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Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

Awake fibreoptic intubation (AFOI) is an established modality in patients with anticipated difficulty with tracheal intubation. This case demonstrates that with careful and meticulous preparations, AFOI can lead to improved airway management and excellent patient outcomes. A 38-year-old woman presented with severe trismus secondary to odentogenous abscess was identified preoperatively as having a potential difficult airway. AFOI was performed successfully using combined Spray-As-You-Go and dexmedetomidine technique.

Resumen El abordaje de la via aerea en la unidad de urgencias prehospitalarias es una practica comun que potencialmente salva vidas. El manejo es complejo debido al entorno, lo cual significa un porcentaje mucho mas elevado de vias aereas dificiles que en un ambiente regulado, como en el caso del quirofano. El intento fallido o prolongado de intubacion traqueal esta asociado a resultados desfavorables y complicaciones graves. La epiglotitis aguda es un trastorno potencialmente letal, clasificado como urgencia medica dentro de las enfermedades de la via aerea respiratoria superior, que se caracteriza por una evolucion repentina y mortal si no se logra una intubacion rapida que permita la oxigenacion del paciente. Describimos el caso de un paciente de 36 anos con estridor, disnea e hipoxemia debido a la obstruccion total de la via aerea, causada por una epiglotitis aguda. Nuestro objetivo es subrayar esta lesion infrecuente y su manejo desde la unidad prehospitalaria hasta el alta, ilustrando la gravedad de la presentacion clinica, el tratamiento actual y el resultado.

Objectives The Airway Alert banner at our institution alerts physicians to patients with the potential for a difficult intubation. Difficult airway guidelines can reduce intubation complications in the operating room, but little research has been done in the emergency department (ED). We hypothesize that patients meeting criteria for the banner will have a more difficult intubation and increased complications. Methods Patients greater than 18 years old who presented to the ED for any complaint and required intubation were reviewed from January 2015 to January 2020 and divided into those meeting criteria for a difficult airway (“criteria cohort”) and those who did not (“non‐criteria cohort”). Past medical history and details of the intubation were collected. Results The mean number of attempts for intubation was 1.60 in the criteria cohort and 1.36 in the non‐criteria cohort (P > .05). The mean grade of view was 1.73 and 1.39, respectively (P

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

The infants are explicitly vulnerable to develop anaesthesia-related complications, with micropreemies being at the end of the spectrum because of their unique morphological and physiological features. Airway changes in pediatric patients are most exaggerated in these tiny infants and their immature lungs provide a little reserve, and therefore, securing airways can be challenging in this population. Moreover, many devices available for managing difficult airways in adults are not available for use in this miniature version. Videolaryngoscopes are a useful addition to anaesthesiologists' armamentarium but for micropreemies, size of videolaryngoscope can be a limiting factor as no vide- olaryngoscope comes in "00" size. The technique of videolaryngoscope may need to be modified in these patients. Regional anaesthesia can be an invaluable component of their perioperative care to facilitate a smooth recovery. The successful management of these vulnerable neonates requires a multidisciplinary team approach to maintain perioperative homeostasis of their immature organ systems.

Introduction Video laryngoscopes improve visibility of the vocal cords, especially in difficult airways, and enable successful intubation at the first attempt. In this study, we aimed to compare the success rate of AirAngel intubation produced by 3D printing and Glidescope video laryngoscopes used routinely in the first attempt. Methods Intubation was performed by emergency physicians with AirAngel and Glidescope video laryngoscopes in a randomized, crossover model in normal and difficult airway simulations. Twenty-three emergency medicine physicians were included in the study. The number of intubation attempts, intubation success and intubation time were recorded. Results In normal airway simulations, the first-pass success of intubation was 47% for AirAngel video laryngoscopy and 100% for Glidescope video laryngoscopy (p Conclusion The intubation success rate of AirAngel video laryngoscopes was significantly lower than that of Glidescope video laryngoscopes.

BACKGROUND: Selective lung intubation is a life-saving procedure in emergency departments. While various equipment can be used in selective lung intubation, most of this equipment is not readily available; therefore, single-lumen endotracheal intubations are performed for rapid interventions. MATERIALS AND METHODS: This study was designed as a randomized, prospective, cross-over study using the 90° rotation technique for selective intubation on a manikin model with and without endotracheal tube introducer (ETI) in difficult airway settings. Forty-six emergency physicians were included in the study. The primary outcome was evaluating time to selective intubations, and secondary outcomes were first and second attempt success rates and the self-perceived difficulty level of each method according to the participants. RESULTS: The mean time to the first successful endotracheal intubation was significantly longer for both right selective and left selective intubations with ETI utilization than without ([39.71 ± 9.83 vs. 21.86 ± 5.94 s], [P < 0.001]), ([42.2 ± 10.81 vs. 26.23 ± 7.97 s], [P < 0.001], respectively). The first-pass success rate did not differ for right selective intubation with or without an ETI (45/46 [97.8%] and 45/46 [97.8%], respectively). However, the first-pass success rate for left selective intubation was significantly higher with ETI as compared to without an ETI (30/46 [65.2%] and 13/46 [28.3%], respectively) (P < 0.001). CONCLUSIONS: While the success rates of right selective intubation were the same, the left selective intubation success rates with ETI are higher than the styletted endotracheal tube, which can be strong evidence for this method's applicability in practice. Expanding the use of ETI and increasing the experience of the practitioners can contribute to further success.

Background and Aims: Patient cooperation, sedation, anxiolysis, and topicalization are important prerequisites for the successful and safe conduct of awake intubation. Because of the pharmacological properties, opioids can facilitate this process. Fentanyl is an opioid agonist and nalbuphine is an agonist-antagonist. This study aims to compare these two opioids for their effect on sedation and intubating conditions during awake fiberoptic intubation. Material and Methods: This randomized double-blind controlled study was conducted on 62 ASA I/II patients of either sex between the age of 20 and 60 years, weight between 40 and 80 kg, with MP class I/II airways requiring general anesthesia with endotracheal intubation. All patients received standard airway topicalization and nebulization. Patients were randomly allocated to one of the two groups according to a computer-generated random number table. Group F (n = 31) received fentanyl 2 μg/kg i.v. and group N (n = 31) received nalbuphine 0.2 mg/kg i.v. over 10 min before intubation. Fiberoptic intubation was attempted and lignocaine spray and propofol boluses were administered as and when required. Hemodynamic responses and intubating conditions were recorded. Repeated measure ANOVA, McNemar test, and Chi-square test or Fischer's exact test were used for data analysis. A P < 0.05 was considered significant. Results: Cough score (P = 0.458), post-intubation score (P = 1.000), and sedation score (P = 1.000) were comparable among the two groups. Hemodynamic responses and propofol and lignocaine requirements were also comparable. Conclusion: Both fentanyl and nalbuphine provide comparable intubating conditions when used before awake fiberoptic intubation with minimal adverse effects on hemodynamic profile.

Случаи сложной или неудачной экстубации редко обсуждаются в нашем анестезиологическом сообществе. В то время как значительное внимание уделяется налаживанию контроля над дыхательными путями (включая сложные дыхательные пути), информации о случаях неудачных экстубаций недостаточно. Нужно помнить, что неудачная экстубация является потенциально более угрожающей ситуацией, чем сложности с интубацией, и имеет серьезные последствия, включая юридическую ответственность. В статье рассмотрены предикторы сложной/неудачной экстубации и пути решения и профилактики на основании данных современных исследований и руководств. Также обсуждается методика поэтапной экстубации трахеи, особенности применения, возможность внедрения в современных условиях и опыт авторов.

Objective:To evaluate the competencies of intensivists and clinicians on endotracheal intubation (ETE) and airway safety.Materials and Methods:The survey was published both as printed and electronically. It was shared in the announcements of speciality associations and congresses.Results:Of the participants, 30% of them received the first ETE training in the medical faculty, 21% during internship, 38% during residency, 1.1% in the critical care subspeciality residency. Of those who received ETE training on a patient, 13 were in emergency medicine, 89 in anesthesiology and reanimation, 1 in infectious diseases, 1 in general surgery, 9 in chest diseases, 11 in internal medicine, and 3 in neurology. Also, 81% of the participants feel that they are experienced enough (18 emergency medicine, 102 anesthesiology and reanimation, 2 infectious diseases, 3 general surgery, 10 chest diseases, 8 internal medicine, 2 neurology, and 4 pediatrics), 58 of whom were critical care specialists or subsepecialty residents.Conclusion:We concluded that ETE education had been started from medical school, but except for anesthesiology and reanimation and emergency and intensive care, the training programmes were not repeated and participation was not sufficient. We recommend at least 40 ETE on the mannequin and capnograph used for patient safety.

Introduction: Poland’s syndrome is an uncommon clinical disorder with a typical musculoskeletal deformity of thorax and ipsilateral upper limb with a variable spectrum of associated anomalies. Although patients of this musculoskeletal disorder have several features with potential anaesthetic risks including malignant hyperthermia, previous reports about anaesthetic management of these patients are limited. Case Presentation: We report the successful anaesthetic management of a child of Poland’s syndrome posted for surgical correction of club foot who had an anticipated difficult airway alongwith unilateral chest wall defect with paradoxical breathing and ipsilateral syndactyly and hence, posing challenges in the insertion of endotracheal tube, ventilatory management, regional anaesthesia and prevention of any risk of development of malignant hyperthermia. Conclusion: Paramount in the anaesthetic care of such patients is a thorough preoperative evaluation and a cautious intraoperative anaesthetic management. Avoidance of halogenated inhalational agents and depolarising neuromuscular blocking drugs, and use of controlled ventilation and regional anaesthetic techniques are recommended. The possibility of a compromised airway should always be kept in mind while anaesthetising these patients. Keywords: Poland’s syndrome, Malignant hyperthermia, Difficult airway.

Background: The incidence of difficult airway in paediatric patients is lower than that the adult population, and the majority should be predictable. Aims: The primary aim of this trial was to evaluate the incidence of difficult airway in pediatric patients. The secondary aim was to predict difficult airway in these patients. Methods: Paediatric patients undergoing elective surgery under general anaesthesia in a tertiary university hospital were examined, and a panel of difficult airway prediction tests was performed. We recorded the incidence, risk factors for difficult airway and events associated with difficult airway together with the sensitivity and specificity of tests for difficult airway and events associated with difficult airway prediction. Results: We prospectively included 389 paediatric patients. The incidence of difficult airway was 3.6%; the incidence of events associated with difficult airway was 10%. The sensitivity for prediction of events associated with difficult airway during the pre-anaesthesia evaluation was 5.3% with the specificity 93.3%. In the operating room, the sensitivity of prediction was 15% with 97.8% specificity. Conclusion: We found minimal efficacy for preanaesthesia difficult airway prediction.

BACKGROUND Patients with ankylosing spondylitis (AS) combined with severe cervical fusion deformity have difficult airways. Awake fiberoptic intubation is the standard treatment for such patients. Alleviating anxiety and discomfort during intubation while maintaining airway patency and adequate ventilation is a major challenge for anesthesiologists. Bronchial blockers (BBs) have significant advantages over double-lumen tubes in these patients requiring one-lung ventilation. AIM To evaluate effective drugs and their optimal dosage for awake fiberoptic nasotracheal intubation in patients with AS and to assess the pulmonary isolation effect of one-lung ventilation with a BB. METHODS We studied 12 AS patients (11 men and one woman) with lung or esophageal cancer who underwent thoracotomy with a BB. Preoperative airway evaluation found that all patients had a difficult airway. All patients received an intramuscular injection of penehyclidine hydrochloride (0.01 mg/kg) before anesthesia. In the operating room, dexmedetomidine(0.5 μg/kg) was infused intravenously for 10 min, with 2% lidocaine for airway surface anesthesia, and a 3% ephedrine cotton swab was used to contract the nasal mucosa vessels. Before tracheal intubation, fentanyl (1 μg/kg) and midazolam (0.02 mg/kg) were administered intravenously. Awake fiberoptic nasotracheal intubation was performed in the semi-reclining position. Intravenous anesthesia was administered immediately after successful intubation, and a BB was inserted laterally. The pre-intubation preparation time, intubation time, facial grimace score, airway responsiveness score during the fiberoptic introduction, time of end tracheal catheter entry into the nostril, and lung collapse and surgical field score were measured. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded while entering the operation room (T1), before intubation (T2), immediately after intubation (T3), 2 min after intubation (T4), and 10 min after intubation (T5). After surgery, all patients were followed for adverse reactions such as epistaxis, sore throat, hoarseness, and dysphagia. RESULTS All patients had a history of AS (20.4 ± 9.6 years). They had a Willson's score of 5 or above, grade III or IV Mallampati tests, an inter-incisor distance of 2.9 ± 0.3 cm, and a thyromental (T-M) distance of 4.8 ± 0.7 cm. The average pre-intubation preparation time was 20.4 ± 3.4 min, intubation time was 2.6 ± 0.4 min, facial grimace score was 1.7 ± 0.7, airway responsiveness score was 1.1 ± 0.7, and pulmonary collapse and surgical exposure score was 1.2 ± 0.4. The SBP, DBP, and HR at T5 were significantly lower than those at T1-T4 (P < 0.05). While the values at T1 were not significantly different from those at T2-T4 (P > 0.05), they were significantly different from those at T5 (P < 0.05). Seven patients had minor epistaxis during endotracheal intubation, two were followed 24 h after surgery with a mild sore throat, and two had hoarseness without dysphagia. CONCLUSION Patients with AS combined with severe cervical and thoracic kyphosis should be intubated using fiberoptic bronchoscopy under conscious sedation and topical anesthesia. Proper doses of penehyclidine hydrochloride, dexmedetomidine, fentanyl, and midazolam, combined with 2% lidocaine, administered prior to intubation, can provide satisfactory conditions for tracheal intubation while maintaining the comfort and safety of patients. BBs are safe and effective for one-lung ventilation in such patients during thoracotomy.

End-expiratory carbon dioxide concentrations can be used to assist endotracheal intubation. The novel multimodal endotracheal intubation guidance device combined visualization with an end-expiratory carbon dioxide concentration vectorization algorithm to achieve more accurate placement in difficult airways. The feasibility of a novel multimodal guidance device for the endotracheal intubation of difficult airways was verified in spontaneously breathing Bama miniature pigs. The glottic exposure time, insertion time, and total intubation time were not significantly different between the fiberoptic bronchoscope group and the multimodal guidance device group in regard to the endotracheal intubation of difficult airways. There were also no significant differences in intubation attempts, first success rate, and total success rate. Animals in both groups experienced hypoxemia, hypotension, and esophageal intubation during endotracheal intubation, but there were also no significant differences in the incidence of adverse events between the two devices. The effect on changes in hemodynamics, heart rate, and oxygen saturation during intubation showed no significant difference between the two devices. The results of the present study demonstrated the feasibility and effectiveness of the initial prototype of a multimodal guidance device for the endotracheal intubation of difficult airways in pigs, which is expected to further assist in adequately positioning the airway during difficult endotracheal intubations with spontaneous breathing.

The primary objective of this study was to evaluate the use of STOP-BANG questionnaire in prediction of difficult airway. The secondary aim of this study is to evaluate the correlation of the questionnaire and other difficult airway determinant tests in predicting difficult airway.Two hundred American Society of Anesthesiologists' Status I, II, and III patients under general anesthesia were enrolled in this prospective randomized study. Patients' age, height, body weight, body mass index, neck circumference, inter-incisor distance when the mouth is fully open, sternomental and thyromental distance, mandibular length, neck length, biting the upper lip, STOP-BANG score, and Mallampati and Cormack-Lehane (C-L) grades were recorded. The first thing we want to find is to determine the usability of the STOP-BANG questionnaire as an indicator of the difficult airway. Comparing difficult airway with the other parameters was secondary objectives. The patients were divided into two groups as difficult and easy intubation with difficult and easy facial mask ventilation. The data were analyzed using an SPSS statistics 16.0 program. Statistical analysis was performed using, Chi-square and Spearman correlation analysis test.Forty-five out of 200 patients had difficulty in intubation and 73 out of them had difficulty in mask ventilation. Between difficult airway and high STOP-BANG score was a moderate positive correlation (p0.05). Furthermore, unnatural dental status, greater head circumference, greater neck circumference, Mallampati, and C-L classification were significantly positive correlated with a difficult airway (p0.05).In our study, the STOP-BANG questionnaire was found to be important in predicting the difficult airway and this test was found to be usable like other difficult airway parameters.

Background: After failed endotracheal intubation, using direct laryngoscopy, rescued using a supraglottic airway device, the choice of subsequent method to secure a definitive airway is not clearly determined. Objective: The aim of this study was to compare the time to intubation using a fibre-optic airway scope, to guide an endotracheal tube through the supraglottic airway device, with a more conventional approach using a hyperangulated video laryngoscope. Methods: A single-centre randomised controlled trial was undertaken. The population studied were emergency physicians working in an adult major trauma centre. The intervention was intubation through a supraglottic airway device guided by a fibre-optic airway scope. The comparison was intubation using a hyperangulated video laryngoscope. The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000018819). Results: Four emergency physicians completed intubations using both of the two airway devices on four cadavers for a total of 32 experiments. The mean time to intubation was 14.0 s (95% confidence interval = 11.1–16.8) in the hyperangulated video laryngoscope group compared with 29.2 s (95% confidence interval = 20.7–37.7) in the fibre-optic airway scope group; a difference of 15.2 s (95% confidence interval = 8.7–21.7, p Conclusion: Successful intubation of the trachea without airway trauma by emergency physicians in cadavers is achievable by either fibre-optic airway scope via a supraglottic airway device or hyperangulated video laryngoscope. Hyperangulated video laryngoscope was statistically but arguably not clinically significantly faster than fibre-optic airway scope via supraglottic airway device.

Background Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment. Methods This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included. Results In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the “thickness of anterior neck soft tissue at the vocal cords level”. Also, “skin to epiglottis” and “anterior neck soft tissue at the hyoid bone level” were among the most common indicators examined in this area. Conclusion This systematic review showed that US can be used for predicting difficult airway. Of note, “skin thickness at the epiglottis and hyoid levels”, “the hyomental distance”, and “the hyomental distance ratio” were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.

Airway management in patients presenting with severe airway obstruction can present a challenge to the anaesthetist, as conventional difficult airway pathways are often inappropriate. The use of a transtracheal jet cannula is an alternative means of airway securement, but lack of familiarity has limited its use in general tertiary hospitals. We report a retrospective audit of the use of transtracheal jet ventilation in a general tertiary healthcare centre over the past seven years, with a total of 50 patients with severe airway compromise undergoing pharyngolaryngeal surgery. Transtracheal jet ventilation was successful in 98% of patients, and was the definitive means of airway management in 43 cases. In six cases, the technique was a useful temporising measure while the airway was secured by other means. Minor complications occurred in 12% of patients. No major morbidities or mortalities were recorded. We conclude that transtracheal jet ventilation for high-risk pharyngolaryngeal surgery can be performed using a high frequency jet ventilator, with a high rate of success and only minor complications. Cannulation of the trachea below the cricothyroid membrane is feasible but more challenging. Low-flow apnoeic oxygenation through the transtracheal jet ventilation cannula maintains oxygenation during initial surgical airway manipulation.

Background Effective communication between anaesthetists is an important way of ensuring adequate management plans are made for patients with known difficult airways. The Difficult Airway Society developed an electronic database to facilitate this. Previous studies have surveyed attitudes and behaviours of anaesthetists and primary care physicians but not patients. Aim We sought opinions of patients who received a difficult airway database alert card (signifying their pre-consented registration) on a variety of topics. Methods We asked 10 questions regarding i) Quality of information received, ii) Views on the relevance of the alert card, iii) patient’s overall experience, iv) their opinion regarding paying a fee. Results All 402 patients on the database were contacted once (follow-up curtailed by COVID-19). We received 221 replies (55%). Ninety-seven percent (205/211) reported the card useful, 90% (191/211) recalling the information given. All those (49/203, 24%) having a further anaesthetic had presented their card to the anaesthetist/preoperative team. 6% (13/203) felt anxious having the card and almost one fifth (12/67) of the respondents suggested improved communication between anaesthetists, patients and primary care physicians (GPs). Half of responders were willing to pay for the service, while 17% (36/211) were not. Conclusion Difficult airway alert cards are well received by the patients and are re-presented when future anaesthetics are required. Improved transfer of information between anaesthetists, primary care physicians and patients was a popular theme in the feedback. The issuing of an airway alert card may prove to be a vehicle for this in the future.

The use of mechanical ventilation can be performed in situations where patients need ventilatory support to maintain adequate oxygenation. Its inappropriate use can cause some complications, among them: pneumothorax and pneumoperitoneum. Our report describes a 28-year-old man admitted to the ICU with a diagnosis of Covid-19 requiring mechanical ventilation with orotracheal intubation due to acute respiratory failure. During the patient’s clinical evolution he presented bilateral pneumothorax with evolution and progression to secondary pneumoperitoneum, where we sought to understand the relationship between the two conditions.

Tracheal extubation is an aerosol-generating medical procedure. A difficult tracheal extubation results in a serious complication that increases the risk of respiratory aerosol and pathogen spread, especially during the COVID-19 pandemic. The management of difficult extubation is potentially even more challenging during the pandemic. We report two cases of difficult extubation due to endotracheal tube cuff malfunction during the COVID-19 pandemic. Special airway maneuvers and infection control measures were employed to successfully manage the unexpected dilemma. This case series highlights the risk of COVID-19 virus transmission during difficult extubation. This report describes the preventive and reactive management of difficult extubation.

Background Adams-Oliver syndrome is characterized by the combination of congenital scalp defects and terminal transverse limb defects. In some instances, cardiovascular malformations and orofacial malformations have been observed. Little is written with regards to the anesthetic management and airway concerns of patients with Adams-Oliver syndrome. Case presentation A five-year-old female with Adams-Oliver syndrome presented for repeat lower extremity surgery. Airway exam was significant for dysmorphic features, such as hypertelorism, deviated jaw, and retrognathia. Video laryngoscope was utilized for intubation due to the patients retrognathic jaw, cranial deformities, and facial dysmorphism. A vein finder with ultrasound guidance was needed to place the peripheral intravenous line due to her history of difficult intravenous access. The patient was successfully intubated with slight cricoid pressure applied to direct the endotracheal tube smoothly. Surgery and recovery were both unremarkable. Conclusions Due to varying presentations of Adams-Oliver syndrome, anesthetic and airway management considerations should be carefully assessed prior to surgery. Anesthesiologists must take into consideration possible orofacial abnormalities that may make intubation difficult. Amniotic band syndrome and other limb defects could potentially impact intravenous access as well.

Introduction: Altered nasorespiratory function leads to altered craniofacial growth. Thus, airway evaluation is important for preventive, interceptive, and corrective orthodontic treatment. The aim of this study was to evaluate and compare adenoids, the upper airway, the tongue, and mandibular dimensions using “predictors of difficult airways” in class II division 1 and class II division 2 cases with class I cases. Method: Sixty subjects of age 15 to 18 years were divided into 3 groups (group 1: class I cases; group 2: class II division 1 cases; and group 3: class II division 2 cases) based on cephalometric parameters, with 20 cases in each group. Cephalometric evaluation of adenoids and the nasopharyngeal airway was done using the Handelman–Osborne area method. Upper and lower airway evaluation was done using McNamara’s linear method. “Predictors of difficult airways” were used for evaluation of the airway, which included nasal competency, the Mallampati scale, mandibular length, mandibular protrusion, and the thyromental distance. Results: The present study found a significant positive correlation between the grades of nasal competency and percentage adenoid wall area, and a significant negative correlation between the grades of nasal competency and the upper airway. There was a significant positive correlation between the grades of nasal competency and mandibular length, and a significant positive correlation between the grades of mandibular protrusion and mandibular length. There was a significant positive correlation between the grades of the thyromental distance and mandibular length. Conclusion: It was concluded that the “predictors of difficult airways” would be helpful in early diagnosis and identification of potential risk factors that may cause “breathing disorders”–related malocclusions and later on increase the risk of developing OSA.

Theanterior approach to the cervical spine is commonly utilized for a variety of degenerative, neoplastic, traumatic, and infectious indications. The distinctive anatomy of the anterior neck presents a unique set of hazards. We encountered a case of delayed esophageal perforation after cervical spine surgery, who presented to us forty-two days post-surgery. Although, timely detection and management of esophageal perforation has a good prognosis, associated vascular complications added on to airway management challenges. We outline the issues with diagnosis and key aspects of airway management in this patient. Keywords: Cervical spine surgery, Esophageal perforation, Difficult airway, Tracheostomy.

Introduction: Altered airway and growth are interrelated; hence, a study was planned to develop a diagnostic protocol that may help in diagnosing difficult airway by utilizing routine radiographic assessment. Material and Methods: Lateral cephalograms of 60 children aged 12 to 14 years who were grouped based on the growth pattern into 3 groups with 20 cases each (Group 1—normodivergent cases; Group 2—hypodivergent cases; Group 3—hyperdivergent cases) were observed. The diagnostic protocol included 3 diagnostic methods (Handelman–Osborne area method, Maw et al method, and Holmberg et al method) routinely used by ENT surgeons for altered airway evaluation, and their diagnostic efficacy was correlated with McNamara’s airway analysis. Results: Highest specificity and diagnostic accuracy were found with Holmberg et al method followed by Maw et al method. Poor specificity was observed with Handelman–Osborne area method. Conclusion: The new diagnostic protocol which includes commonly used cephalometric methods by ENT surgeons can be helpful for orthodontists in early evaluation of altered airways, so that preventive and interceptive procedures can be carried out to normalize the altered craniofacial growth. Among the methods used in this diagnostic protocol, Holmberg et al and Maw et al methods had better sensitivity and specificity.

Background Difficult airway is a clinical situation in which a trained anesthesiologist experiences trouble with facemask ventilation and/or laryngoscopy and/or intubation. Poor identification of at-risk patients has been identified as one of the causes of difficult airway management. Objectives We aimed to review the literature regarding the use of wristbands to identify adult patients with known or predicted difficult airway in hospitals. Methods We searched Web of Science (WoS), Scopus, MEDLINE and OVID following the stages described by the PRISMA Extension for Scoping Reviews (PRISMA-ScR). We used a combination of MeSH terms and non-controlled vocabulary regarding the use of difficult airway wristbands in adults. Three researchers independently reviewed the full texts and selected the papers to be included based on the inclusion criteria. Results Our search generated 334 articles after removing duplicates. After reviewing full text articles, only seven studies were included. Here we found that most were from the United States, in which the authors report the use of in-patients’ wristbands in adults. According to the authors, the use of wristbands is being implemented as a measure of improved quality and safety of in-patients with difficult airway either known or suspected. Conclusions The identification with wristbands of a difficult airway at an appropriate time is an identification strategy can have a low cost but a high impact on morbidity. It is pertinent to develop a methodology such as the use of wristbands, that allows a good classification and identification of patients with difficult airway in hospitals from Latin America.

Background It is recommended that difficult airway predictors be evaluated before emergency airway management. However, little is known about how patients with difficult airway predictors are managed in emergency departments. We aimed to explore the incidence, management and outcomes of patients with difficult airway predictors in an emergency department. Methods We conducted a retrospective study using intubation data collected by a prospective registry in an academic emergency department from November 2017 to October 2018. Records with complete assessment of difficult airway predictors were included. Two categories of predictors were analyzed: predicted difficult intubation by direct laryngoscopy and predicted difficult bag-mask ventilation. The former was evaluated based on difficult external appearance, mouth opening and thyromental distance, Mallampati score, obstruction, and limited neck mobility as in the mnemonic “LEMON”. The latter was evaluated based on difficult mask sealing, obstruction or obesity, absence of teeth, advanced age and reduced pulmonary compliance as in the mnemonic “MOANS”. The incidence, management and outcomes of patients with these difficult airway predictors were explored. Results During the study period, 220 records met the inclusion criteria. At least 1 difficult airway predictor was present in 183 (83.2%) patients; 57 (25.9%) patients had at least one LEMON feature, and 178 (80.9%) had at least one MOANS feature. Among patients with at least one difficult airway predictor, both sedation and neuromuscular blocking agents were used in 105 (57.4%) encounters, only sedation was used in 65 (35.5%) encounters, and no medication was administered in 13 (7.1%) encounters. First-pass success was accomplished in 136 (74.3%) of the patients. Compared with patients without predictors, patients with positive LEMON criteria were less likely to receive neuromuscular blocking agents (OR 0.46 (95% CI 0.24–0.87), p = 0.02) after adjusting for operator experience and device used. There were no significant differences between the two groups regarding glottic view, first-pass success, or complications. The LEMON criteria poorly predicted unsuccessful first pass and glottic view. Conclusions In emergency airway management, difficult airway predictors were associated with decreased use of neuromuscular blocking agents but were not associated with glottic view, first-pass success, or complications.

Difficult airway management in critically ill patients remains a difficult task associated with high morbidity and mortality rates. In difficult airway populations, prompt effective intubation is more important to prevent hypoxia and neurological injury. During the ongoing COVID-19 pandemic, prolonged intubation time and repeated intubation can lead to an increase in the risk of infection. Therefore, digital devices can shorten intubation times and decrease the risk of infection among clinical staff. The advantages of the Trachway videolight intubating stylet suit these conditions. Trachway stylet intubation is an effective method for video laryngoscopy to enhance patient safety and improve the intubation success rate. However, a few studies have focused on the effect of stylet intubation by reducing repeated intubation and oxygen desaturation. In this study, we reviewed current data of Trachway intubation and shared our four major training scenarios in Taipei Tzu Chi Hospital via the Trachway videolight intubating stylet system for emergency intubation, comparing them with other modes of intubation.

Purpose Education in airway management is a fundamental component of anesthesiology training programs. There has been a shift towards the use of simulation models of higher fidelity for education in airway management. The goal of this study was to create a novel cadaveric model of a simulated parapharyngeal abscess with features of a difficult airway such as distorted anatomy and narrow airway passages presenting as stridor. The model was further assessed for its suitability for enhanced experiential learning in the management of difficult airways. Methods Cadaver heads were modified surgically to simulate parapharyngeal abscess. Airtight torso of the cadaver was connected to an Oxylog ventilator to simulate respiratory movements—the opening and closing of air channels with breaths in a patient with parapharyngeal abscess. Advanced airway workshop facilitators conducted directed one-to-one learning, and provided feedback to participants. A paper-based feedback was obtained from 72 participants on their confidence level, and the realism, attractiveness, beneficial, and difficulty levels of the simulated cadaveric models. Results The modified cadavers were reliable in simulating difficult airways. The majority of participants (91%) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers and found the models realistic (93%), attractive (92%), beneficial (93%), and difficult (85%). Conclusions Surgical modifications of cadavers to simulate difficult airways such as parapharyngeal abscess with edema and stridor can be incorporated into advanced airway management courses to enhance experiential learning in airway management by awake fibreoptic intubation, and promote patient safety. Supplementary Information The online version contains supplementary material available at 10.1007/s00540-021-02904-0.

Over the past few decades, oncosurgical procedures are increasing in number, require considerable expertise and training for anaesthetising such patients. Aortic Stenosis itself poses great challenge, causes significant increase in morbidity and mortality in the perioperative period. Head, neck oncosurgical procedures with difficult airway requiring awake fiberoptic intubation in such patients adds to the challenge. We describe once such case of previously operated Carcinoma of oral cavity with new growth involving mandible for excision of tumour with neck dissection and mandibular reconstruction with a free Fibula flap. This patient now presented with anticipated difficult airway with restricted mouth opening and a recent diagnosis of severe Aortic stenosis with mean gradient across aortic valve of 52mmHg and valve area 0.8 cm2. Such patient requires multidisciplinary team approach by cardiologist, anaesthesiologist, surgeon and intensivist to prevent perioperative morbidity and facilitate early recovery. Keywords: Difficult, Airway, Aevere, Aortic, Stenosis, Oncosurgery.

Supraglottic airway devices (SAD) have got popularity in the anesthetic practice owing to easy insertion, rapid airway access and lower incidence of complications. Igel® is a second generation SAD with a non‐inflatable cuff and gastric drainage channel. Despite ease of insertion, there are still cases of failure of Igel® insertion to secure airway. We are hereby presenting a case of unanticipated difficulty in Igel® insertion in a 35-years-old female due to a hypopharyngeal growth. This article aims to send a reminder that despite anticipated easy airway, definitive plan for securing airway should always be ready.

espanolIntroduccion: La evaluacion y prediccion de una via aerea dificil en el paciente pediatrico es de gran importancia para su correcto manejo, aplicacion de algoritmos y disminucion de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a traves de la aplicacion de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la via aerea pediatrica. Objetivos: Determinar la incidencia de via aerea dificil e identificar los factores de riesgo en los pacientes pediatricos con cardiopatia de 1 dia hasta 10 anos, sometidos a cirugia bajo anestesia general a traves de escala de COPUR. Metodologia: Es un estudio analitico transversal realizado en 235 ninos con cardiopatias congenitas de un Hospital Pediatrico en Quito- Ecuador sometidos a intervenciones quirurgicas electivas bajo anestesia general en el periodo entre junio de 2015 y diciembre del 2016. Resultados: Se encontro una intubacion normal y facil en un 73.19%, una mayor dificultad en la intubacion y una necesaria maniobra de presion laringea en el 24.26% y una dificil intubacion con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusion: La incidencia de via aerea dificil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubacion dificil, una uvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada prediccion de una via aerea dificil, su anticipacion permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solucion inmediata. EnglishIntroduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution.

Background There has been a renewed interest in using the plastic intubation bougie to facilitate first-attempt endotracheal intubation success. The sterile single-use telescopic steel bougie (AIROD) was invented to overcome the limitations of the plastic bougie which is easily deformed during storage. Methods This is a retrospective study involving critically ill patients who were intubated with the AIROD in the intensive care unit at a single institution. The purpose of this case series is to compare the success rate of the AIROD to the generally accepted success rate for the traditional plastic bougie of 96%. Results A total of 54 patients were enrolled at a single ICU over a 10 months period. All patients were critically ill with 76% having a difficult airway, Cormack-Lehane grade view 2 or greater in 60%, and ARDS secondary to COVID-19 in 54%. The primary outcome of first-attempt intubation success in critically ill patients intubated in the ICU with the AIROD was 97% with a 95% confidence interval of 0.89 to 0.99. The average time for intubation of all airway classifications was 15 seconds. Conclusion The AIROD first-attempt intubation success rate was found to be similar to the rate for the traditional plastic bougie.

Background and Aims: The All India Difficult Airway Association (AIDAA) has come up with difficult airway (DA) guidelines to suit the Indian context. We conducted an online survey with the primary aim to find out the awareness about AIDAA guidelines and adherence to them in clinical practice. The secondary aims were to explore variations in practice with respect to experience or the type of the institute. Methods: An online web-based questionnaire survey was sent to all practising anaesthesiologists who attended an airway workshop. The validated and piloted questionnaire consisted of 23 questions and the practice patterns were asked to be graded on a Likert scale of four. Results: The response rate was 66%. Awareness about AIDAA guidelines was high (81%) but adherence varied. Apnoeic nasal oxygen insufflation was always practised by only 19.59%.Only 79.7%of the respondents always used capnography to confirm intubation. While 23.64% did not ensure a safe peripheral oxygen saturation (SpO2) level of 95% to do repeat laryngoscopy, 64% chose supraglottic devices after three failed laryngoscopic attempts. A departmental debriefing of a DA event and issuing an alert card to the patient was practised by 58.78% and 52.7%, respectively. Although 50% had training to do cricothyrotomy, only 41% had ready access to a cricothyrotomy set in their workplace. The use of capnography was more prevalent in private institutions. The survey revealed a safety gap with some recommendations like debriefing of a DA event, alert card, nasal oxygenation etc. Conclusion: Awareness about AIDAA guidelines is high among our practising anaesthesiologists, but adherence to the recommendations varied and there is room for improvement, especially for debriefing a DA event, issuing an alert card, the use of capnography and nasal oxygenation.

Airway management has undergone dramatic transformation since the development of videolaryngoscopy (VL). VL improves glottic views when compared to direct laryngoscopy (DL). The image obtained is from a camera at the tip of the curved blade, and the view is not direct line of sight. Placement of the endotracheal tube (ETT) may therefore require the ETT to be manipulated in multiple planes to match the curvature of the VL blade. This placement of the ETT "around the corner" may be difficult without additional airway aids. The aim of this retrospective observational study was to determine whether endotracheal placement during VL in patients with a difficult airway required the use of an additional airway aid (bougie or fiberoptic scope). Difficult airway was defined as a Cormack and Lehane (CL) grade 3 or 4 view obtained using DL prior to VL use. Data from 165 patients was included in the study. Simple ETT placement without an additional airway device was achieved in only 20.6% of cases (n = 34). The remaining 131 patients required a bougie or fiberscope to assist intubation. ETT placement was not possible with the bougie in 33 patients. These 33 patients were successfully intubated using a fiberscope-assisted VL (FAV) technique. VL improved CL grade 3 views by at least one grade in 99.1% of cases, and grade 4 view to a grade 1 or 2 in 96.3% of cases. VL improves glottic view in patients with a difficult airway; but in nearly 80% of patients, a bougie or fiberscope is required to properly place the ETT. Practitioners should be aware that improved glottic views with VL may not translate into simple ETT placement, and additional airway aids need to be readily available.

Background and Aims: This study assesses the extubation practices of anaesthesiologists and whether these practices differ from existing guidelines. Methods: The literature related to tracheal extubation was searched and a validated questionnaire was designed to assess practices of tracheal extubation. The questionnaire included techniques, manoeuvres, preparation, timing and plan of extubation. The survey link was shared with eligible participants. The responses were assessed using Statistical Package for Social Sciences (SPSS) software. Results: Of the 1264 respondents, 66.8% keep difficult airway cart ready only when difficult extubation is anticipated. Only 12.3% of respondents perform deep extubation with supraglottic airway device (SAD) exchange while 73.3% of respondents perform awake extubation with pharmacological control for preventing haemodynamic fluctuations. In the case of anticipated difficult extubation, 48.3% anaesthesiologists prefer the airway exchange catheter (AEC) exchange technique. Of all, 84.8% anaesthesiologists administer 100% oxygen before performing extubation and 81.7% continue to oxygenate during and 83.9% provide oxygen after extubation in all patients. In the case of suspected airway edema or collapse or surgical cause for airway compromise, 70% anaesthesiologists perform a leak test. The most preferred plan of extubation in patients with suspected airway collapse after surgery is direct extubation in fully awake position (54.6%). In patients with anticipated difficult extubation, 50.8% anaesthesiologists prefer to ventilate for 24 hours and reassess. Conclusion: We observed that the extubation practices vary widely among anaesthesiologists. Almost half of the anaesthesiologists were unaware of extubation guidelines.

Introduction: Awake fiberoptic intubation (AFOI) is the gold standard for the management of recognized difficult airway. Good airway anesthesia along with sedation is necessary to ensure patient comfort. Aim: The aim of the study was to evaluate topical lignocaine administered by “spray-as-you-go” versus transtracheal injection technique on intubating conditions during AFOI. Patients and Methods: After obtaining written informed consent, 36 patients were randomly allocated to one of two groups: Group T – transtracheal technique and Group S – Spray-as-you-go technique. All patients were sedated with intravenous dexmedetomidine infusion titrated to a Ramsay Sedation Score of 2–3 during AFOI. All patients received oral gargle and nasal packing with lignocaine 2%. Patients in Group T received 2 mL lignocaine 2% intratracheally just prior to beginning fiberscopy. Patients in Group S received 2 mL lignocaine 2% spray over the vocal cords and another 2 mL below the vocal cords during fiberscopy. Tracheal intubation was then performed. Primary outcome measure was a composite score of patient comfort. Secondary measures were intubation and fiberscopy time, adverse effects, and postoperative patient evaluation. Results: The demographic data were comparable. A composite score of 15 unacceptable. Significantly more patients in Group T had optimal composite score compared to Group S. There were no differences between the two groups as regards postintubation score, ease of intubation, and postoperative survey. Conclusion: During awake nasal fiberoptic intubation, in comparison with spray-as-you-go technique, the transtracheal instillation of lignocaine improves patient tolerance and comfort during tracheal intubation and provides better patient satisfaction.

Intubation of a critically ill patient in the emergency department is always considered a difficult airway. Timing, patient factors which are not optimized, and intubation done by infrequent intubators. Add to this the complications and demands of Covid 19 pandemic which make crash intubations a thing feared for personal safety as well as successful completion of intubation without complications. If the patient has intrinsic comorbid conditions contributing to a difficult airway, worse the procedure would be. Furthermore, Covid pneumonia presents its own challenges in preoxygenation, timing of the intubation, ventilation of the patient and transport as well. This is a patient I came across during the third wave of covid19 pandemic in Sri Lanka, working in the Emergency department night shift. He came in acute respiratory distress and required intubation and ventilation.

Background: Emergency endotracheal intubations (EEI) performed outside of operating theatre (OT) tend to be more challenging and associated with higher risk of complications. In 2011, with the objective of improving patient outcomes, we set up an Emergency Airway Service (EAS) at our 1000-bed regional hospital, with the aim of providing specialized assistance for outside of OT difficult airway management. Method: A retrospective audit of EAS activation from 12/9/2016 and 27/10/2020 was conducted. EAS forms and electronic medical records were reviewed. We collected information on patient characteristics, EAS activation characteristics and its outcomes. Descriptive analysis method was used to present the collected data. Results: There were a total of 275 activations, of which 268 were analysed. Reasons for activation were anticipated difficult intubation (42.2% n = 113), failed intubation attempt (52.6%, n = 141) and advanced intubation equipment required (5.2% n = 14). Intubation was attempted in 261/268 (97.4%) cases by the EAS team. Of these, 255 (97.7%) cases were successful while 6 (2.3%) cases failed intubation. Of the successful intubations by the EAS team, 208/255 (81.5%) were successful on the first attempt. Out of the 6 unsuccessful intubation cases, 1 case required a rescue cricothyroidotomy and 4 cases required an open tracheostomy. Intubation was deemed easy by the EAS team in 170/261 (65.1%) cases. 64/170 (37.6%) cases were intubated with a video laryngoscope (VL). There were 85 cases (32.3%) classified as difficult intubation by the EAS specialist, 13/85 (15.3%) were intubated using only VL, 54/85 (63.5%) cases were intubated using VL with style/bougie. Conclusion: Audit results showed that providing an experienced and well-equipped team of airway specialists round-the-clock to assist in difficult and potentially difficult endotracheal intubations is justifiable and may reduce complications associated with EEI.

Context: Airway management in the emergency department is challenging because conventional screening tools cannot be applied. Therefore, a rapid noninvasive means of identifying a difficult airway will be advantageous for emergency physicians. Aims: The aim of this study is to examine the association between ultrasound measurements of anterior neck soft tissue and difficult airway as judged by the Cormack Lehane grading. Settings and Design: A prospective study was done for 18 months on patients requiring intubation presenting to the emergency medicine department. Subjects and Methods: Ultrasound measurements of anterior neck soft tissue were obtained in 60 cases at the levels of thyrohyoid membrane, hyoid bone, and vocal cords. Another examiner who was blinded to the ultrasound measurements performed endotracheal intubation and noted Cormack–Lehane grading. Statistical Analysis Used: Descriptive statistics such as mean, standard deviation, frequency, and percentage were used. Inferential statistics such as Student's t-test and receiver operating characteristic (ROC) curve analysis were done using the SPSS software version 22. Results: The thickness of anterior neck soft tissues at the level of hyoid bone in difficult patients was 0.73 cm (95% confidence interval = 0.65–0.80) compared to easy patients 0.47 cm (95% confidence interval = 0.44–0.51) with a P = 0.001 and at the level of thyrohyoid membrane in difficult patients it was 1.83 cm (95% confidence interval = 1.7–1.89) compared to easy patients 1.46 cm (95% confidence interval = 1.41–1.51) with a P = 0.001. Area under the ROC curve was significant at all the three levels with the highest at the level of thyrohyoid membrane 0.99 and least at the level of vocal cords 0.79, the area under the curve was 0.92 at the level of hyoid bone. Conclusions: Sonographic measurements of the anterior neck soft tissue can be used as a screening tool by an emergency physician to detect difficult intubation.

Airway management of patients with maxillofacial trauma remains a challenging task for an anesthesiologist in the emergency and perioperative settings due to anatomical distortion. Detailed knowledge of maxillofacial and airway anatomy is desired for the correct diagnosis of extent and severity of the injury. Basic principles of advanced trauma life support protocols should be followed while managing such patients. Establishing unobstructed airway remains the top priority while maintaining C-spine immobilization and preventing aspiration. Although multiple options exist for securing the airway, a universal technique of airway management may not be applicable to all the patients. Hence, a high index of suspicion along with timely and skillful management is warranted. In this brief review, issues affecting the airway management in cases of maxillofacial trauma are addressed with the possible uses of a wide range of airway management devices available in emergency and elective scenarios.

Digital intubation was discovered as one of the first methods to face a difficult airway without direct laryngoscopy. From the very beginning, this technique has been surrounded by much controversy, mainly because it required to be performed by an expert. Nowadays, it remains a useful technique when treating patients with difficult airways, so it is of utmost importance all personnel involved with airway management must know and perfect this technique when scenarios where conventional laryngoscopy or rescue devices for difficult airway are not available or contraindicated. The present work’s main objective is to suggest digital intubation as a safe and effective technique for the management of patients with difficult airways when there are no other devices available. The authors present a successful case of digital intubation on a patient with a difficult airway, demonstrating this technique is useful when performed by expert practitioners and when there is no other equipment available.

A abordagem de via aérea difícil é um dos principais desafios para a anestesiolgia, sendo o manejo inadequado uma causa comum de complicações e óbito. A intubação com paciente acordado permanece como padrão ouro, uma vez que apresenta baixas taxas de complicações e preserva o controle da respiração pelo paciente. Nesse cenário, a interação farmacodinâmica por meio de terapia multimodal com sedação consciente torna-se fundamental a fim de maximizar a colaboração do paciente durante o procedimento. O objetivo deste relato é registrar abordagem da via aérea em um paciente com volumosa massa cervical apresentando preditores de via aérea difícil e o benefício da conduta farmacológica multimodal neste manejo e breve revisão da literatura.

The concept of neonatal and pediatric airway team is somewhat new in India. : In Western countries, though this concept has been established recently, it remains only limited to children's hospitals. We report the case of a 15-month-old girl with failure to thrive and critical life-threatening severe subglottic stenosis. She was managed in a comprehensive manner by multidisciplinary pediatric airway team at a tertiary-level children's hospital.

Management of the unanticipated difficult airway is one of the most relevant and challenging crisis management scenarios encountered in clinical anesthesia practice. Several guidelines and approaches have been developed to assist clinicians in navigating this high-acuity scenario. In the most serious cases, the clinician may encounter a failed airway that results from failure to ventilate an anesthetized patient via facemask or supraglottic airway or intubate the patient with an endotracheal tube. This dreaded cannot intubate, cannot oxygenate situation necessitates emergency invasive access. This article reviews the incidence, management, and complications of the failed airway and training issues related to its management.