, waking the patient from a planned operation is the safest way until the problem is detected. We did not need invasive intervention because our patient also had elective surgery and ventilation was not difficult. In addition, we think that it is an important decision to make a diagnosis using fiberobtic bronchoscopy in operating room conditions and to wake up our patient with sugammadex without repeated attemps of tracheal intubation and delay elective surgery. In coclusion, it should be kept in mind that TBO may be one of the unpredictable causes of difficult intubation in the operating room.

Goldenhar syndrome, also called oculoauriculovertebral dysplasia, is characterized by craniofacial, central nervous system, cardiac, renal, and vertebral anomalies. It occurs due to the faulty unilateral development of vertebral arches. Patients presenting for surgery are usually in the pediatric age group. General anesthesia is the preferred mode of anesthesia considering the type of surgery, age of the patient, and vertebral anomaly in this patient group. The first and foremost consideration while anesthetizing these patients is the anticipated difficult airway. Frequently encountered airway abnormalities in these patients are micrognathia, retrognathia, mandibular dysplasia, craniovertebral anomalies leading to limited neck flexion and cervical spine instability, decreased thyromental distance, fascial asymmetry, cleft lip and palate, high arched palate, dental abnormalities, and temporomandibular joint abnormalities. Difficult airways often come disguised as syndromes, and thorough pre-operative evaluation along with preparation for the worst scenarios is a must. We have a myriad of alternative airway management equipment at our disposal. Adequate knowledge is a must for their best use.

Supraglottic masses can be an anaesthesiologist's nightmare due to the difficult airway scenario and bleeding risk during airway manipulation. Awake fibreoptic intubation is the primary method to secure the airway in such cases. However, most practising anaesthesiologists are not experts at handling the fibreoptic scope, especially in cases with a floppy supraglottic mass where it becomes difficult to displace the mask with the thin flexible bronchoscope. A hybrid technique of intubation in supraglottic masses using Bonfils rigid scope and C-MAC is often described but frequently not available. Here we describe a case of an elderly patient in their 80s presenting with a floppy supraglottic mass where an awake fibreoptic bronchoscope failed to secure the airway. Without access to a rigid Bonfils scope, we intuitively used a C-MAC to visualize the larynx and a yankauer suction catheter to displace the mass and perform a bougie-guided endotracheal intubation. [ABSTRACT FROM AUTHOR]

Abstract Background Vascular malformations are composed of morphologically abnormal vascular tissue, and when located in the head and neck region, they can make it difficult to secure the airway during general anesthesia. Case presentation A 28-year-old pregnant woman with vascular malformations in the pharynx was scheduled to undergo a cesarean section, for which spinal anesthesia was initially chosen. However, after magnetic resonance imaging results revealed the presence of multiple vascular malformations in the lumbar multifidus muscles, spinal anesthesia was considered to be of high risk. Thus, the patient was subjected to general anesthesia tracheal intubation under sedation, and the course of the surgery was without complications. Conclusions Because the pathophysiology and clinical sequelae of vascular malformations may be involved in complications, thorough presurgical evaluation of the patient’s physical condition and careful anesthesia planning should be done.

ABSTRACTBackground This prospective study was done on patients with suspected difficult airway to compare between C-MAC video-stylet (VS) and D-blade video-laryngoscope for tracheal intubation.Patients and methodology Randomization was done on 160 adult patients with anticipated difficulty in intubation for different causes to divide them into two equal groups (VS group and D group). Patients in each group were divided into five categories according to the cause of anticipated intubation difficulty. Duration of intubation, number of attempts, and success intubation rate were recorded. Hemodynamics parameters were measured before intubation as baseline, then after intubation at 1 and 5 min.Results In VS group, intubation time ranged between 23 and 166 s with mean of 53.2 ± 24.19 s and in D group it ranged between 30 and 279 s with mean of 65.5 ± 40.63 s (P-value 0.021). This shorter intubation time was not constant in different patient’s categories. The first attempt intubation was successfully done in 68 patients (85%) in VS group versus 61 patients (76.3%) in D group. Hemodynamically, HR and MABP showed significant increase in D group more than in VS group at 1 and 5 min after intubation (P-value = 0.001).Conclusion Both devices are helpful when there is a risk of difficult intubation. C-MAC VS is a better choice in cases of limited mouth opening and obesity, but in cases of limited cervical motility, the use of C-MAC D-blade is a better choice with a faster intubation time.