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Latar Belakang: Insiden tracheoesophageal fistula (TEF) dan esophageal atresia (EA) berkisar antara 1:3000 dan 1:4500 kelahiran. Antara 20% sampai 50% bayi dengan TEF/EA memiliki defek kongenital lainnya yang biasa disebut VACTERL (vertebral, anal, cardiac, tracheoesophageal, renal, limb). Kasus: Bayi usia 30 hari berat badan 2600 gram dengan diagnosis TEF tipe C dengan komplikasi pneumonia neonatal dan penyakit jantung bawaan ASD sinus venosus besar dan PDA sedang direncanakan tindakan thorakotomi ligasi fistel. Pasien sudah dilakukan gastrostomi dan esofagostomi sebelum tindakan ligasi. Pasien dilakukan manajemen anestesi dengan general anestesi intubasi dengan kontrol ventilasi. Selama operasi terjadi beberapa kali desaturasi akibat retraksi paru yang dimanajemen dengan ventilasi manual dengan pemberian PEEP dan pengurangan retraksi oleh operator. Dua hari post operasi pasien dilakukan ekstubasi dan diganti dengan CPAP. Kesimpulan: Manajemen anestesi dengan TEF/EA memerlukan evaluasi dan perencanaan mulai preoperatif, intraoperatif, dan postoperatif. Evaluasi preoperatif berupa investigasi VACTERL, masalah kardiak dan respirasi berkaitan perencanaan manajemen anestesi yang akan dilakukan. Manajemen intraoperatif termasuk teknik intubasi, pemilihan teknik awake atau apnea bergantung kondisi dan komorbid dari pasien. Manajemen postoperatif berupa perawatan ventilator, kontrol nyeri optimal serta pengawasan kardiorespirasi.

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.

Introduction: In the management of the anticipated difficult airway (DA), awake intubation is the strategy of choice. In this context, flexible fibroscopy is the tool most widely used as the first choice. However, there is always the rare case where it may fail. Important findings: Six successful rescue cases using videolaryngoscopy following failed fibroscopy in patients with anticipated DA, and 1 case of rescued extubation of an airway previously secured with fiberoptic bronchoscopy. Conclusion: Videolaringoscopy may be an adequate tool to use as a backup plan for the management of an anticipated DA.

There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners.To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps.A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices.A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a "cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques.Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.HINTERGRUND: Es besteht ein weltweiter Konsens unter Experten, dass Leitlinien und Algorithmen zum Atemwegsmanagement zu einer verbesserten Patientensicherheit in der Anästhesie beitragen. Diese Studie beschreibt die aktuelle Praxis des Atemwegsmanagements deutscher Anästhesisten und identifiziert Sicherheitslücken, definiert als Differenz zwischen der durch den Antwortenden berichteten Praxis und Empfehlung.Ermittlung der Umsetzung der Leitlinie zum Atemwegsmanagement in der Praxis durch deutsche Anästhesisten und Identifizierung möglicher Safety Gaps.Im September 2019 wurde eine Online-Umfrage durchgeführt. Alle registrierten Mitglieder der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) wurden per E‑Mail kontaktiert. Die Teilnehmer wurden nach ihrem persönlichen und institutionellen Hintergrund, der Einhaltung der Empfehlungen der aktuellen deutschen S1-Leitlinie und der Verfügbarkeit von Gerätschaften zur Atemwegssicherung befragt.Insgesamt 1862 DGAI-Mitglieder füllten die Fragebögen vollständig aus (Rücklaufquote: 17 %). Das Hauptergebnis war, dass sich die Anästhesisten größtenteils an die Leitlinie hielten, jedoch zeigten bestimmte Empfehlungen, insbesondere in Bezug auf die Besonderheiten der Präoxygenierung und der Ausbildung, eine Sicherheitslücke. Mehr als 90 % der Teilnehmer verfügten über ein Videolaryngoskop und die Hälfte hatte mehr als 25 Intubationen im Wachzustand mit einer flexiblen Optik durchgeführt. Allerdings verfügten nur 81 % über ein Videolaryngoskop mit stärker gekrümmtem Spatel. Schätzungsweise 16 % aller Intubationen erfolgten mit einem Videolaryngoskop, und jeder vierte Teilnehmer hatte damit eine Intubation im Wachzustand durchgeführt. Fast alle Teilnehmer hatten Patienten mit erwartet schwierigen Atemwegen betreut. Die Hälfte der Teilnehmer war bereits mit einer CICO-Situation konfrontiert und jeder fünfte musste mindestens einmal eine Notfallkoniotomie durchführen. In diesem Fall verwendeten fast zwei Drittel Punktionstechniken und ein Drittel ein Skalpell.Die derzeitige Praxis des Atemwegsmanagements zeigte insgesamt eine gute Übereinstimmung mit den Empfehlungen der aktuellen deutschen Leitlinie zum Atemwegsmanagement, dennoch besteht insbesondere bei der Ausbildung Verbesserungsbedarf.

Summary Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

The difficult airway remains an ongoing concern in daily anesthesia practice, with awake intubation being an important component of its management. Classically, fiberoptic bronchoscope-assisted tracheal intubation was the method of choice in the awake patient. The development of new generation videolaryngoscopes has revolutionized the approach to tracheal intubation in the anesthetized patient. The question whether videolaryngoscopes have a place in the intubation of the difficult airway in the awake patient is currently being addressed.Randomized controlled trials and their meta-analysis have shown that videolaryngoscopes provide similar success rates and faster intubation times when compared with fiberoptic bronchoscope intubation in awake patients with difficult airways.Videolaryngoscopy is a valid technique that should be considered for difficult airway management in the awake patient.

Awake intubation is indicated in difficult airways if attempts at securing the airway after induction of general anesthesia may lead to harm due to potential difficulties or failure in those attempts. Conventional awake flexible bronchoscopic intubation is performed via the nasal, or less commonly, oral route. Awake oral flexible bronchoscopic intubation (FBI) via a supraglottic airway device (SAD) is a less common technique; we refer to this as 'supraglottic airway guided' FBI (SAGFBI). We describe ten cases with anticipated difficult airways in which awake SAGFBI was performed. After sedation and adequate airway topicalization, an Ambu AuragainTM SAD was inserted. A flexible bronchoscope, preloaded with a tracheal tube, was then inserted through the SAD. Finally, the tracheal tube was railroaded over the bronchoscope, through the SAD and into the trachea. The bronchoscope and the SAD were carefully removed, whilst keeping the tracheal tube in-situ. The technique was successful and well tolerated by all patients, and associated complications were rare. It also offered the advantages of performing an 'awake test insertion' of the SAD, an 'awake look' at the periglottic region, and an 'awake test ventilation.' In certain patients, awake SAGFBI offers advantages over conventional awake FBI or awake videolaryngoscopy. More research is required to evaluate its success and failure rates, and identify associated complications. Its place in difficult airway algorithms may then be further established.

A 68-year-old patient with a huge dangling vocal papilloma was admitted for surgical resection. Preoperative data regarding the patient’s mass-related symptoms, endoscopic view, and radiological evaluation indicated that airway management would be difficult. Fiberoptic intubation has been considered an ideal primary approach to managing problematic airways, but blind advancement of the endotracheal tube without a clear, consistent view of the mass presents a significant threat to patient safety. This report describes how safe intubation was accomplished while the patient was awake using laryngeal nerve blocks and a McGrath® videolaryngoscope.

Airway topicalization is frequently utilized by anesthesiologists to facilitate open airway procedures, aid intubation for a difficult airway, and prevent adverse respiratory events. This review article summarizes the techniques available for airway topicalization for a patient who is deemed to be difficult to intubate. We focus on the indications for use, local anesthetic maximum dosages and safety profiles, sedation techniques, and trials and pitfalls during airway topicalization for difficult intubation.

BackgroundSufentanil has sedative and inhibitory effects on the intubation response, but high doses of sufentanil can cause coughing and respiratory depression. Dezocine has been documented effectively suppressing sufentanil-induced cough. Whether dezocine can inhibit the respiratory depression caused by sufentanil is unknown. This study aims to observe the efficacy of dezocine combined with sufentanil in awake intubation.MethodsFour hundred and three patients of American Society of Anesthesiologists physical status Classes I and II, aged 18–65 years, were randomly allocated into four groups: Group saline (saline + 0.4 ug/kg sufentanil), Group D0.05 (dezocine 0.05 mg/kg + 0.4 ug/kg sufentanil), Group D0.10 (dezocine 0.10 mg/kg + 0.4 ug/kg sufentanil), and Group D0.15 (dezocine 0.15 mg/kg + 0.4 ug/kg sufentanil). The primary outcome of our study was to observe the incidence of respiratory depression. Secondary outcomes included the success rate of intubation, ease of intubation, intubation comfort score, sore throat, hoarseness, lethargy, limb movement, glottis exposing and the satisfaction of patients during intubation. Hemodynamic changes were recorded after sufentanil injection and awake intubation.ResultsThere was no difference in the effect of normal saline and 0.05 mg/kg dezocine on respiratory depression (P = 0.603). The incidence of respiratory depression in Group D0.10 and Group D0.15 was lower than that of Group saline. Cough was statistically different between the four groups (P P P > 0.05).ConclusionsOur study indicated that 0.10 mg/kg and 0.15 mg/kg dezocine might prevent the occurrence of cough and respiratory depression induced by sufentanil during awake intubation and improve patient satisfaction.Trial registrationClinicaltrials.gov (NCT02673723), 2- 4- 2016.

RSI is our go-to method of intubation in the ED and ICU. However, not all patients are appropriate candidates for RSI. For some patients, maintaining spontaneous respirations until the tube is in between the cords is far safer. Developing a comfort level with awake intubation is a helpful tool in a practitioner’s airway arsenal.

A "difficult airway" should be suspected in patients with any anatomical or physiologic abnormality that might result in the loss of the airway or significant cardiopulmonary compromise upon induction of general anesthesia. Historically, an awake intubation has often been the preferred approach for airway management in these patients. Here we describe a case in which an awake intubation was safely performed in a patient with both anatomical (i.e., laryngeal mass) and physiologic (i.e., pulmonary hypertension) abnormalities. Oxygenation, airway patency, and spontaneous breathing were well maintained with successful intubation on the first attempt. We recommend that the patient's physiologic state should always be considered in airway management planning.

New airway equipment has recently become available that has reduced morbidity and mortality. However, airway disasters still occur. This article discusses the prudent escalation of the use of advanced airway equipment to prevent these disasters. We illustrate when and how to use a gum elastic bougie and a video-laryngoscope (VL). We also strongly recommend the combined use of the VL together with a flexible intubation scope (FIS) for both asleep and awake intubation when dealing with a genuinely difficult airway. Blind intubations should no longer be performed today. When an airway has been recognized as difficult it is the safest to aim for an awake or at least a spontaneously breathing intubation if circumstances do not allow for an awake intubation. Emergency cricothyroidotomy needs to be prepared for so that it can be executed rapidly in case the attempted awake intubation leads to complete airway obstruction.

A 71-year-old man with advanced vocal cord carcinoma presented with severe airway obstruction. Therapeutic anticoagulation with enoxaparin complicated management. Failure of an oral awake bronchoscopic intubation was rescued by passing a guidewire through the working channel and threading an Arndt exchange catheter into the trachea under videoscopic vision. Ventilation with the Ventrain device lasting 40 minutes (15 L/min, inspiration/expiration 1:1, 15 breaths/min), during IV anesthesia with muscle paralysis, resulted in excellent blood gas values until placement of the tracheal cannula. This case report highlights the effectiveness of a novel ventilation technique that should be considered as back-up when bronchoscopic intubation fails.

Introduction: Difficult airway management is an important cause of morbidity and mortality, and the implementation of new techniques and devices has contributed to the reduction of complication rates. Case presentation: A 62-year-old woman with a large neck mass scheduled for palliative percutaneous tracheostomy in which awake intubation with videolaryngoscopy was performed successfully in the first attempt; additionally, it was necessary to perform percutaneous tracheostomy under ultrasound guidance because of the significant degree of anatomical distortion of her neck. Conclusion: There is little evidence about awake intubation with videolaryngoscope in patients with neck masses, which makes our case interesting. Ultrasonography should be immediately available in difficult airway cases, because it facilitates the identification of structures and helps guide percutaneous access in real time.

Tomasz Gaszyński Department of Anaesthesiology and Intensive Therapy, Medical University of Łódź, Łódź, Poland Abstract: The C-MAC videolaryngoscope was evaluated for intubation in patients with predicted extremely difficult airway. The presented cases are patients with neoplasm tumors in larynx. In all cases, awake intubation using C-MAC videolaryngoscope was performed in patients breathing spontaneously, under local anaesthesia, with oxygen administered via nasal catheter. All intubations were successful and uneventful. The pre-surgery examination (CT scans and fiberscope laryngeal examination) was compared with view of larynx obtained during laryngoscopy. Based on my experience, I assume that C-MAC videolaryngoscope is a very useful tool for anaesthesiologists and can be applied not only for unexpected difficult intubation but also for predicted difficult airway. Moreover, it could be used as an additional diagnosis tool before larynx surgery. The view obtained with the C-MAC videlaryngoscope corresponds with larynx examination performed before surgery, and could potentially reveal more details. Keywords: videolaryngoscope, airway management, predicted difficult airways, C-MAC

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.

Awake intubation is frequently described in the literature as the preferred method for securing the airway in adult patients with epiglottitis, whereas children with epiglottitis are usually intubated following an inhalational induction. However, if topicalization is difficult due to the presence of an abscess or an uncooperative patient, an inhalational induction may still be a reasonable approach in the adult patient. In a review of the literature, only one recent case report had been found describing an inhalational induction with video laryngoscopy. However, this attempt was unsuccessful, mandating the need for a surgical airway. Our case report describes a successful inhalational induction and video laryngoscope intubation without the use of a paralytic agent in an adult patient with an epiglottic abscess and moderate airway stenosis.

Perioperative difficult airway management is one of the most challenging tasks encountered by anesthesiologists. Awake intubation is considered the gold standard in securing the anticipated difficult airway. Effective communication between the anesthesiologist and patient is vital during awake intubation. A language barrier can significantly hinder success and jeopardize patient safety. We report a case of a monolingual Arabic-speaking patient with a difficult airway who required awake intubation to undergo surgery. Google Translate, a free and accessible translation software application, was used during his awake intubation-we recommend such an approach to be considered to reduce anxiety and facilitate success by providing concise, real-time instruction in the patient's preferred language.

The posterior fossa and craniovertebral junction are well known to surgeons as neuroanatomically critical locations with a myriad of complex and sensitive structures packed into a small area. It is often said that benign lesions in this part of the brain are in a malignant location. Anesthesia for such surgeries is also appropriately recognized as complex and presents unique challenges for the anesthesiologist as well. The choice of anesthesia technique and agents based on the neurophysiologic monitoring anticipated, induction and intubation challenges, unique patient positioning requirements, as well as postoperative airway decisions pertaining to adequacy of gag and swallow reflexes, all lend to the special challenges. For this reason, a thorough conversation should be had prior to the induction of anesthesia between the surgeon, neurophysiologic monitoring personnel and anesthesiologist as to the particulars of the case at hand.

Background The anesthesia of patients with large mediastinal mass is at high-risk. Avoidance of general anesthesia in these patients is the safest option, if this is unavoidable, maintenance of spontaneous ventilation is the next safest technique. In these types of patients, it is not applicable to use double-lumen tube (DLT) to achieve one-lung ventilation (OLV) because the DLT has a larger diameter and is more rigid than single-lumen tube (SLT), so the mass may rupture and bleed during intubation. Even using a bronchial blocker, a small size of SLT is required for once the trachea collapses the SLT can pass through the narrowest part of trachea. However, it is difficult to control the fiberoptic bronchoscopy (FOB) and the bronchial blocker simultaneously within the lumen of a small size SLT with traditional intubation methods. Case presentation The current study presented a 66 years old female patient with a large mediastinal mass that presented with difficulty breathing when lying flat. In this case, we combined use of dexmedetomidine and remifentanil to preserve the patient’s spontaneous ventilation during intubation and achieved one-lung ventilation with extraluminal use of Uniblocker. Conclusions Extraluminal use of Uniblocker and maintenance of spontaneous ventilation during intubation may be an alternative to traditional methods of lung isolation in such patients with a large mediastinal mass.

Awake intubation is a key technique in anesthesia, allowing for the safe management of a patient with signs and predictors of a difficult airway/intubation. It is commonly undertaken electively, but can also be used in an emergency. An appropriate history must be taken, along with review of investigations (e.g CT scan, nasendoscopy), followed by a physical examination and development of a safe management plan. A variety of local anesthetic methods exist for topicalization of the airway (2-4% lidocaine), including nerve blocks (glossopharyngeal, recurrent laryngeal, superior laryngeal) to assist this. Sedation and amnesic techniques commonly include the use of benzodiazepines (midazolam), opioids (remifentanil infusion) and alpha agonists (dexmedetomidine). Knowledge of the side effects of these are paramount, including the cardiac and central nervous system with local anesthetic toxicity. 20% lipid emulsions are available in the event of this. This review contains 4 figures, 5 tables, and 25 references. Keywords: awake flexible bronchoscopic intubation, awake endoscopic intubation, remifentanil, dexmedetomidine, airway anesthesia, glossopharyngeal nerve block, recurrent laryngeal nerve block, superior laryngeal nerve block, local anesthetic toxicity, lipid emulation.

We report successful awake intubation in a morbidly obese patient (body mass index of 61.2) using an epidural catheter inserted through the external forceps channel of the fiberscope for delivery of local anesthetic. Direct application of local anesthetic to the pharyngolaryngeal area and proximal tracheal, through the use of a relatively firm epidural catheter. We conclude that awake intubation can be achieved by this method which spares the subsequent use of any sedative drugs.

We demonstrated the importance of managing a patient who presented with stridor due to severe Reinke’s oedema. The concept of managing difficult airway has thus been introduced for the otolaryngologists according to a plan of action as described by the American Society of Anaesthesiologist’s difficult airway algorithm. Methods: A case report of interest and review of literature. PubMed search with keywords of difficult airway, stridor, awake intubation and Reinke’s oedema was used. Result: Management of an anticipated difficult airway with awake fiberoptic intubation with backup strategies of direct laryngoscopies with Eshmann stylet and awake invasive intubation is highlighted. Conclusion: This case report demonstrated a definitive strategy of securing a difficult airway with obstruction at the glottis and highlighted the role of teamwork between otolaryngologist and anaesthesiologist to secure difficult airway.

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.

We present a case of extremely difficult airway management in a 56-year-old patient presenting for an elective repair of a recurrent inguinal hernia. He was a diagnosed case of severe ankylosing spondylitis resulting in limited cervical spine mobility and restricted mouth opening. Airway management was achieved with awake nasal intubation and the procedure was completed uneventfully.

Thoracic anesthesia is mainly the world of OLV during anesthesia. The indications for OLV, classified as absolute or relative are more representative of the new concepts in OLV: It includes either the separation or the isolation of the lungs. Modern DLTs are most widely employed worldwide to perform OLV including the concept of one lung separation. Endobronchial blockers are a valid alternative to DLTs, and they are mandatory in the education of lung separation and in case of predicted difficult airways as they are the safest approach (with an awake intubation with an SLT through a FOB). Every general anesthesiologist should know how to insert a left-sided DLT, but he/she should also have in his technical luggage and toolbox, basic knowledge and minimal expertise with BBs, this option being considered a suitable alternative, particularly in emergency situation where the patient is already intubated and/or in case of difficult airways. One should keep in mind that extubation or re-intubation after DLT might be difficult too, and additional intubation tools are necessary for the safety conditions., SCOPUS: re.j, info:eu-repo/semantics/published

Awake fiberoptic intubation is the most widely used approach in the management of the known difficult airway. However, there are several problems that limit this technique. Most anesthesiologists agree on the challenging nature of fiberoptic intubation training. The maintenance of this skill requires regular practice. Among the known risks of this technique are airway hiperreactivity due to inadequate topic anesthesia, excessive sedation or agitation, nasal hemorrhage and, in some cases, progression from partial to complete airway obstruction. Vídeolaryngoscopy can be an alternate option in the management of known difficult airway. These devices are becoming widely used because they are easy to use, inexpensive and versatile, and thus they can be used in a wider variety and number of patients., La intubación del paciente despierto con fibrobroncoscopio es la técnica más ampliamente utilizada ante la presencia de una vía aérea difícil conocida. Sin embargo, hay varias razones que limitan su ejecución. La mayoría de los anestesiólogos están de acuerdo en que el fibrobroncoscopio constituye un reto en cuanto a su aprendizaje. Además, una vez aprendida esta habilidad, requiere una práctica regular para su mantenimiento. La hiperreactividad de la vía aérea por una anestesia tópica inadecuada, el exceso de sedación y agitación, la hemorragia nasal, y en algunos casos, la progresión de una obstrucción parcial existente la vía aérea hasta una total, han sido comunicados como riesgos de la técnica. Los videolaringoscopios pueden ser una solución ante una vía aérea difícil prevista. Su uso se está extendiendo ampliamente porque son dispositivos fáciles de manejar, económicos y versátiles, permitiendo su utilización en un mayor número y variedad de pacientes.

Airway management of patients undergoing thyroidectomy for Retrosternal Goitre (RSG) poses a unique challenge. Associated comorbidities, manipulation of the airway by the surgeons, airway compromise during induction, intubation, intraoperative and postoperative period can contribute to adverse events. We describe anaesthetic management of a patient with long standing goitre for 61 years with retrosternal extension with tracheal narrowing and compression for thyroidectomy. We secured the airway in an awake, spontaneously breathing patient under topical anaesthesia and sedation using direct laryngoscopy. Airway management of RSG is challenging at every phase of anaesthesia. Maintaining airway patency, vigilance and preparedness are keys to the success of intubation.

Jia Jiang,1 Da-Xu Ma,1 Bo Li,2 An-Shi Wu,1 Fu-Shan Xue31Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; 2Beijing Hospital of Traditional Chinese Medicine, Affiliated to Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing 100010, China; 3Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China Background: Awake intubation with videolaryngoscopy (VL) is a novel method that is drawing more and more attention as an alternative to awake intubation with fiberoptic bronchoscope (FOB). This meta-analysis is designed to determine the performance of VL compared to the FOB for awake intubation.Methods: The Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of science were searched from database inception until October 30, 2017. Randomized controlled trials comparing VL and FOB for awake intubation were selected. The primary outcome was the overall success rate. Rev-Man 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE system was used to assess the quality of evidence for all outcomes.Results: Six studies (446 patients) were included in the review for data extraction. Pooled analysis did not show any difference in the overall success rate by using VL and FOB (relative risk [RR], 1.00; P=0.99; high-quality evidence). There was no heterogeneity among studies (I2=0). Subgroup analyses showed no differences between two groups through nasal (RR, 1.00; P=1.00; high-quality evidence) and oral intubations (RR, 1.00; P=0.98; high-quality evidence). The intubation time was shorter by using VL than by using FOB (mean difference, -40.4 seconds; P0.05).Conclusion: For awake intubation, VL with a shorter intubation time is as effective and safe as FOB. VL may be a useful alternative to FOB.Keywords: airway management, awake intubation, videolaryngoscopy, fiberoptic bronchoscopy, randomized controlled clinical trials, outcomes

We present a case of a 63-year-old man with nasocutaneous fistula located outside the area covered by a large adult facemask. The patient was uncooperative for the standard airway assessment and any attempt at awake intubation. Positive pressure ventilation was compromised by the fistula. Although the incidence of overall complications, including fistula formation, following free flap reconstruction for oropharyngeal cancer is reported as high as 20%, few case reports detailing airway management exist. We demonstrate that it is possible to use conventional techniques to induce and ventilate a patient with a large, externalized, airway fistula by covering the defect with an occlusive transparent dressing.