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The high-risk airway is a common presentation and a frequent cause of anxiety for emergency physicians. Preparation and planning are essential to ensure that these challenging situations are managed successfully. Difficult airways typically present as either physiologic or anatomic, each type requiring a specialized approach. Primary physiologic considerations are oxygenation, hemodynamics, and acid-base, whereas anatomic difficulty is overcome using proper positioning and skilled laryngoscopy to ensure success. It is essential to be comfortable performing alternative techniques to address varying presentations. Ultimately, competence in airway management hinges on consistent training, deliberate practice, and a dedication to excellence.

Flexible fibreoptic intubation offers options of airway control in awake and asleep patients, in cases with limited or absent mouth opening and complex anatomy. It may be used as a first choice or a rescue technique. Despite its limitations, for example in situations with significant airway blood or secretions, and airway obstruction, it is a valuable core skill for every anaesthetist.

We report a case of a pregnant woman with multiple pterygium syndrome who presented for elective caesarean section. Neuraxial anaesthesia failed and the backup plan of awake intubation was extremely difficult.

Local airway anaesthesia for awake fibreoptic intubation is generally recommended to improve patient comfort, which will help make the procedure a success. There are multiple approaches in practice and several descriptions of methods in the literature. However, there is limited evidence regarding which method is the most common and which offers the best results. This review presents current data about topicalisation of the airway, including nebulisation, spray-as-you-go techniques and airway nerve blocks. This article aims to help the anaesthesiologist choose the right method, tailored to the individual needs of his patients, after weighing up the advantages and disadvantages of the presented methods.

Topical anesthesia of the airway is a necessary for awake intubation and is usually achieved using lidocaine delivered by various means. Although some experts favor the use of airway blocks, a more common approach is to use pure topical methods in combination with "spray as you go" techniques. Once the topicalization is complete, the patient should be able to easily tolerate the use of an oral airway used to facilitate awake oral intubation. Nasal intubation requires additional topicalization of the nasal passages in conjunction with a vasoconstrictor. Finally, judicious sedation is frequently used when awake intubation is carried out.

Background and objectives Lipoma represents very common soft tissue tumour, which may appear anywhere in the body. Appearance of a giant lipoma at the nape of neck, can severely compromise neck extension especially in elderly patients where age related degenerative changes in airways present significant challenges to anesthesiologists in airway management whenever needed. This paper evaluates the role of Ambu® aScope™ 3 in such a patient. Case report An expected case of difficult airway where an old man presents with a huge lipoma of 15.5 × 12.4 cm at the nape of neck where we achieved awake intubation using a non-fiberoptic flexible bronchoscope Ambu® aScope™ 3. In the absence of fiberoptic bronchoscope, this device helped us secure airway in this very challenging case. Conclusion Ambu® aScope™ 3 can be used for elective awake intubations in patients with difficult airways.

Summary To provide an up-to-date review on drugs and airway management equipment required in anaesthesia for pre-hospital and in-hospital emergencies. Current literature is reviewed and reasonable approaches are discussed. Preoxygenation should be performed with high-flow oxygen delivered through a tight fitting face mask connected with a reservoir. Ketamine may be the induction agent of choice in haemodynamically unstable patients. Sugammadex, a rocuronium antagonist, may have the potential to make rocuronium the first-line neuromuscular blocking agent in emergency induction. Experienced healthcare providers may consider pre-hospital anaesthesia induction; lesser experienced healthcare providers should refrain from endotracheal intubation, but optimise oxygenation, hasten hospital transfer and ventilate patients only in life-threatening circumstances with a bag–valve–mask device or a supraglottic airway. Senior help should be sought early. In the hospital, with an expected difficult airway fibreoptic awake intubation should be performed. With a not difficult airway, airway management according to the rescuer's skills should be attempted. In a ‘cannot ventilate, cannot intubate' situation, a supraglottic airway should be used and, if ventilation is still unsuccessful, a surgical airway should be achieved. Capnography should be used in every ventilated patient. Continuous clinical practice is essential to retain anaesthesia and airway management skills.

Summary Background and objectives The objective of this study was to review the literature and to question the concept that obese patients should be considered as having a potential full stomach and, therefore, question how the airways, considered as of difficult access due to obesity, should be approached during anesthetic induction. Contents Classically, obese patients are viewed as having a potential full stomach, leading to conducts to protect the airways during anesthetic induction. Frequently, awake intubation or rapid sequence intubation is performed. However, this concept is based on a single study, which has been cited by other authors. Obese patients are also considered difficult to intubate, raising the concern on the successful approach of the airways. However, studies in the literature question this concept, leading to questioning of the techniques used to access the airways. Conclusions Studies in the literature demonstrate that gastric emptying is not slowed in obese patients as previously believed, and gastric contents are not greater in this patient population; intubation can, therefore, be safely done after anesthesia. Although obesity alone does not lead to failure to intubate, other signs can be used to predict difficult intubations.

The awake fiberoptic intubation (AFI) is an important part of the anesthesiologist’s armamentarium. As well as being technically challenging, it is also uncomfortable and stressful for all involved. We discuss the use of an alpha-2 agonist, dexmedetomidine, to help the clinician and patient through this procedure. The advantages of dexmedetomidine are that it produces a unique “Cooperative Sedation,” which reduces discomfort in the patient and assists in the topicalization of the airway. Most importantly, dexmedetomidine does not produce significant respiratory depression, so the airway may be secured in the safest manner possible. We discuss the history of sedation for AFI, other medications, as well as guidelines and pitfalls in the use of dexmedetomidine.

Airway problems are a major concern to anaesthetists; however, the introduction of fibre-optic intubation and awake fibre-optic intubation have revolutionized the anaesthetic management of the difficult airway. To perform fibre-optic intubation it is essential to have a basic understanding of the equipment, how to use it and how to prepare and maintain the airway for intubation under local or general anaesthetic. Effective endoscopy requires a good view, skilful manipulation of the instrument and a thorough understanding of airway anatomy. Careful handling of the endoscope and effective cleaning are essential for patient safety and to preserve the life of the equipment. Steps must be taken to ensure effective decontamination and to prevent recontamination before use.

The successful conduct of fiberoptic aided intubation is dependent upon effective local anaesthesia. The aim of the study was to compare three different methods of anaesthetizing the airway.60 adult patients (American Society of Anaesthesiologists status I-III and Mallampati class IIIIV), scheduled for elective surgery, received sedation followed by spraying of the nares and posterior pharyngeal wall with 4% lignocaine. Thereafter the patients received 4 ml of 4% lignocaine either by transtracheal injection (n=20, group A), via intubating fiberscope (Pentax F1-10P2) using 'spray as you go' technique (n=20, group B) or by nebulizer (Devilbiss 5610W) 20 min before intubation, (n=20, group C). Patients were asked to score the procedure using visual analog scale (VAS) and severity scores. Episodes of coughing, choking, stridor, extra / total local anaesthetic used and intubation times were recorded. Patients were monitored continuously for vital parameters.Group B patients showed better VAS scores with shorter intubation times and had a lower incidence of coughing and choking. The endoscopists' VAS scores also showed a preference for group B.In conclusion the 'spray as you go' technique was safe, provided effective local anaesthesia and was preferred by both patients and endoscopists.

Background The modified nasal trumpet (MNT) is a standard nasopharyngeal airway with an added distal fenestration and fitted with a 15 mm adaptor to permit connection to an anaesthesia circuit. Methods Based on its successful use as an emergency device in the ‘cannot intubate, cannot ventilate’ scenario, we considered that the MNT would aid fibreoptic intubation by providing a patent airway, spontaneous ventilation, and inhalation anaesthesia during the procedure. We report use of the MNT for this purpose seven times in six patients with difficult airways. Results In each case, the MNT allowed oxygenation and general anaesthesia while maintaining spontaneous ventilation when awake intubation was unsuccessful or not possible. Conclusion The MNT has a place in the operating room suites as a useful airway management device.

IMPLICATIONS FOR PRACTICE Extrapolating information from the adult and pediatric literature suggests that awake intubation is probably inappropriate in most neonates. Because premedication attenuates the physiologic responses to intubation, its use is recommended. Adequately skilled staff who have a full understanding of the potential benefits and harms of the interventions used should perform intubation and the administration of premedication in neonates. IMPLICATIONS FOR RESEARCH There is a need for well-designed and well-executed randomized controlled trials assessing the effectiveness and potential adverse effects of premedicated intubation in neonates. A valid pain assessment measure or approach should be used. Both short-term and long-term physiologic and clinical outcomes should be incorporated into the trial design.

A survey of anaesthetists in the Oxford region was conducted to determine their skills and practice in performing awake fibreoptic intubation. Forty-two consultant obstetric anaesthetists (group O), 21 consultant anaesthetists with an interest in difficult airway management (group D) and 20 anaesthetic specialist registrars in their final training year (group S) were sent a questionnaire on management of a patient with a known difficult airway for elective caesarean section. All but one responded. If regional anaesthesia was unsuccessful or contraindicated, 75/82 respondents (91.5%) would choose to secure the airway by awake intubation. Of the remaining seven, six would use general anaesthesia and spontaneous respiration, five (6.1%) with the laryngeal mask airway and one (1.2%) with mask and airway and one (1.2%) local infiltration by the surgeon. Although awake fibreoptic intubation was the technique chosen by 98.7%, only six (8.1%) had experience of its performance in an obstetric patient. Of the 68 anaesthetists without such experience, only 12/31 (38.7%) group O compared to 13/18 (72.2%) group D and 12/19 (63.2%) group S would be confident to perform awake fibreoptic intubation in an obstetric patient. Only one anaesthetist in the survey practised awake fibreoptic intubation in non-obstetric patients regularly (>3/month). However, 69/82 respondents replied that all consultant obstetric anaesthetists should be experienced in performing awake fibreoptic intubation. We conclude that despite the value of awake fibreoptic intubation, consultant obstetric anaesthetists are less confident in performing it than those with an interest in difficult airway management and final year specialist registrars.

SUMMARY Difficulty managing the airway is the single most important cause of morbidity and mortality related to anesthesia. Recognition of a potentially difficult airway is the first step in its management. A careful evaluation of the airway is an essential requirement for all patients presenting for intubation. If there is a possibility that intubation following induction of anesthesia will be difficult, then the airway should be secured while the patient is in a conscious state. Careful preparation of the patient is necessary and adequate time should be allowed for sedation and topical anesthesia to take full effect. The use of fiberoptic-assisted intubation has largely replaced direct laryngoscopy during awake intubation. This advance along with more effective methods of recognizing difficult airways may help to reduce anesthesia-related morbidity and mortality.

Intubation of the trachea with the patient awake is sound practice, affording protection against inhalation of gastric contents and against cardiovascular collapse. The writer reviews various methods of awake intubation and describes his own, illustrating it with a discussion of 12 seriously ill patients.