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Summary A myriad of new intubation equipment has been introduced commercially since the appearance of Macintosh/Miller blades in the 1940s. We review the role of devices that are relevant to current clinical practice based on their presence in the scientific literature. The comparative performance of new vs traditional direct laryngoscopes, their complications, their use in awake intubation techniques and the prediction of unsuccessful intubation with new devices are reviewed. Manikin studies are of limited value in this area. We conclude that in both predicted and unpredicted difficult or failed intubation, carefully selected new intubation equipment has a high success rate for tracheal intubation. Ideally, such devices should be available in all settings where tracheal intubation is performed. Most importantly, experience and competence with any of the new devices are critical for their successful use in any clinical setting.

Laryngocoele is a rare, benign laryngeal disease causing a variety of symptoms. However, this condition can lead to upper airway obstruction, thus posing problems in airway management and ventilation. Therefore, prior planning of anaesthetic and airway management of such patients is desirable, wherein awake intubation techniques are safer methods of securing a definite airway. Awake videolaryngoscopy-guided intubation can be safely used as an alternative to awake fibreoptic bronchoscopy-guided intubation.

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

Background In the majority of patients with difficult airways intubated using the Bonfils fibrescope, intubations have been performed under general anaesthesia. Our aim is to report a consecutive series of intubations on awake patients with anticipated difficult airways, performed using the Bonfils fibrescope. Methods A prospective case series of intubations performed with the Bonfils fibrescope by a single anaesthesiologist is described in this article. Thirty patients with anticipated difficult airways were included (11 of them after failed intubations with Macintosh laryngoscope). Awake intubation attempts were performed under mild sedation and topical anaesthesia (with or without transcricothyroid membrane injection). The effectiveness was assessed in terms of success rate, number of attempts, difficulties, and complications encountered. Results Overall, awake intubation was successful in 29 out of 30 patients (96.6%). In the predicted difficult airway group, 19 patients with anticipated difficult airways were included. Awake intubation with Bonfils fibrescope was successful in 18 out of 19 patients (94.7%). In the known failed intubation group, 11 patients were included; the airways of five of them had already been managed with flexible fibrescope. All patients were successfully intubated awake with the Bonfils fibrescope. Conclusions Our findings confirm that awake intubation with the Bonfils fibrescope is well tolerated and highly successful, even if performed by operators in training, and strengthen the evidence that the Bonfils fibrescope is one of the most promising devices to assist intubation in patients with difficult airways.

Awake intubation (AI) is one of the most important tools of the airway manager. If you are going to manage airways, you must be good at AI (one day you’ll need it)! And if you have not performed an awake intubation in years, you probably are not doing enough of them (Don’t confuse being good with being lucky.) After speaking to thousands of anesthesiologists, I have come to two conclusions: The typical anesthesia practitioner 1) is insecure about his or her technique and 2) confuse airway anesthesia with AI technique. The sentinel grounds for these conclusions are deduced from the single question I have been asked almost every time I speak about airway management (no matter what the lecture topic): “Dr. Rosenblatt, what local anesthetic do you use?” This question betrays the misconception most clinicians have about AI: that AI is about producing a “numb” airway. In fact the topical anesthetic(s) chosen matter little. AI involves a systemic approach to patient preparation – once appreciated, and a consistent technique developed, AI can become as easy as routine airway management.

We studied 21 patients with known difficult airways who underwent awake tracheal intubation using the LMA CTrach. Patients were given midazolam, atropine, a continuous infusion of remifentanil and topical lidocaine applied to the oropharyx. We limited the number of insertion attempts to three and the time to adjust the view to 5 min. In case of failure, we performed awake fibreoptic tracheal intubation. We found insertion of the device was successful and well tolerated in all patients. Vocal cords could be seen immediately in nine patients and following corrective manoeuvres in 10 patients. Tracheal intubation was successful in 20 patients: 19 cases under direct vision and in one blindly. In one patient with undiagnosed lingual tonsil hyperplasia, tracheal intubation was impossible using the device. No patient had an unpleasant recall of the procedure. We conclude that the LMA CTrach is easy to use, well tolerated and suitable for awake orotracheal intubation in patients with known difficult airways.

Background: Careful airway management, including tracheal intubation, is important when performing anaesthesia in order to achieve safe tracheal intubation. Aim: To study airway management in anaesthesia care from both the professional and patient perspectives. Methods: 11 RNAs performed three airway tests in 87 patients, monitored in a study-specific questionnaire. The tests usefulness for predicting an easy intubation was analysed (Study I). 68 of 74 anaesthesia departments in Sweden answered a self-reported questionnaire about the presence of airway guidelines (Study II). 20 anaesthesiologists were interviewed; a phenomenographic analysis was performed to describe how anaesthesiologists' understand algorithms for management of the difficult airway (Study III). 13 patients were interviewed; content analysis was performed to describe patients' experiences of being awake fiberoptic intubated (Study IV). Results: The Mallampati classification is a good screening test for predicting easy intubation and intubation can be safely performed by RNAs (Study I). The presence of airway guidelines in Swedish anaesthesia departments is poorly implemented (Study II). Algorithms can be understood as law-like rules, a succinct plan to follow in difficult airway situations, an action plan kept in the back of one's mind while creating flexible and versatile personal algorithms, or as consensus guidelines based on expert opinion in order to be followed in clinical practice (Study III). One theme emerged describing experiences of being awake intubated; feelings of being in a vulnerable situation but cared for in safe hands, described in five categories: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff's competence, professional caring and support, and no hesitation about new awake intubation (Study IV). Conclusions: The Mallampati classification is a good screening test for predicting easy intubation, when the airway assessment is performed in a structured manner by RNAs. The presence of airway guidelines in Swedish anaesthesia departments was poorly implemented and should receive higher priority. Algorithms need to be simple and easy to follow and based on the best available scientific evidence. Tailored information about what to expect, ensuring eye contact, and giving breathing instructions during the procedure may reduce patients' feeling distress.

Polyps are common lesions in pharynx and larynx. A 46-year-old woman was transferred to our department because of the huge laryngeal mass, which was incidentally detected during routine health screening. On laryngoscopic exam, both vocal folds were not visualized due to the mass but she had no symptom such as hoarseness, dysphagia, and dyspnea. Awake intubation was safely performed using flexible bronchoscope without tracheostomy. A 4-cm sized mass on the left aryepiglottic fold was removed with trans-oral approach and discharged without complication. The pathologic diagnosis was reported as 'fibrovascular polyp'. Herein, we describe a unique case of giant fibrovascular polyp on aryepiglottic fold, which is the first report in the English literature.

We report the case of a 59-year-old woman with mitochondrial myopathy who underwent elective laparoscopic cholecystectomy and hemorrhoidectomy, and we review the literature discussing general anesthesia for adults with mitochondrial myopathy. Our management technique avoids neuromuscular-blocking drugs and uses a modified awake intubation method not previously described in such patients. We hope to improve patient safety by discussing evidence-based anesthetic concerns and complications specific to these uncommon patients and aid practitioners in devising a suitable anesthetic plan.

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

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

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

Introduction: Retrograde laryngeal block is a new technique that blocks complete supraglottic and glottic area by introducing cath- eter retrograde from trachea to these regions. Methods and Materials: This is a clinical trial conducted on two groups each containing 15 patients, who were candidate for awake intubation. The first group (A) underwent conventional method of airway block, by multiple injections of local anesthetic. The second group (B) underwent retrograde laryngeal block as a new method of regional airway anesthesia. In this method the catheter is inserted from cricothyriod membrane through a flexible guide wire, and then local anesthetic drug will be administered by direct vi - sion of tip of the catheter by employing glide scope. The catheter has three separate orifices; each will stay on distinct area of either supraglottic and glottis area which can be adjusted at any level through this area that is considered to be blocked. Result: Both groups had hemodynamic stability during performing block. In group A we had two incidences of laryngospasm due to pain of multiple needle insertion; in group B we had no incidence of laryngospasm (P=0.1). In group A we had 5 patients with partial airway block which needed further intervention during awake intubation but in group B all the cases had complete and perfect airway block (P=0.001). Patients comfort was better in group B with single injection than group A with multiple injections (P=0.005). Discusion: The advantage of this method is single injection and high quality of block performance in comparison with the other technique. It can be conducted for the patients with neck pathologies that make conventional airway block impossible. Conclussion: This method can be applied in patients with neck pathologies that make conventional block impossible.

Summary To examine the education of trainees with regard to difficult airway management, we sent a questionnaire to all 89 Japanese University Departments of Anaesthesia (to be answered by a person who was responsible for teaching trainees) and all 280 Royal College of Anaesthetists' Tutors in the UK. The presence or absence of a formal training module for difficult airway management, timing and methods of training, types of airway devices that should be taught, and tutors' expertise with various techniques and devices were surveyed. Sixty-seven of the 89 Japanese tutors (75%) and 167 of 280 UK tutors (60%) replied to the questionnaire. Only 19 of 67 (28%) Japanese anaesthetists and 33 of 167 (20%) UK anaesthetists who replied, indicated that they had a difficult airway training module. In six Japanese departments (9%) and 115 (69%) UK departments, equipment for percutaneous transtracheal ventilation was readily available. Airway devices and techniques that tutors considered necessary to be mastered in the first 2 years of training, differed considerably between Japan and the UK, with notable differences in the use of gum elastic bougies and awake intubation. A training module for difficult airway management is often not provided and equipment for emergency transtracheal ventilation is often unavailable in both countries.

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

Study Objective To assess the efficacy of both Bonfils and GlideScope in obese patient with difficult airways for bariatric surgery using awake intubation. Design Comparative study. Setting Operating room. Patients The study was carried out on 60 patients, for laparoscopic bariatric surgery, after approval of the Medical Ethics Committee and having an informed written consent from each patient. Patients were randomly categorized into 2 equal groups 30 patients in each group. Interventions Awake intubation with either Retromolar Bonfils or GlideScope. Measurements Time to visualize the laryngeal inlet, time of intubation, time of scope manipulation, success rate at each attempt, the lowest oxygen saturation, hemodynamic parameters, and any complication. Main Results Regarding intubation criteria, GlideScope achieves shorter times compared with Retromolar for visualization of the vocal cords and intubation, in addition to less intubation attempts, but both without a statistically significant difference. Retromolar shows better patient satisfaction than does GlideScope, with statistically significant difference. Conclusions Both Bonfils fiberscope and the GlideScope can be successfully used for awake intubation in morbidly obese patients with expected difficult airways. Bonfils intubating fiberscope was more tolerated by patients with statistical difference; on the other hand, GlideScope provided shorter intubation time and less intubation attempts but not statistically significant.

This case discusses two pharmacokinetic interactions between lidocaine and cimetidine (metabolic and distribution) resulting in lidocaine toxicity.

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

Flexible fiberoptic bronchoscope-guided awake intubation is the most trusted technique for managing an anticipated difficult airway. Even after successfully negotiating the bronchoscope into the trachea, the possibility remains that the preloaded tracheal tube might prove to be inappropriately large, and may not negotiate the nasal structures. In such a situation, the most obvious solution is to take out the bronchoscope, replace the tracheal tube with a smaller one, and repeat the procedure. Unfortunately, sometimes the second attempt is not as easy as the first, as minor trauma during the earlier attempt causes tissue edema and bleeding, which makes the subsequent bronchoscopic view hazy and difficult. We present the anesthetic management of five cases with temporomandibular joint ankylosis where, after successful, though slightly traumatic, bronchoscope insertion into the trachea, the tube could not be threaded in. We avoided a repeat bronchoscopy by making an innovative change in the plan.

Numerous indirect laryngoscopes have been introduced into clinical practice and their use for tracheal intubation under local anaesthesia has been described. However, a study comparing indirect laryngoscopic vs fibreoptic intubation under local anaesthesia and sedation appears lacking. Therefore, we evaluated both techniques in 100 patients with an anticipated difficult nasal intubation time for intubation the primary outcome. We also assessed success rate, glottic view, Ramsey score, and patients' and anaesthetists' satisfaction. The median (IQR [range]) time for intubation was significantly shorter with the videolaryngoscope with 38 (24-65 [11-420]) s vs 94 (48-323 [19-1020]) s (p0.0001). There was no difference in the success rate of intubation (96% for both techniques; p0.9999) and satisfaction of the anaesthetists and patients. We conclude that in anticipated difficult nasal intubation a videolaryngoscope represents an acceptable alternative to fibreoptic intubation.

Ewelina Gaszynska, Tomasz GaszynskiDepartment of Emergency Medicine and Disaster Medicine, Medical University of Lodz, Lodz, PolandAbstract: Intubation of patients with a supraglottic mass causing obstruction of the glottis remains a difficult problem for the experienced anesthesiologist. Awake fiberscopic endotracheal intubation is the recommended approach in such cases; however, use of a video laryngoscope for awake intubation can be an alternative to a fiberscope. Here we present two cases of awake intubation using a King Vision™ video laryngoscope in patients with a supraglottic mass, and a literature review on use of video laryngoscopes for awake intubation. After topical anesthesia and sedation with opioids, the patients were successfully intubated.Keywords: airway management, difficult airway, awake intubation, video laryngoscope

Background: Problems with managing the airways in relation to anaesthesia causes severe morbidity and mortality. A large proportion of these adverse respiratory events is preventable. Still patients continue to die from airway disasters related to anaesthesia, also in Scandinavia. The goal of this study is to identify which efforts are likely to improve this situation. Methods: A questionnaire asking about experience, behaviour and availability of various items of equipment was mailed to all members of the Danish Society of Anaesthesiologists and were returned anonymously. Results: More than 65% of respondents have sufficient access to a flexible fibrescope, but still 17% of specialists have no access and the vast majority (>67%) has little (1–10 times) or no experience in its use for awake intubation. A total of 52–70% knew the basic principles of the ASA difficult airway algorithm, but despite this only 25–50% would perform awake intubation if a difficult intubation was expected. More than 20% of respondents had experienced preventable airway management mishaps. In all, 18–46% did not know how to oxygenate via the cricothyroid membrane. Conclusion: There is room for improvement regarding airway management skills among Danish anaesthesiologists. It is likely that airway management can be improved by: A) Better knowledge of an appropriate plan, algorithm, for airway management. B) Awake intubation used more often. C) More experience in fibreoptic intubation. D) All anaesthesiologists accepting that previous difficult intubation is an indicator of future difficulties. E) All anaesthesiologists knowing, and practising on manikins, how to oxygenate via the cricothyroid membrane. F) Always having a laryngeal mask airway immediately available when inducing anaesthesia.

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

Highlights • CT scan has a great value for retrosternally extended giant goiter cases. • If the general status of the patient prevents CT scan, bedside ultrasound can be used instead. • Nasal awake intubiation is an appropriate choice for the patients with destructed trachea. • Emergency thyroidectomy is a common option for the treatment of giant goiter causing airway obstruction., INTRODUCTION Giant cervical and mediastinal goiter may lead to acute respiratory failure caused by laryngotracheal compression and airway obstruction. Here, we present a case admitted to the emergency service with a giant goiter along with respiratory failure and poor general health status, which required urgent surgical intervention. PRESENTATION OF CASE A 71-year-old female admitted to the emergency room with shortness of breath and poor general health status resulting from a giant cervical swelling progressively increased during the last 7 years and constituted severe respiratory failure which has become severe in the last one month. A giant nodular goiter of the left thyroid lobe extending retrosternally, causing tracheal compression, limiting the neck movements was detected with clinical examination and bedside ultrasound. Emergency thyroidectomy was planned. Fiberoptic-assisted awake nasal intubation was performed in the operating room. Emergency total thyroidectomy was performed for the life-threatening respiratory failure. Postoperative period was uneventful. She was transferred from intensive care unit to the ward on postoperative day 3 and was discharged from the hospital on the postoperative 7th day. Benign multinodular hyperplasia was reported on the histopathological report. Patient was included in routine follow-up. DISCUSSION In the present case tracheal destruction due to compression of the giant goiter was found in agreement with previous reports. Emergency thyroidectomy was performed after awake intubation since it is a common surgical option for the treatment of giant goiter causing severe airway obstruction. CONCLUSION Respiratory failure due to giant nodular goiter is a life-threatening situation and should be treated immediately by performing awake endotracheal intubation following emergency total thyroidectomy.

Patients presenting with unstable cervical spine injuries are at risk for additional neurological injury as a consequence of airway manipulation. Techniques of awake intubation may not always be desirable or practical, particularly in the pediatric patient. We describe the use of fluoroscopy during the induction of anesthesia and intubation of a child with an unstable C1/C2 spinal subluxation. Fluoroscopy is readily available and noninvasive. This technique allows for rapid establishment and maintenance of optimal head and neck positioning during induction of general anesthesia and performance of laryngoscopy and tracheal intubation.

The role of the anesthesiologist during procedures where intraoperative electrophysiological monitoring (IOM) is being performed involves anesthetic titration, attaining physiological homeostasis, and medical management of the patient. Further, the anesthesiologist participates in mitigating neural injury when the monitoring indicates that the nervous system may be at risk for injury. More specifically, the choice of anesthetic agents directly impacts the ability to reliably record IOM responses, and the physiological management (e.g., blood pressure) impacts on the reserve of the nervous system to tolerate procedural trespass. When altered responses indicate the health of the nervous system may be compromised, the insights of the anesthesiologist and the ability to improve the physiological reserve are keys to reducing neurological risk. This chapter is written to discuss these aspects to improve integration of the anesthesiologist into the IOM monitoring team effort.

Airway management in patients with head and neck tumors can be challenging. In this anticipated difficult airway, an awake fiberoptic intubation with a NIM tube was performed in a patient with a large neck mass.

Awake fibreoptic intubation (AFI) is a standard method of airway management in a case of anticipated difficult intubation. It is usually performed using flexible fibroscopes. In this report, we describe the case of a 42 year-old female patient who suffered from congenital disease producing severe deformation of the head, face, neck and chest. In this case, the AFI procedure was performed successfully using a rigid intubation stylet: the Clarus Video System. One of the advantages of rigid stylets is that they are very easy to use, and in the hands of anaesthesiologists not very familiar with fibroscope intubation, they can be an alternative to flexible fibroscopes in AFI procedures.