Awake Fiberoptic Intubation Research Articles

Comparison of dexmedetomidine, fentanyl, ketamine nebulization as an adjuvant to lignocaine for awake fibreoptic intubation: A randomised control trial

Comparison of dexmedetomidine, fentanyl, ketamine nebulization as an adjuvant to lignocaine for awake fibreoptic intubation: A randomised control trial

Upper Airway Block Using Lidocaine Nebulisation Versus Targeted Nerve Block for Awake Fibre-Optic Intubation in Patients with Head and Neck Burns: A Randomised Controlled Trial

Background: A difficult airway is a scenario in which an adequately trained anesthesiologist faces challenges with mask ventilation, endotracheal intubation, or both. Various anesthetic techniques have been proposed to prepare adequately for awake flexible fiber-optic intubation (AFOI), including nerve blocks for the upper airway, topical anesthesia via a specialized cannula, and lidocaine nebulization (LN). Proper anesthesia of the upper airway is crucial for successful AFOI. Objectives: This study aimed to evaluate the efficacy of airway block (AB) by LN compared to traditional upper AB techniques. Methods: This prospective, randomized, single-blinded study was conducted on 100 patients with head and neck burns scheduled for reconstructive surgery. Participants were randomly assigned to two groups of 50 patients each. In the AB group, AFOI was performed following an AB, while in the LN group, AFOI was performed 30 minutes after LN. The primary outcome measured was the time to successful awake nasal fiber-optic intubation. Secondary outcomes included the number of failed attempts and the revised nonverbal pain scale score. The time to successful awake nasal fiber-optic intubation showed no significant difference between the two groups. Results: Although the AB group had a higher number of failed attempts compared to the LN group, statistical analysis revealed no significant difference. Additionally, there was no significant difference in hemodynamic parameters between the groups. Conclusions: Both AB and LN are effective for awake nasal fiber-optic intubation, with comparable intubation times. However, LN offers a less invasive alternative.

Perioperative Management for Microvascular Free Tissue Transfer for Head and Neck Reconstruction – Commentary

Le et al. provided a comprehensive commentary on perioperative management for head and neck oncologic patients undergoing microvascular reconstructive surgery. This commentary is based on a detailed review and consensus statements from the Society for Head and Neck Anesthesia (SHANA), an international organization dedicated to enhancing perioperative care for these patients. The consensus statement, published in 2021 by Healy et al., addressed preoperative, intraoperative, and postoperative considerations to optimize clinical outcomes. It included 14 statements from 16 SHANA members across 11 institutions, following two rounds of literature reviews. The commentary emphasized the importance of preoperative nutrition optimization, tobacco cessation, and early recognition of alcohol withdrawal symptoms. In the intraoperative phase, key aspects such as airway management in cases of extensive tumor burden (including awake fiberoptic intubation and tracheostomy), fluid management, hemodynamic monitoring, and multimodal analgesia were briefly discussed. Notably, vasopressors can be used to optimize hemodynamic management without compromising flap perfusion. Additionally, careful fluid resuscitation is crucial to avoid fluid overload, which could increase the risk of flap failure. Multimodal pain management strategies were highlighted, including inhalational anesthetics, anti-inflammatories, narcotics, and regional anesthesia. In the postoperative period, effective communication between healthcare provider teams is essential. Airway management was linked to three of the five consensus statements, underscoring the need for clear and concise communication between the anesthesia and surgical teams. This includes coordinating ventilatory support weaning, extubation planning, and preparation for reintubation if necessary. Such measures help reduce intensive care unit (ICU) utilization, minimize airway-related adverse events, and shorten the length of hospitalization. Overall, the commentary hopes to serve as a guide for multidisciplinary head and neck oncology units across all international centers in managing this complex patient population.

Dexmedetomidine vs. Fentanyl for Awake Fiberoptic Intubation Among Adults in Tamil Nadu - A Randomized Control Trial.

Background: Dexmedetomidine and fentanyl are often administered medications for inducing conscious sedation, a technique employed for performing awake fibreoptic intubation. However, there is a scarcity of literature that directly compares the effects of these drugs when administered at equivalent doses. This study sought to assess the effectiveness and safety of using dexmedetomidine and fentanyl in adult patients undergoing Awake Fiberoptic Intubation (AFOI). Methodology: The current research study undertaken was a randomized controlled trial conducted among adult patients at A hospital providing specialized medical services in Salem, Tamil Nadu. There were 60 study participants, 30 participants in each group. A group received the drug dexmedetomidine 1-µg/kg while B group received fentanyl l-µg/kg intravenously. Primary outcomes measured were the efficacy of both drugs for sedation, patients’ comfort and compliance during AFOI, cough score, BP, HR, post-intubation score, and the Ramsay sedation score and SpO2 for 15 minutes intraoperatively. Results: The study found that 80% of study participants in A group had cough score below 2, compared to only 6.7% in group B. Post-intubation cooperation was also higher in group A, with 83.3% of patients showing cooperation. The Ramsay sedation score showed significant differences between the groups. Intubation length was shorter in group A, while group B experienced HR increased, SBP, and oxygen saturation. These findings highlight the importance of individualized care in patient care. Conclusion: Dexmedetomidine is superior to fentanyl for AFOI. Regarding the provision of heightened sedation, enhanced intubating circumstances, and increased tolerance to intubation, and greater hemodynamic stability, all within a shorter duration for intubation.

AIRWAY CHALLENGES IN A ANKYLOSING SPONDYLITIC PATIENT WITHTRAUMATIC CERVICAL SPINE FRACTURE - A CASE REPORT

Background:Ankylosing Spondylitis (AS) is a chronic inflammatory condition that results in the fusion of the spine and decreased flexibility, commonly known as bamboo spine. This condition presents significant challenges to anesthesiologists due to potential difficulties in managing the airway, cardiovascular issues, and compromised respiration. AS patients face an increased risk of fractures and spinal cord injury, especially in the cervical spine, which is prone to instability and higher morbidity and mortality rates. Maneuvers to manage the airway and intubation techniques may exacerbate movement in the cervical spine, potentially leading to further injury. Case Report: A 42-year-old man with a history of AS presented with a cervical spine injury after a road traffic accident. MRI showed fractures at the posterior arch of C1 and C4-C5 levels with nerve root compression. The patient, who was not regularly followed up, was taking medication. Preoperative assessment revealed a potentially difficult airway, and the patient had quadriparesis and reduced sensation. Due to the risk of spinal cord injury, an awake fiberoptic intubation (AFOI) was planned. The AFOI was successfully performed through the nasal route, and the patient underwent a C4-C5 discectomy and stabilization. The postoperative recovery was uneventful, with no new neurological deficits. Discussion: The case emphasizes the need to minimize movement of the cervical spine when managing the airway in AS patients with cervical spine fractures. Using AFOI is more effective than other techniques in this scenario, as it minimizes cervical movement and allows for post-intubation neurologic assessments. Although the glidescope video laryngoscope and intubating laryngeal mask airway are considered as alternatives to direct laryngoscopy, anesthesiologists still prefer AFOI as the primary option. Conclusion: This case report demonstrates the best airway management for an AS patient with a cervical spine fracture, with a focus on the role of the anesthesiologist in preventing further injury and neurologic deterioration. Awake fiberoptic intubation is the safest alternative for AS patients with cervical spine fractures, as long as the anesthesiologist has the requisite skills and knowledge.

Awake fiberoptic intubation of a patient with severe multiple trauma in prone position: a case report

BackgroundFiberoptic-guided intubation is considered as “gold standard” of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist.Case presentationA man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient’s recovery was uneventful, and he was discharged from the hospital one month after the surgery.ConclusionsAwake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

Flexible Fiber-Optic Scope Use in Retrieval Medicine: A Case Series

ObjectiveThe use of flexible fiber-optic scopes is increasing across critical care specialities, but there is limited literature on their use in retrieval medicine. This study aims to describe a case series in which flexible fiber-optic scopes were used by New South Wales Ambulance Aeromedical Operations critical care teams. MethodsA retrospective case series was performed in our service from January 1, 2019, to December 31, 2021. We searched our electronic medical retrieval database for the terms “aScope,” “Awake Fibreoptic Intubation (AFOI),” “Fibreoptic Intubation (FOI),” and “Nasal Endotracheal Tube (ETT)” to identify when a flexible fiber-optic scope was used. ResultsThere were 16 uses of flexible fiber-optic scopes during the study period. The most common procedure was awake nasal fiber-optic intubation, which was performed during 9 cases, 7 of which were successful. Other procedures performed included 4 cases of intubation through a supraglottic airway, 1 case of an asleep fiber-optic intubation, 1 case of flexible nasoendoscopy for upper airway assessment, and 1 case of fiber-optic bronchoscopy via tracheostomy. These procedures were performed by anesthetic, emergency and intensive care doctors. This case series describes 4 of these cases in more detail. ConclusionThis case series demonstrates a variety of procedural and diagnostic uses for flexible fiber-optic scopes in retrieval medicine. These procedures can have an important bearing on decision making and patient management. The training and clinical governance provided by our service in this skill appears to be safe and robust with high success rates of awake fiber-optic intubations.

RANDOMIZED TRIAL FOR COMPARISON OF BUPRENORPHINE AND FENTANYL FOR AWAKE FIBEROPTIC INTUBATION

Objectives: Awake fiberoptic intubation (AFOI) is a step-forward technique for successful intubation of patients with difficult airways. The popularity of its usage is increasing day by day in handling difficult airways. Our study aims to compare the efficacy and efficiency of Buprenorphine and Fentanyl as sedative agents for AFOI. The primary and secondary outcome measure was to assess hemodynamic response and on intubating condition of the patient after AFOI. Methods: This randomized, prospective study was conducted in tertiary Center hospital. Total of 100 patient were enrolled for study and divided into two groups, Group A patients received intravenous Buprenorphine injection (2.5 (microgram/kilogram [μg/kg] over 10 min) and Group B Fentanyl injection (2 μg/kg over10 min) was injected prior to AFOI. The degree of sedation was assessed using the Observer’s assessment of alertness/sedation score (OAA/S), and the score of coughing during awake bronchoscopy was used to assess intubation status. Tolerability of intubation was assessed using a 5-point intubation score and a 3-point post-intubation assessment score immediately after the placement of the endotracheal tube into the trachea. Results: Group A had more favorable OAA score than Group B, whereas other intubation conditions cough score, limb movement, 5-point intubation score, 3-point post intubation score was more favourable in Group B than in Group A. Conclusion: Intravenous Fentanyl is better than Buprenorphine agent in terms of intubation score for AFOI. Both groups are comparable in terms of hemodynamic changes and stability.

Opioid-free General Anesthesia and Awake Fiberoptic Intubation with Dexmedetomidine in a Class IV Obese Patient with Cervical Spondylosis

Abstract Patients with Class IV obesity (C4O) (body mass index [BMI] >50 kg/m2) are at a particularly high risk of anesthesia-related complications during the postoperative period, e.g., critical respiratory events (CREs) including respiratory arrest and oversedation, leading to problems with maintaining open airway, hypoxia, and hypercapnia. We present the case of a 67-year-old C4O (BMI 57.2 kg/m2) female patient with cervical spondylosis, scheduled for laparoscopic sleeve gastrectomy. Preanesthesia evaluation revealed hypertension, type 2 diabetes mellitus (DM), nonalcoholic steatohepatitis, and obstructive sleep apnea as comorbidities. Awake fiberoptic intubation was planned because of a high potential for difficult intubation (neck circumference of 45 cm, cervical spondylosis, reduced neck mobility, and type 2 DM), using topical anesthesia and dexmedetomidine (Dex) infusion. General anesthesia was given with desflurane and muscle relaxant. “Opioid-free anesthesia,” wherein use of systemic, neuraxial, or intracavitary opioids is completely eliminated, was maintained with Dex infusion for sedation and analgesia. Reversal of anesthesia was done in Fowler’s position (FP), and after extubation, nasopharyngeal airway connected to high-flow oxygen (10 L/min) via tubing was used, which facilitated spontaneous breathing, maintaining oxygen saturation and uneventful recovery. Postoperatively, intravenous paracetamol alone was adequate for effective pain relief. The patient remained hemodynamically stable throughout the perioperative period. This case underscores the benefits of “opioid-free anesthesia” using intraoperative Dex infusion and efficacious use of nasopharyngeal airway in FP postoperatively, avoiding requirement of ventilator, in supermorbidly obese patients, reducing CREs and optimizing postoperative outcomes.

Should Conventional Retrograde Intubation Be Taught in Academic Institutions as a Rescue Approach for Difficult Airways When Other Methods of Intubation are Neither Available Nor Feasible?

Abstract Retrograde intubation (RI) is an approach to secure the airway in case of a difficult intubation. Conventionally, this technique involves placing a guide wire through the cricothyroid membrane into the tracheal lumen, and then advancing an endotracheal tube over the wire towards the glottis. Despite being a relatively safe technique, it has not gained widespread acceptance, as other methods of intubation such as awake fibreoptic intubation, videolaryngoscopy and supraglottic airways have taken precedence over it. However, in certain circumstances, such as in situations, where other methods of intubation are not available or feasible, RI can play a vital role in securing the airway. Given the potential benefits of the RI technique, it is crucial to re-evaluate its significance as a rescue approach for difficult airways. Academic institutions should consider including RI in their airway management curriculum to equip healthcare providers with a versatile set of skills and techniques for managing difficult airway situations. This approach can potentially save lives as it is a reliable and safe alternative technique to other conventional methods of intubation. Here, we provide a case report of a patient who underwent RI for an operable case of carcinoma buccal mucosa with flap coverage and plates in situ when our primary method of intubation, i.e. fibreoptic, malfunctioned.

Evaluation of different doses of dexmedetomidine for awake fibreoptic nasotracheal intubation in patients undergoing oromaxillofacial and oral malignancy surgeries: A randomised, double-blind study.

In patients undergoing cancer surgeries with anticipated difficult airway, awake fibreoptic nasotracheal intubation (AFONI) is critical for securing the airway. However, different doses of dexmedetomidine (DEX) are yet to be evaluated in these patients. Thus, we compared three doses of DEX for AFONI in patients undergoing oromaxillofacial and oral malignancy surgeries. In this randomised, double-blind study, 90 patients aged 18-60 years of either gender, with American Society of Anesthesiologists physical status I/II, and undergoing elective oromaxillofacial and oral malignancy surgeries were randomised to three groups: Group D1 (0.5 µg/kg DEX), Group D2 (1 µg/kg DEX), and Group D3 (1.5 µg/kg DEX). The primary outcome measure was the airway obstruction score. Secondary outcome measures were intubation scores (including vocal movement, coughing, and limb movements) and a 5-point fibreoptic intubation comfort score. Sedation was assessed using the Ramsay sedation score (RSS). One-way ANOVA and Chi-square test were used to assess the association between quantitative and qualitative variables, respectively. A P value of <0.05 was considered statistically significant. The airway obstruction score was comparable between the groups (P = 0.78). Similarly, vocal movement (P = 0.15), coughing (P = 0.31), limb movement (P = 0.51), and 5-point fibreoptic intubation comfort score (P = 0.49) did not differ between the groups. The mean RSS was significantly greater in Group D3 than in Groups D1 and D2 (P = 0.001). In combination with topical spray and airway block, all three doses of DEX resulted in comparable airway obstruction scores and thus provided favourable conditions for AFONI.

Comparative evaluation of nebulized versus intravenous dexmedetomidine on intubating conditions during awake fiberoptic nasotracheal intubation

BackgroundThere is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring. MethodsIn this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1μg.kg−1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1μg.kg−1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects. ResultsThe cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group. ConclusionsNebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation.

Comparative study of midazolam–dexmedetomidine combination with propofol for sedation during awake fiberoptic nasotracheal intubation

Aim and objective The present study was conducted to compare the efficacy and safety of dexmedetomidine and midazolam with propofol alone for sedation during awake fiberoptic nasotracheal intubation. The study was conducted on 40 patients of either sex aged between 18 and 60 years belonging to ASA I–II grade scheduled for elective surgery. The patients were randomly divided into two groups of 20 patients each. Group I patients received intravenous midazolam 0.02 mg/kg followed by dexmedetomidine 1 μg/kg bolus infusion over 10 min, and then an infusion of dexmedetomidine 0.1 μg/kg/h and titrated to 0.7 μg/kg/h to achieve an adequate level of sedation. Group II patients received intravenous propofol 6 mg/kg/h bolus over 10 min with an additional dose of 2.4 mg/kg/h as infusion until they were adequately sedated. Hemodynamic parameters, comfort scale values, and patient’s tolerance were assessed. Patients and methods Fiberoptic nasotracheal intubation was done in both groups of patients, and after securing the tube, general anesthesia was administered. Within 24 h of the surgical procedure, each patient was asked to assess their experience with awake fiberoptic intubation. The data were recorded in the proposed proforma, and the final result was analyzed statistically. Results During sedation during fibreoptic procedure (FOS) and ET insertion, pulse rate (P=0.0116), systolic blood pressure (P=0.30), diastolic blood pressure (P=0.326), oxygen saturation (P=0.53), total comfort score (TCS) (P=0.031), and patient tolerance (P=0.023) were observed and showed statistically significant values. Conclusion Dexmedetomidine and midazolam group had a lower baseline mean heart rate. Systolic and diastolic blood pressure responses measured at preoxygenation, fiberoscope insertion and endotracheal tube placement were not significantly different for both patient groups. The five-point fibreoptic intubation scores showed better patient tolerance in the dexmedetomidine and midazolam group of patients and better comfort score as compared with propofol, and patients were calmer in the dexmedetomidine group.

Combined Transcervical and Median Sternotomy Approach for a Massive Substernal Goiter.

Herein, we describe a combined transcervical and median sternotomy approach for a massive substernal goiter causing tracheal stenosis. A goiter of this size, specifically weighing 630g, is rare. We advocate for a multidisciplinary approach for airway management and for consideration of awake fiberoptic intubation with tracheosomy avoidance for similar patients.

Difficult Airway Management with Awake Fiberoptic Intubation and Cross Table Ventilation in a Case of Acquired TEF with Severe Subglottic Stenosis

We report a case of 30-year male who presented with Acquired Tracheoesophageal Fistula with subglottic stenosis and Aspiration Pneumonitis. Patient was managed with Feeding Jejunostomy, Tracheoesophageal Fistula repair and Tracheoplasty, after which patient recovered well. Difficult airway was managed by Awake Fiberoptic Intubation and cross-table ventilation through flexometallic tube intraoperatively during TEF repair.

Tongue base schwannoma: a case report

Schwannoma is a benign, slow growing tumor which is most commonly seen in the VIII cranial nerve. Schwannoma was first described by Verocay in 1910. We have reported a case of a 52 year old female who presented to the hospital with complaints of difficulty swallowing, change of voice and a growth on the posterior one third of the tongue. Biopsy was done and sent for histopathological evaluation which confirmed the diagnosis of Schwannoma. She underwent Lip Split with Mandibulotomy surgery which was done with a awake fiberoptic nasal intubation followed by general anesthesia. The tumor was excised in toto. Her postoperative period was uneventful. Mandibulotomy with lip split provides more than adequate visualization of the masses on the posterior region of the tongue, allowing better maneuvering, ease and precise results for a skilled surgeon. Transoral approach may be the most widely used technique but the decision should be based on the clinical evaluation such as the size, shape and the anatomy of the patient. Narrowing down to the technique of choice should be done after a comprehensive evaluation of that patient. A team of various specialities like Otolaryngologist, Anaesthetist and radiologist is required for optimal execution for this surgery. To enhance our understanding a literature review between 2006 and 2023 was done which included the reports on tongue base schwannoma. A large number of them underwent transoral excision of the mass with a minority choosing mandibulotomy with lip split. A limited array of literature is available for tongue base schwannoma cases.

A Case Series Reflecting Airway Difficulty Challenges: Insights into Intubation and Extubation for Large Retrosternal Goitres

Retrosternal goitres, often due to longstanding thyroid enlargement, can compress critical structures like the trachea and oesophagus, necessitating thyroidectomy. Managing the airway while ensuring patient safety presents a significant challenge for anaesthesiologists. This case series explores the complex airway management in three patients with large retrosternal goitres undergoing total thyroidectomy. The patients, aged 50, 60, and 73, presented with long-standing neck swelling, tracheal deviation and symptoms including breathlessness, dysphagia and hoarseness of voice. The goitres had progressively enlarged over many years, leading to significant tracheal compression and deviation, which posed a high-risk for airway obstruction during surgery. Given these challenges, Awake Fiberoptic Intubation (AFOI) was chosen to secure the airway while minimising the risk of airway loss. AFOI was performed under conscious sedation with dexmedetomidine and local anaesthesia, providing effective intubation with minimal discomfort and stable haemodynamics. This approach was critical in managing the anticipated difficult airway due to the retrosternal extension of the goitres and their impact on surrounding structures. Postoperatively, the patients were kept intubated to prevent tracheomalacia, a potential complication arising from prolonged tracheal compression. Tracheomalacia, characterised by the weakening of tracheal walls, can lead to airway collapse after extubation. To ensure airway stability, extubation was delayed until a satisfactory cuff-leak test was performed 24-36 hours after surgery. This case series emphasises the importance of careful preoperative planning and the use of AFOI in managing patients with large retrosternal goitres to avoid a ‘can’t intubate, can’t ventilate’ situation. The successful management of these cases highlights the effectiveness of AFOI in reducing perioperative risks and ensuring patient safety, particularly in scenarios where difficult airway management is anticipated. By implementing appropriate postoperative protocols, the risk of complications such as tracheomalacia can be significantly reduced, leading to improved surgical outcomes.

Blockbuster Laryngeal Mask Airway as a Rescue Device in Paediatric Patient with Retrognathia Posted for Microtia Reconstruction Surgery: A Case Report

The first and second branchial arches, along with the first branchial cleft, contribute to the development of ear and mandible. Children with microtia can have retrognathia or micrognathia and have challenging airway management. Managing the airway in these patients presents a significant challenge for anaesthesiologists as they have the potential for upper airway obstruction and challenging tracheal intubation because of facial deformities. Although awake fiberoptic intubation is a well-accepted method for handling difficult intubations, it can be uncomfortable and stressful for paediatric patients. Moreover, it demands expertise and is unsuitable for patients unwilling to undergo awake intubation. This case report highlights the use of the blockbuster Laryngeal Mask Airway (LMA) in an 11-year-old retrognathic child with microtia with anterior larynx scheduled for auricular reconstruction surgery. There was a failure to secure the airway with multiple attempts at traditional intubation and the supraglottic airway device i-gel, as the child had an anterior larynx and Cormack Lehane (CL) grading of 4 on direct laryngoscopy. The blockbuster LMA, distinguished by its innovative design facilitating both ventilation and intubation through an integrated channel, emerged as a pivotal alternative. The supraglottic device is not the technique of choice, but it can definitely be an alternative and could be life-saving in situations where fiberoptic bronchoscopy and tracheostomy are not available.

Perioperative Management Challenges and Anaesthetic Considerations for a HIV Positive Patient of Multiple Symmetric Lipomatosis (Madelung Disease): A Case Report

A 60-year-old man with obstructive sleep apnea and human immunodeficiency virus positive status presented to this hospital with a huge mass at the base of his neck which caused him to sleep on his left side for the past 6 years; he was eventually diagnosed with Madelung’s disease. He was scheduled for the removal of the tumor through reconstructive surgery. Madelung’s disease is a rare disorder characterized by the development of benign fatty tumors in a symmetrical pattern primarily in the upper body. Considering the patient’s American Society of Anaesthesiologists grade, co-morbidities, and specific challenges such as difficult airway and prone positioning, careful planning for anaesthesia was crucial. Therefore, the decision was made to use general anaesthesia with awake fiberoptic intubation to reduce the possible dangers of difficult airway complications during the initial stages of the procedure. Management of Madelung’s disease requires a multidisciplinary approach and thorough pre-operative assessment, patient counseling, meticulous monitoring and airway planning to achieve patient comfort and safety. Continuous monitoring, pain treatment and adequate follow-up after surgery all help to ensure a smooth recovery. Keywords: Multiple symmetric lipomatosis, General anaesthesia, HIV infection, Awake fiberoptic intubation.

Awake Bougie-guided versus Awake Fiber-optic Intubation: An Anesthetic Dilemma in a Patient with Symptomatic Tracheal Compression

Awake Bougie-guided versus Awake Fiber-optic Intubation: An Anesthetic Dilemma in a Patient with Symptomatic Tracheal Compression