Supraglottic airways (SGA) are common advanced airway devices for out-of-hospital cardiac arrest (OHCA) that are simpler to place than endotracheal tubes. Little is known about SGA placement by emergency medical technicians (EMTs). We sought to evaluate SGA placement by EMTs for OHCA. We retrospectively studied the 2019-2023 NEMSIS database. We included adult OHCAs with SGA insertion on first airway attempt. We stratified encounters by the credentials of the provider placing the SGA: EMTs and paramedics. We evaluated the change in SGAs placed by EMTs over time using Cochran-Armitage tests and the number of Emergency Medical Services (EMS) agencies with EMT-placed SGAs over time, and we evaluated regional variation. Using mixed-model logistic regression and compared to paramedics, we evaluated the association between EMT-placed SGAs and first-pass success. SGA placement occurred in 189,307 OHCAs: 41,035 (21.7%) placed by EMTs, 148,272 (78.3%) placed by paramedics. EMT placed SGAs increased from 3140 (20.6%) in 2019 to 10,371 (23.3%) in 2023 (p<0.01). The number of EMS agencies with EMT-placed SGAs also increased from 664 (38.0%) in 2019 to 1525 (51.7%) in 2023. The regions with the highest proportions of EMT placed SGAs were West North Central (38.9%), East North Central (31.4%), and Mountain (25.0%). First-pass success (SGA) was slightly lower for EMTs (93.7% v 94.3% for paramedics, aOR 0.93 [0.89-0.98]). The proportion of SGAs placed by EMTs and the proportion of EMS agencies with EMT-placed SGAs have increased over time. The FPS rate was similar between EMT and paramedic-placed SGAs.

Quality of intubation using remifentanil in obese patients (OBEREM): A randomised, double-blind pilot trial.

The mnemonic "MR SOPA" (Mask adjustment, Repositioning head/airway, Suctioning, Open mouth, Pressure increase and Alternative airway) facilitates remembering corrective steps when ventilation during neonatal resuscitation is inadequate. Here, we critically evaluate the scientific evidence for each step and appraise the usefulness of the mnemonic as a sequential guidance in airway management of newborn infants: Mask: Size and placement are crucial to minimize mask leak and airway obstruction. Firm top and flexible edges may help form a better seal, while mask shape seems to be less important. Two-person holding technique may optimize applied tidal volumes. Repositioning: A neutral head position in newborns may improve airway patency. Suctioning: Suctioning should be reserved for infants with perceived airway obstruction to reduce vagal stimulation or tissue damage. Open the mouth/airway: There is no data on opening the mouth per se. Airway maneuvers like chin lift and jaw thrust may improve airway patency. Pressure increase: Despite weak evidence, increased PIP of ≥25cmH2O may be necessary to overcome closed glottis and fluid-filled lungs in non-breathing infants but must be titrated carefully to preclude lung injury. Alternative airway: Nasopharyngeal tubes and laryngeal masks are valid options when face mask ventilation fails. Endotracheal intubation remains the gold standard but should be reserved for experienced staff. These statements are based on scarce and limited evidence, largely from preclinical or smaller clinical studies. There is no evidence for performing the MRSOPA steps in its original sequence. Thus, more rigorous studies are needed to substantiate nature, timing and order of the interventions.

Airway management in patients with cervical spine injury is high risk in anesthesia because of potential neurological worsening with cervical spine movement. Contemporary recommendations emphasize maximal reduction of cervical movement, multidisciplinary planning, and use of a technique mastered by the operator. Awake fibreoptic tracheal intubation (AFOI) retains an important role in this context because it allows airway securement while preserving spontaneous ventilation and minimizing cervical motion. We report the case of a 25‑year‑old male road‑traffic accident victim with an unstable C5–C6 fracture‑dislocation and incomplete neurological deficit, scheduled for urgent decompression and fusion. Awake nasal fibreoptic intubation was chosen. Preparation included gargling with 2% viscous lidocaine 5 mL (100 mg), bilateral superior laryngeal nerve blocks with 1% lidocaine 2 mL per side (40 mg), and 2% lidocaine gel applied to the endotracheal tube and in the selected nostril (2 mL, 40 mg). The total lidocaine dose was therefore 180 mg, well below the recommended ceiling of 9 mg/kg lean body weight. The procedure allowed atraumatic intubation without desaturation, without significant hemodynamic instability, and without immediate neurological deterioration. This observation highlights the value of meticulous topical anesthesia and awake fibreoptic intubation in anesthetic management of cervical spine trauma in neurosurgery.

Airway obstruction remains a leading cause of preventable death on the battlefield. Extraglottic airway devices are recommended for emergent ventilation when definitive airway management is impractical in austere and prehospital environments. To compare the performance of the i-gel and King LT-D when placed by combat medics under simulated tactical conditions incorporating physical exertion and combat equipment. Prospective randomized crossover study of active-duty combat medics performing a standardized react-to-contact exertion protocol while wearing full combat gear, followed by placement of both devices on a high-fidelity manikin. The primary outcome was time to successful ventilation. Secondary outcomes included first-attempt success and device preference. Forty participants completed the protocol. The i-gel was placed significantly faster than the King LT-D (mean difference approximately 34.6 seconds; P < .001). First-attempt success (97.5% vs 87.5%) and user preference (90%) favored the i-gel. No significant difference in delivered tidal volume was observed. Under simulated tactical conditions, the i-gel enabled faster and more reliable airway placement than the King LT-D. Its simplified, cuffless design may offer advantages under physiologic stress, supporting current guideline recommendations for frontline airway management in military and other austere environments.

This review examines recent advances in pediatric airway management, including emerging technologies, updated guidelines, and innovative strategies for improving safety across diverse clinical settings. We address the unique challenges faced when managing airways in neonates, infants, and children with complex conditions. The 2024 ESAIC-BJA neonatal and infant airway guidelines provide the first evidence-based recommendations emphasizing preoperative identification of the difficult airway, the use of neuromuscular blockade, videolaryngoscopy, and optimized preoxygenation to mitigate risk in this vulnerable population. Use of videolaryngoscopy continues to increase, with multicenter randomized controlled trials demonstrating 5-10% absolute improvements in first-attempt success rates and significant reduction in severe complications including esophageal intubation and hypoxemia, particularly when combined with supplemental oxygen during laryngoscopy. Registry and meta-analysis data now provide robust evidence that neuromuscular blocking agents improve intubation conditions and reduce complications. Artificial intelligence applications show promise for predicting difficult airways and optimizing endotracheal tube sizing. Front-of-neck access strategies have been refined, acknowledging the limitations of cricothyrotomy in young children. Extracorporeal membrane oxygenation has emerged as a rescue strategy in anticipated cannot-intubate-cannot-oxygenate scenarios. Global disparities in pediatric anesthesia safety persist, with collaborative educational initiatives addressing workforce challenges in low- and middle-income countries. The future of pediatric airway management lies in individualized, technology-enhanced approaches guided by evidence-based algorithms, multidisciplinary collaboration, comprehensive education, and simulation-based training, with a commitment to equitable care delivery worldwide.

Background: Traumatic neck injuries (TNIs) are relatively uncommon but potentially life-threatening due to the presence of vital vascular, aerodigestive, and neurological structures in a confined anatomical space. Prompt diagnosis and management are crucial to reduce morbidity and mortality. Aim: To evaluate the clinical spectrum, severity, management, and outcomes of traumatic neck injuries in a tertiary care setting. Materials and Methods: This prospective observational study was conducted over one year at LLRH hospital &amp; GSVM Medical College Kanpur, UP and included 95 patients with traumatic neck injuries requiring admission and intervention. Data regarding demographic profile, mechanism and type of injury, clinical presentation, anatomical zones, injury patterns, management strategies, and outcomes were collected and analyzed using SPSS version 25.0. A p-value &lt;0.05 was considered statistically significant. Results: The majority of patients were in the 31–45 years age group (35.8%), with a male predominance (71.6%). Road traffic accidents (44.2%) were the most common mechanism, and blunt trauma (60.0%) predominated. The most frequent presenting feature was visible neck wound (75.8%), followed by bleeding (61.1%). Zone II involvement (54.7%) was most common, and soft tissue injuries (51.6%) were the predominant pattern. A total of 62.1% patients required surgical intervention, and 43.2% required ICU admission. Overall, 67.4% recovered, while 20.0% developed complications, and 12.6% mortality was observed. The most common hospital stay was 4–7 days (48.4%), with a mean duration of 6.2 ± 2.8 days. A statistically significant association was found between type of injury and outcome (p = 0.047) and between mechanism of injury and management/hospital stay (p = 0.027). Conclusion: Traumatic neck injuries predominantly affect young males and are most commonly caused by road traffic accidents. Early recognition, prompt airway and vascular management, and timely surgical intervention are critical in improving outcomes. Penetrating injuries and RTA-related trauma are associated with increased severity, complications, and prolonged hospitalization.

Association of Obesity With Respiratory Complications in Trauma Patients Undergoing Emergent Surgery.

This article addresses the legal, ethical, and juridical limits of the actions of police officers without medical or nursing training in providing care to victims in the pre-hospital setting, whether in tactical or conventional scenarios. This care, provided by public security professionals, has become an essential practice in the face of the increase in violent traumatic events in Brazil. However, the actions of police officers without medical or nursing training raise questions about the legal limits of their intervention in the pre-hospital environment, whether tactical or conventional. Normative, technical, and scientific foundations that define this action were analyzed, considering the professional legislation of medicine and nursing, the national guidelines for tactical pre-hospital care, and international protocols such as ATLS, PHTLS, TCCC, and TECC. This is a qualitative, exploratory, and descriptive research study, with documentary and bibliographic analysis, using content analysis techniques. The results indicate that police officers can act within the specific normative guidelines of authorized training, especially in the control of external hemorrhages, basic airway management, and tactical evacuation, provided that clear legal restrictions are respected, avoiding interventions that exceed the regulated professional competencies of acts exclusive to doctors and nurses as defined by law. It is concluded that the legality of the action is conditional upon formal training, observance of official protocols, and respect for regulated professional competencies, under penalty of administrative, civil, and criminal liability.

Obesity is increasingly prevalent among critically ill patients and profoundly alters respiratory mechanics, gas exchange, and cardiopulmonary interactions, complicating ventilatory management. Excess adipose tissue increases pleural pressure, reduces functional residual capacity, and promotes airway closure and atelectasis, increasing susceptibility to hypoxemia, hypercapnia, and ventilator-induced lung injury. These physiological alterations necessitate tailored ventilatory strategies distinct from those used in patients without obesity. Lung-protective ventilation using tidal volume indexed to predicted body weight remains the cornerstone of management, as lung size does not increase proportionally with body mass. Patients with obesity often require higher positive end-expiratory pressure to counteract elevated pleural pressure and prevent airway closure although optimal titration strategies remain uncertain. Interpretation of airway pressures requires caution, as increased chest wall elastance may result in elevated plateau and driving pressures without excessive lung stress. Adjunctive monitoring tools, including esophageal pressure measurement and electrical impedance tomography, may help individualize ventilatory management by improving assessment of transpulmonary pressure and regional ventilation. Airway management is particularly challenging in patients with obesity due to rapid oxygen desaturation and increased risk of difficult intubation; positive-pressure preoxygenation and video laryngoscopy improve procedural safety. Adjunctive therapies, such as prone positioning, non-invasive ventilation, and extracorporeal membrane oxygenation, are feasible and may provide benefit when clinically indicated. Liberation from mechanical ventilation requires careful assessment, and prophylactic non-invasive ventilation may reduce extubation failure in selected patients. Despite increasing recognition of obesity-specific physiology, most current recommendations are extrapolated from general ICU populations. Dedicated clinical trials are needed to define optimal ventilatory strategies and improve outcomes in this growing population of critically ill patients with obesity.

Anesthesia for pediatric neurosurgery represents a highly complex and challenging field, characterized by age-dependent physiological variability, heterogeneous patient populations, and the critical need to protect the developing central nervous system. Conventional clinical approaches often rely on adult-derived data, which may inadequately reflect the distinct neurophysiological and hemodynamic characteristics of neonates, infants and children. Recent advances in artificial intelligence (AI) have enabled the integration of multimodal perioperative data, including physiologic signals and neurophysiologic monitoring, with the aim of supporting clinical decision-making in complex surgical settings. This review summarizes the current landscape of AI applications relevant to pediatric anesthesia, with particular attention to preoperative risk assessment, airway management, and real-time prediction of intraoperative adverse events such as hypoxemia and hemodynamic instability. Although AI-based approaches have demonstrated encouraging results in adult populations, their application to pediatric neuroanesthesia remains limited. The integration of AI into this field faces several distinct challenges, including the scarcity of high-quality datasets for rare neurosurgical conditions, substantial heterogeneity across developmental stages, and difficulties in aligning model outputs with clinically interpretable physiologic mechanisms. Addressing these limitations will require the development of explainable, physiology-informed AI frameworks and disease-specific models tailored to conditions such as moyamoya disease or complex craniofacial reconstruction. Ultimately, AI should be positioned as an adjunctive decision-support tool that complements, rather than replaces, anesthesiologists' expertise. Through multidisciplinary collaboration and human-centered implementation, AI may contribute to improved perioperative safety and long-term neurodevelopmental outcomes in vulnerable pediatric neurosurgical patients.

Airway management is an important skill for clinicians who care for adults who are acutely ill. Tracheal intubation can be life saving, but also carries a high rate of complications. Numerous tools are available to assess the difficulty of bag-valve-mask ventilation, intubation, and cricothyroidotomy; however, these tools currently have limited predictive value. Preparation, preoxygenation with non-invasive positive pressure ventilation, and physiological optimization are therefore essential steps to all airways. Drugs for induction and paralysis should be tailored to the patient. If rapid sequence intubation is performed, video laryngoscopy is preferred over direct laryngoscopy because it increases the likelihood of first pass success. Confirmation should include capnography or point-of-care ultrasound. Clinicians should ensure adequate analgesia and sedation to avoid patients experiencing awareness with paralysis, but this must be balanced with avoiding oversedation. This review summarizes the current data and provides an evidence based approach to airway management in the acute care setting.

Procedural Techniques, Airway Management and Specimen Acquisition for Peripheral Lung Transbronchial and Endobronchial Ultrasound Guided Cryobiopsy: A Modified Delphi Consensus Statement.

This review provides a comprehensive update on advancements and evolving paradigms in cleft-related facial skeletal surgery. It evaluates recent literature concerning the integration of artificial intelligence in surgical prediction, optimal orthognathic surgical sequencing, the utility of virtual surgical planning (VSP) and patient-specific implants (PSIs), strategies for managing skeletal surgery related velopharyngeal insufficiency (VPI) and airway patency, the evolution of alveolar bone grafting (ABG) techniques, and the increasing emphasis on patient-reported outcome measures (PROMs). Recent studies demonstrate that machine learning models utilizing preadolescent cephalometric data can predict the need for orthognathic surgery with high accuracy (over 83%). The implementation of 3D VSP has validated the mandible-first surgical sequence and significantly improved occlusal accuracy while reducing preoperative planning time. While PSIs reduce skeletal relapse in large maxillary advancements (>10 mm), they carry a higher risk of hardware removal compared to conventional plates. Regarding speech and airway management, safe maxillary advancement thresholds have been established to minimize VPI risk, and preserving prior pharyngeal flaps during surgery, if possible, is highly recommended to prevent speech deterioration. In alveolar reconstruction, synthetic grafts and allografts combined with osteogenic agents (like rhBMP-2) are showing success rates comparable to traditional iliac cancellous autografts, with a marked shift toward earlier intervention (ages 4-8) and outpatient procedures. Finally, while orthognathic surgery significantly improves psychosocial well being and facial aesthetics, significant disparities in care access persist based on insurance status and geopolitical factors. The landscape of cleft-related facial skeletal surgery is rapidly advancing through the integration of artificial intelligence, 3D digital planning, and novel biomaterials. These innovations allow for earlier, more accurate surgical predictions, reduced operative morbidity, and enhanced long-term skeletal stability. Balancing structural advancements with airway and speech preservation remains a delicate, patient-specific process. Ultimately, while surgical and technological refinements continue to optimize functional and aesthetic results, addressing socioeconomic barriers is critical to ensuring timely care and maximizing health-related quality of life for all cleft patients.

Background: Unanticipated difficult airways remain a leading cause of anesthesia-related morbidity and mortality, with traditional bedside predictors demonstrating limited sensitivity. Point-of-Care Ultrasound (POCUS) has emerged as a non-invasive adjunct offering real-time visualization and quantitative measurement of airway anatomy. This narrative review, structured according to the Scale for the Assessment of Narrative Review Articles (SANRA), synthesizes current evidence on POCUS as an adjunct for airway evaluation. We explore the sonoanatomy of the upper airway, the utility of ultrasound in predicting difficult laryngoscopy and intubation, its critical role in emergency front-of-neck access, and the verification of endotracheal tube placement. Furthermore, we discuss the integration of Artificial Intelligence (AI) in image interpretation and the necessity of standardized training curricula. Methods: We systematically searched PubMed/MEDLINE, Scopus, and Web of Science for English-language peer-reviewed studies addressing sonographic airway assessment, including sonoanatomy, prediction of difficult laryngoscopy/intubation, guidance for emergency FONA and endotracheal tube confirmation. Results: POCUS enhances visualization of critical anatomical structures, may improve anatomical assessment and risk stratification when combined with clinical assessment, and it may provide real-time guidance during emergency procedures. Integration of AI has shown promising diagnostic performance, primarily based on surrogate outcomes. Conclusions: Airway ultrasound may represent a shift toward personalized, safer airway management. However, standardized training protocols and validation in diverse clinical settings remain essential. Future research should focus on developing evidence-based algorithms integrating POCUS into airway management guidelines.

Adenotonsillectomy is one of the most common elective pediatric surgeries. However, its routine occurrence can mask substantial preventable risks arising from practitioner inexperience, underappreciated comorbidities, airway proximity to the surgical field, and challenging postoperative pain management. This review highlights common "error traps" that contribute to perioperative adverse events and outlines evidence-based mitigation strategies. Key preoperative challenges include unrecognized moderate-to-severe obstructive sleep apnea (OSA) and recent upper respiratory infections (URIs), both of which markedly increase perioperative respiratory adverse events (PRAEs). Intraoperative hazards include challenging airway management at induction and emergence, risk of airway fire, and excessive opioid administration. Postoperatively, inadequate analgesia and inappropriate disposition planning remain major preventable causes of morbidity. Perioperative management of the child with post-tonsillectomy hemorrhage is uniquely challenging. Structured OSA and URI screening and mitigation strategies, multimodal opioid-sparing analgesia, and institution-specific discharge algorithms are strongly recommended. A systematic, team-based approach emphasizing awareness of cognitive biases, vigilance, protocolized management, and hospital outcome monitoring can significantly reduce preventable complications and improve safety in pediatric adenotonsillectomy.

The optimal airway management strategy in out-of-hospital cardiac arrest has been controversial. Whereas endotracheal intubation currently represents the gold standard, supraglottic airway securement may provide advantages with respect to handling out-of-hospital cardiac arrest. This meta-analysis of randomized controlled and clinical studies evaluates the effects of the advanced airway strategy (supraglottic vs. endotracheal intubation) on return of spontaneous circulation (ROSC). This systematic review and meta-analysis was performed based on a predefined protocol. Literature search included PubMed, Web of Science, and the Cochrane Library. A total of eight clinical studies including 14,797 patients were analyzed. Pooled analysis indicated no higher rate of ROSC in patients treated with supraglottic airway vs. endotracheal intubation (risk difference [RD] 0.02, 95% confidence interval [CI] 0.0-0.04, p = 0.11) and no higher rate of survival to hospital discharge (RD 0.01, 95% CI -0.01-0.02, p = 0.30). Interestingly, additional training indicated a significant effect of supraglottic airway on ROSC, whereas the subgroup difference was not significant (RD [additional training] 0.02, 95% CI 0.0-0.04, p = 0.02, RD [no additional training] 0.01, 95% CI -0.05-0.01, p = 0.72, test for subgroup differences, p = 0.73). Training programs differed between the investigated studies. Statistical heterogeneity was not observed. Overall, the type of advanced airway (supraglottic vs. endotracheal intubation) did not impact ROSC or survival to hospital discharge. However, after additional training, supraglottic airway use may have a positive effect on ROSC in out-of-hospital cardiac arrest.

Airway management and outcomes in surgical drainage of severe odontogenic infections: a retrospective cohort study.

Sugammadex reverses the effects of steroidal neuromuscular blocking agents rapidly and completely. Unlike neostigmine, its antagonism is long lasting, has no ceiling effect, and minimizes the risk of residual neuromuscular block. These unique pharmacologic properties may influence not only the emergence from anesthesia but also induction and tracheal intubation strategies across perioperative settings, including critical care, emergency medicine, and prehospital resuscitation, especially in the context of difficult airway management. However, the full impact of sugammadex on airway management has been underappreciated. As a reversal agent for difficult airways, it remains underutilized, largely due to limited awareness of its unique properties. This narrative review synthesizes the current literature, highlights practical considerations in daily airway management, and examines the potential paradigm shift introduced by sugammadex while also outlining future directions for research.

Penetrating neck injuries present as a formidable challenge to anaesthesiologists and the trauma care team due to the risk of rapid airway compromise, exsanguination and involvement of multiple vital structures. Securing the airway remains the top priority, especially in patients presenting with neck injuries, active bleeding, tissue disruption, and altered sensorium. Safest methods to secure the airway is in an awake and spontaneously breathing patient. We report a case of a 55-year-old male who presented with a deep anterior neck laceration in hypovolaemic shock in an emergency, in whom a conventional airway was deemed impossible. Then, as a game-changer, the MADgic Atomiser, a mucosal atomiser, was used to facilitate topical anaesthesia in airway management. The traumatic airway being complex, airway management in such a scenario is extremely difficult. Multidisciplinary teamwork remains the gold standard. Here, in this case, oxygenation was utmost important, looking at the blood loss and Glagow Coma Scale (GCS) of the patient. Hence, direct placement of a tracheostomy tube through the exposed tracheal lumen was initiated, followed by definitive oral endotracheal intubation using a C-MAC for further management. This case highlights the novel use of MADgic Atomiser, an innovative airway adjunct, C-MAC, and the critical role of adaptability, along with multidisciplinary teamwork in managing life-threatening neck injuries.