Difficult Airway Cases Research Articles

Comparison of intravenous nalbuphine and dexmedetomidine in combination with lidocaine aerosol inhalation in awake direct laryngoscopy: a randomized, double-blind, placebo-controlled trial

BackgroundThe airway should be thoroughly and accurately evaluated before anesthesia induction and endotracheal intubation. Awake direct laryngoscopy (ADL) can provide rapid, accurate, and intuitive airway assessment, especially for suspected difficult airways, and sometimes eliminates the need for fiberoptic intubation in some suspicious difficult airway cases. However, an optimal regimen has not been determined.MethodsIn this double-blind, controlled study, prior to ADL, 60 patients scheduled for general anesthesia were randomly allocated to receive 0.75 μg/kg of dexmedetomidine (Dex group, n = 20), 0.15 mg/kg of nalbuphine (Nal group, n = 20), or a placebo (control group, n = 20) intravenously over 10 min. At the same time, all study subjects received nebulized lidocaine for 15 min. The primary outcome was patient tolerance as assessed by a 5-point ADL comfort score, while secondary outcomes included satisfaction, coughing, pain, nausea and vital signs.ResultsPatients undergoing ADL in the Nal group had higher tolerance scores than those in the control and Dex groups [4 (3,4) vs. 3 (2,2.75), P < 0.017, and 4 (3,4) vs. 2 (2,2,75), P < 0.001, respectively] and higher satisfaction [7 (6,8) vs. 4 (3,5.75), P < 0.017, and 7 (6,8) vs. 5.5 (5,6), P < 0.001, respectively]. Additionally, the Nal group had significantly fewer adverse events, such as pain and nausea than the control and Dex groups. The sedation score and peripheral oxygen and saturation were significantly higher in the Nal group than in the Dex group, with no difference between the Nal and control groups (P < 0.001, P = 0.159, respectively).ConclusionsIntravenous nalbuphine in combination with lidocaine aerosol inhalation significantly improved patient tolerance and satisfaction while reducing nausea, coughing, pain, sedation, and SpO2 levels during ADL.

Nontechnical Skills Assessment in Acute Care Trauma Simulations: A Mixed Methods Approach Using Eye Tracking and Behavioral Marker Systems.

The condition of trauma patients and the urgent need for timely resuscitation present unique challenges to trauma teams. These difficulties are exacerbated for military trauma teams in combat environments. Consequently, there is a need for continued improvement of nontechnical skills (NTS) training for trauma teams. However, current approaches to NTS assessment rely on subjective ratings, which can introduce bias. Accordingly, objective methods of NTS evaluation are needed. Eye-tracking (ET) methods have been applied to studying communication, situation awareness, and leadership in many health care settings, and could be applied to studying physicians' NTS during trauma situations. In this study, we aimed to assess the relationship between trauma team leaders' objective gaze patterns and subjective expert NTS ratings during patient care simulations. After Institutional Review Board approval, 9 trauma teams from first-year post-graduate general surgery and emergency medicine residents were recruited to participate in 1 of 2 trauma simulations (a difficult airway case and a multi-patient trauma). Each scenario lasted approximately 15 minutes. All team leaders wore a mobile ET system to evaluate gaze metrics-time to first fixation (TTFF), average fixation duration (AFD), and total percentage of the scenario (TPS) focused on Areas of Interest (AOI), which included patient, care team, diagnostic equipment, and patient care equipment. Trained faculty raters completed the Non-Technical Skills for Surgeons (NOTSS) assessment tool and the Trauma Non-Technical Skills (T-NOTECHS) scale. One-way analysis of variance, Kruskal-Wallis, and appropriate post-hoc pairwise comparison tests were run to assess differences between ET metrics across AOI groups. Spearman's Rho tests were used to assess correlations between ET and subjective NTS ratings. Compared to other NTS domains, trauma teams scored relatively poorly on communication across both T-NOTECHS (3.29$ \pm $0.61, maximum = 5) and NOTSS (2.87$ \pm $0.66, maximum = 4). We found significant differences in trauma team leaders' TTFF between teammates and the patient (Team: 1.56 vs Patient: 29.82 seconds, P < .001). TTFF on the diagnostic equipment was negatively correlated (P < .05) to multiple measures of subjective NTS assessments. There were no significant differences in AFD between AOIs, and AFD on teammates was positively correlated (P < .05) to communication and teamwork. There were significant differences in TPS across most AOI pairs (P < .05), and the average TPS fixated was highest on the patient (32%). Finally, there were several significant correlations between additional ET and NTS metrics. This study utilized a mixed methods approach to assess trauma team leaders' NTS in simulated acute care trauma simulations. Our results provide several objective insights into trauma team leaders' NTS behaviors during patient care simulations. Such objective insights provide a more comprehensive understanding of NTS behaviors and can be leveraged to guide NTS training of trauma physicians in the future. More studies are needed to apply these methods to capture NTS from a larger sample of teams in both simulated and real trauma environments.

Regional Anaesthesia with Non Invasive Ventilation and Conscious Sedation: An Alternative to General Anaesthesia in Morbidly Obese Patients with Obstructive Sleep Apnea in Retrograde Intrarenal Surgery

Obstructive sleep apnea(OSA) is a syndrome characterized by obstruction in the upper airway during sleep. OSA patients undergoing procedures under GA are at increased risk for hypoxemia, pneumonia, difficult intubation, atelactasis, myocardial infarction making it a challenge for anesthesiologist. Retrograde intrarenal surgery(RIRS) is normally performed under GA to prevent respiratory embaracement. There are very few studies focusing on Regional anesthesia in RIRS procedure. A Sixty-three-year-old male known case of morbid obesity (BMI- 35 kg/meter square), OSA (on CPAP support at night) presented with left renal pelvis calculus, STOP BANG score (=5) therefore making it a case of difficult airway. Respiratory discomfort improved at 30-35-degree head up due to existing OSA considering the severe OSA and anticipated difficult airway, the surgery was planned under Lumbar subarachnoid block with preparation for management of difficult airway if conversion to GA required. 3 ml of 0.5 percent Bupivacaine heavy and 25 mcg fentanyl injected into subarachnoid space. T6 level block acheived after 3 minutes. The patient was put on his home CPAP machine with 5cm H2O PEEP. The patient was maintained on sponatneous ventilation and monitored using Etco2 at aliquot of 1mg midazolam given to mimic natural sleep pattern. The surgery was uneventful and the risk of induction of GA and difficult intubation was succesfully avoided. Patient with regional anaesthesia who are prone to converted to GA due to multiple risk factors, i.e., OSA with anticipated difficult airway can create a chaotic situation. So as a preliminary step NIV can be used, and along with it, mild sedation can be supplemented to improve acceptance and to avoid asynchrony. In this case NIV was used as a preemptive ventilation strategy even before actual requirement of BiPAP by mimicing the natural sleep pattern and make patient comfortable while a smooth conductance of the procedure.

Long-Term Outcomes of Cricothyroidotomy Versus Endotracheal Intubation in Military Personnel: A Retrospective Comparative Analysis Cohort Study

IntroductionEmergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. MethodsData on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. ResultsOf the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture. ConclusionsThis retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.

Video Laryngoscopy vs. Direct Laryngoscopy in Adult Patients with Difficult Airways Who Require Emergency Intubation

This review compares the efficacy of video laryngoscopy (VL) with that of direct laryngoscopy (DL) in adult patients with difficult airways who require emergency intubation. Intubation and laryngoscopy are critical in emergency settings, and VL has emerged as an alternative to DL, particularly in difficult airway cases and when performed by non-experienced practitioners. VL demonstrates advantages such as a wider field of view, enhanced glottic visibility, and higher first-pass success rates, particularly in difficult airway scenarios. However, it also presents limitations, including potential view obstruction and technical complexity. While the evidence points to the advantages of VL, particularly in achieving higher first-pass success rates and minimizing adverse events in adult patients with difficult airways, the inconclusive findings from randomized trials emphasize the importance of future research in refining practices and improving patient outcomes.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange to the Rescue of the Anaesthesiologist in a Difficult Airway Case

Airway surgeries pose challenges to the anaesthesiologist due to a potentially difficult airway and shared workspace with the surgeons. Apnoeic oxygenation is a technique to increase apnoea time safely during airway surgeries, which can be achieved with multiple devices, one of which is high-flow nasal oxygen (HFNO). Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is one of the modes of delivering HFNO. We present an interesting case report wherein THRIVE was incorporated into successful anaesthetic management of an intratracheal tumour located close to the carina almost obliterating the tracheal lumen.

An Unusual Case of Difficult Airway and a Serious Complication of Intubation Due to Forestier Syndrome

An Unusual Case of Difficult Airway and a Serious Complication of Intubation Due to Forestier Syndrome

Managing difficult airway in a post burn neck contracture: A case report

Post burns neck contracture is always considered a difficult airway and requires meticulous planning for proper management. Awake fiberoptic intubation (AFOI) have been gold standard for managing difficult airways [1]. Here we will discuss a case of difficult airway due to post burn contractures at the neck posted for debridement and Split Skin Grafting (SSG) for Marjolin’s ulcer at the nape of the neck. Internal changes in the airway due post inhalational injury fibrosis proved the major cause of difficulty and following traditional clinical teachings helped in successful management of airway.

Video laryngoscopy: a double-edged sword

Endotracheal intubation revolutionized anesthesia and allowed prolonged surgical procedures to be performed. It also made positive pressure ventilation possible in patients in respiratory insufficiency and being managed in intensive care units. But successful intubation required the development of laryngoscopes. A variety of blades were developed to be used in different sets of patients. A laryngoscope came to be known as a symbol of the specialty of anesthesiology. But it was not always safe, nor successful, necessitating more sophisticated instruments. Video laryngoscopes were introduced with a sigh of relief for the anesthesiologists in difficult airway cases. Many variations of video laryngoscopes with slight differences have been marketed. But cases of video laryngoscope related injuries have been reported. This paper gives an over-view of the possible mechanism and preventive measures.&#x0D; Abbreviations: DL - Direct laryngoscopy; ETT – Endotracheal intubation; IDL - indirect laryngoscopy; VL - Video laryngoscopy; &#x0D; Key words: Airway management; Instrumentation; Intubation, endotracheal; Laryngoscope; Laryngoscopy&#x0D; Citation: Dhoon TQ, Wilson L, Rajan GRC. Video laryngoscopy: a double-edged sword. Anaesth. pain intensive care 2023;27(3):413−416; DOI: 10.35975/apic.v27i3.2219&#x0D; Received: March 30, 2023; Reviewed: April 11, 2023; Accepted: April 15, 2023

Does Regular Practice with a "Flexible Bronchoscopy Simulator" Improve Fibreoptic Intubation Skills in Experts and Novices? A Randomized Controlled Study.

The appropriate management of a "difficult airway" remains a challenge for novices and experienced anaesthetists. With the current available airway technologies, e.g., video laryngoscopy, flexible bronchoscopy (fibreoptic intubation (FOI)) for endotracheal intubation is decreasing, likely diminishing caregiver skills. We investigated whether bronchoscopy simulator training improved FOI skills. 72 volunteers, consisting of anaesthetists, anaesthesia residents, and nurses, performed six exercises on a bronchoscopy simulator. At baseline and after 12 months, the six exercises included one serious game (to train agility), two basic airways, and three difficult airways. After a baseline assessment, subjects were randomly allocated to the intervention group (with) or control group without bronchoscopy simulator training every six weeks for 10 min using a preloaded serious game. The primary outcome was the difference in the time to reach the carina after 12 months, as measured objectively by the simulator. The level of stress and FOI confidence after 12 months were secondary outcomes. The control and intervention groups had a similar time to reach the carina in difficult airway cases and the reported stress levels, at baseline and 12 months, showed no difference. In contrast, the intervention group's self-reported confidence in FOI skills improved more. Although participants rated higher in confidence, practicing FOI skills on an airway simulator with an agility game did not increase their performance in simulated challenging airway instances.

Hemodynamic Response and Patient Comfort in Conscious Intubation with Recurrent Laryngeal Nerve Block

Introduction: Anesthetic management of conscious intubation in difficult airway cases can be done with topical anesthetics, airway nerve blocks, or a combination of both. Inadequate quality of anesthesia can cause hemodynamic turmoil, pain, gag reflex, and patient discomfort. This study presents a case report on the use of recurrent laryngeal nerve blocks in patients who were consciously intubated.&#x0D; Case presentation: This man was premedicated in the reception room using 10 mg IV dexamethasone, 10 mg IV diphenhydramine, 2 drops of 0.05% oxymetazoline right nose, 4 ml of 4% lidocaine nebulization, 10% lidocaine spray on the uvula and 2 puffs of pharyngopalatine fauces. Once in the operating room, this man was given midazolam 1.5 mg IV, fentanyl 25 mcg IV, followed by ultrasound-guided recurrent laryngeal nerve block. The local anesthetic used was 2 ml of 2% lidocaine. After that, right intranasal conscious intubation was performed. During intubation, this man began to show discomfort in the form of frowning when the flexible scope (FIS) was in the larynx and briefly passed the vocal cords. In addition, a gag reflex and cough are seen when the FIS and airways pass over the larynx and vocal cords. Intubation is done in about 4 minutes with 1 attempt.&#x0D; Conclusion: Awake intubation can be performed with topical anesthesia, airway block, or a combination of the two. Awake intubation with a combination of laryngeal recurrent nerve blocks and topical anesthesia, in this case, was inadequate because there was coughing, gag reflex, and increased heart rate during intubation.

Common Anesthesia Challenges in a Case of Ankylosing Spondylitis Posted for the Correction of Spinal Deformity

Background: Ankylosing spondylitis (AS) is a type of inflammatory arthritis. Due to the rigid and brittle nature of spinal joints and multisystem involvement in the patients affected by ankylosing spondylitis, they are more prone to developing various complications. Different deformities require several surgical manipulations and perioperative anesthetic challenges, such as difficult intubation and positioning within the operating room. Case presentation: A 42-year-old man was diagnosed with ankylosing spondylitis, which has progressed over the last six years. He suffered from increasing pain and could not look forward, therefore; he has been scheduled for a corrective surgical procedure to address his spinal deformity to alleviate his pain and enhance the quality of his life by improving his functional abilities. Conclusion: Effective management of difficult airway cases with ankylosing spondylitis involving anatomical changes and reduced spinal mobility can be achieved by using awake fiberoptic-assisted nasal intubation. Intraoperative neuromonitoring and careful attention to proper positioning should be considered during the corrective spinal surgery to reduce complications.

Retrospective Investigation of Difficult Airway Cases Encountered in Bursa Uludag˘ University Medical Faculty Operating Room.

Ensuring airway patency and proper management of ventilation by anticipating difficulties that can occur in airway control are vital in preventing anaesthesia-related complications. We aimed to determine the role of preoperative assessment findings in difficult airway management. In this study, critical incident records of difficult airway patients between 2010 and 2020 in the operating room of Bursa Uludag˘ University Medical Faculty were retrospectively analysed. A total of 613 patients, whose records were fully accessible, were grouped as paediatric (under 18 years old) and adult (18 years and over). The success rate for maintaining an airway in all patients was 98.7%. Pathological situations which cause difficult airways were head and neck region malignancies in adult patients and congenital syndromes in paediatric patients. Anatomical reasons that cause difficult airway were anterior larynx (31.1%) and short muscular neck (29.7%) in adult patients and small chin (38.0%) in paediatric patients. A significant statistical relationship was found between difficult mask ventilation and increased body mass index, male gender, modified Mallampati class 3-4, and thyromental distance <6 cm (P = .001, P < .001, P < .001, and P < .001, respectively). The correlation of Cormack-Lehane grading with modified Mallampati classification, upper lip bite test, and mouth opening distance was statistically significant (P < .001, P < .001, and P < .001, respectively). In male patients with increased body mass index, modified Mallampati test class of 3-4 and thyromental distance of < 6 cm should suggest the possibility of difficult mask ventilation. In modified Mallampati classification and upper lip bite tests, the possibility of difficult laryngoscopy should be considered as class increases and mouth opening distance becomes shorter. Preoperative assessment, including a good history taken from the patient and a complete physical examination, is crucial to provide solutions for difficult airway management.

A case of a syndromic preterm neonate in a “can ventilate, can’t intubate” condition: Guedel airway to the rescue!

Introduction: Upper airway distress associated with craniofacial anomaly has been reported widely. An antenatal scan of craniofacial anomaly should alert the attending team to prepare for respiratory distress in any neonate following delivery. Additionally, a stepwise algorithm is imperative to manage the difficult airway in children with craniofacial anomalies. Aim: To outline a case of difficult airway in a newborn with a craniofacial anomaly. Case study: A premature neonate, born at 36 weeks, was referred to the otorhinolaryngology team following the failure of intubation. Guedel oropharyngeal airway was inserted, and temporarily airway was managed with non-invasive ventilation. However, tracheostomy was subsequently performed, while the neonate was ventilated via face mask. Discussion and conclusion: Prompt management is of dire importance in handling a newborn with craniofacial anomaly in respiratory distress. Guedel oropharyngeal airway is a temporary measure used to secure the airway, while tracheostomy is performed.

Accuracy of Preoperative Ultrasonographic Airway Assessment in Predicting Difficult Laryngoscopies in Adult Patients.

Background and objectives Presently, neck ultrasonography is used as a tool to predict a difficult airway. There are no standardized ultrasonographic criteria that help to predict a difficult airway. This study aims to ultrasonographically assess the anterior neck soft tissue thickness preoperatively based on two parameters-the minimal distance from the hyoid bone to skin (DSHB) and the distance from the skin to the epiglottis midway between the hyoid bone and thyroid cartilage (DSEM)-and find out whether these parameters can predict a difficult airway in adults by correlating with the Cormack-Lehane (CL) grading. Background and objectives After obtaining ethical committee clearance and patient consent, we conducted this study on 96 patients aged between 18 and 60 years, belonging to American Society of Anesthesiologists (ASA) classes one and two, who were admitted for elective surgery under general anesthesia with endotracheal intubation to RL Jalappa Hospital and Research Centre, Tamaka, Kolar, from January 2020 to May 2021. The exclusion criteria were patients with anticipated difficult airway cases, such as obesity, pregnancy, head and neck anatomical pathologies, maxillofacial anomalies, and edentulous patients. The sonography of the airway was first performed preoperatively by an anesthesiologist along with standard clinical tests such as Mallampati (MP) grading. The sonography included two parameters: DSHB and DSEM. The patients were later classified as having easy or difficult laryngoscopy based on USG criteria from the available literature. A DSHB value of greater than 0.66 cm was predicted to be a difficult airway, and less than 0.66 cm was predicted to be easy. A DSEM value greater than 2.03 cm was predicted to be a difficult airway, and less than 2.03 cm was predicted to be easy. After induction of anesthesia, another experienced anesthesiologist performed direct laryngoscopy in the sniffing position with an appropriate-sized Macintosh blade and CL grades. CL grades I and II were considered to be easy laryngoscopies. The quantitative data were presented by mean SD and confidence interval (CI). The qualitative data were presented in percentages, and p-values less than 0.05 were considered statistically significant. To determine the discriminative power of individual tests, the receiver operating characteristic curve and the area under the curve with a 95% confidence interval was noted. Results The two USG parameters DSHB and DSEM may be used to predict difficult laryngoscopy in adult patients, as both have very strong statistical significance. Of the two parameters, DSHB seems to have a better diagnostic value for predicting a difficult airway in our study, as supported by thearea under the curve (AUC) of 97.4% compared to DSEM with an AUC of 88.8%. DSHB has better sensitivity (100%), and DSEM has better specificity (89.77%). Conclusion Our study showed that DSHB and DSEM may aid in predicting difficult laryngoscopies, as a strong statistical significance was present between sonographic measurements and CL grading. DSHB also appeared to have a better diagnostic value for predicting a difficult airway.

Accuracy of airway ultrasound parameters to predict difficult airway using the LEMON criteria as a reference: A cross-sectional diagnostic accuracy study.

Ultrasound (US) airway indexes were frequently compared with other scoring systems such as Mallampati score and Cormack - Lehane classification system, but to the best of our knowledge never with LEMON. Here, in this study, we evaluated the accuracy of some recommended airway US parameters in terms of screening difficult airway using the LEMON criteria as a reference. This was a cross-sectional diagnostic accuracy study in which people with at least 18 years old coming to the emergency departments for any reason who had consent for participation, were enrolled with the simple random sampling method. Hyo-mental distance (HMD), skin to epiglottis distance (EP), and peri-epiglottic space to epiglottis to vocal cord ratio (PEP/E. VC) were the US indexes that were calculated in all participants. Using a preprepared checklist, measured US parameters were recorded. For each participant, the LEMON score variables were also assessed and recorded, and the cutoff point for considering as a difficult airway case, based on LEMON score, was 2. Demographic characteristics of the participants were also registered. A total of 299 cases with a mean age of 41.1 years (95% confidence interval [CI]: 39.3-42.9), were participated. Based on LEMON score ≥2, 20 participants (6.7%) were categorized in difficult airway group. Comparison of the PEP/E. VC (P = 0.007) and EP distance (P = 0.049) of the participants based on LEMON score showed a statistically significant difference; but comparison of the means of HMD in the two groups was not statistically significant (P = 0.144). The median of EP of the participants was 7.70 mm (interquartile range [IQR]: 6.70-9.40). The best cutoff point of EP distance for evaluating a difficult airway was 12.27 mm and more with the sensitivity of 35% and the specificity of 86.96% (accuracy = 0.614; 95% CI: 0.492-0.736). The median of PEP/E. VC was 1.01(IQR: 0.79-1.23). The best cutoff point of PEP/E. VC for evaluating a difficult airway was 0.88 and less with the sensitivity of 70% and the specificity of 67.38% (accuracy = 0.701; 95% CI: 0.583-0.818). As per our results, PEP/E. VC and EP distance measured with sonography can be used in distinguishing the difficult airway, using the LEMON criteria as the reference. However, further studies are needed to use PEP/E. VC and EP distance as a part of reliable indexes.

Difficult Airway Management in Pediatric Patient with Neck Contracture

Background: A specific airway evaluation and physical examination should be performed in all pediatric patients undergoing anesthesia. Pediatric difficult airway problems can occur due to congenital, inflammation, trauma, or malignant disorders. Laryngeal mask airway (LMA) is an alternative breathing device for difficult airway cases. Case: We reported a 5-year-old girl, 12 kg of weight, with a diagnosis of Colli region contracture planned for contracture release. Physical examination revealed glasgow coma scale score 15, with a pulse of 98 beats per minute, a breath rate of 22 times per minute and SpO2 of 98% on the room air. In the airway evaluation, it was found that the lower mouth was pulled down by the contracture tissue, 2-fingers-wide of mouth opening, the mallampati score was difficult to evaluate, there was no obstruction and neck motion was limited due to contractures. In this report, intubation via video laryngoscope was failed due to the severely restricted neck motion caused by the contracture. The use of LMA became an alternative difficult airway management in this patient after failed intubation with a video laryngoscope. Conclusion: Preoperative evaluation for assessing and evaluating difficult airway in pediatric patients greatly determines the success of airway management. The use of airway devices such as LMA is still very helpful in cases of pediatric difficult airway.

Multi-institutional quality improvement case series: Pediatric airway emergencies leading to the creation of a pediatric otolaryngology airway cart

To describe a specialty pediatric airway emergency cart developed as a multi-institutional quality improvement initiative for difficult pediatric intubations. This study was a retrospective case series at two academic tertiary care centers. Baseline data was compiled from consecutive difficult airway cases from 2018 to 2020 and presented to the performance improvement coordinating group to determine whether a specialty emergency airway cart would be of use.Implementation of a pediatric emergency airway cart was accomplished after presentation of these cases. To our knowledge, this is the first description of the use of a specialty pediatric airway cart to help in difficult airways requiring otolaryngologic assistance.

Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry.

Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of this study was to compare the first-attempt success rate of tracheal intubation during sedated tracheal intubation versus tracheal intubation under general anesthesia. The hypothesis was that sedated intubation would be associated with a lower first-attempt success rate and more complications than general anesthesia. This study used data from an international observational registry, the Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. The use of sedation versus general anesthesia for tracheal intubation were compared. The primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and nonsevere and severe complications. Propensity score matching was used with a matching ratio up to 1:15 to reduce bias due to measured confounders. Between 2017 and 2020, 34 hospitals submitted 1,839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation, and 1,764 patients received general anesthesia. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the general anesthesia group. The rate of first-attempt success of tracheal intubation was 28 of 58 (48.3%) in the sedation group and 250 of 522 (47.9%) in the general anesthesia group (odds ratio, 1.06; 95% CI, 0.60 to 1.87; P = 0.846). The median number of intubations attempts was 2 (interquartile range, 1 to 3) in the sedation group and 2 (interquartile range, 1, 2) in the general anesthesia group. The general anesthesia group had 6 of 522 (1.1%) intubation failures versus 0 of 58 in the sedation group. However, 16 of 58 (27.6%) sedation cases had to be converted to general anesthesia for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low. Sedation and general anesthesia had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to general anesthesia to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low.

The Incidence of Trauma with the Use of Glidescope in Anticipated Difficult Airway Cases – A Prospective Observational Study

Background: Glidescope video-laryngoscope (GVL) is an invaluable equipment for patients with anticipated difficult intubations that aids in visualizing the vocal cords out of line-of-sight. However, despite the ease in the visualization and shortening of the time taken to visualise the cords, the intubation time is often prolonged and is associated with trauma. This study aims at identifying incidence of trauma with glidescope in anticipated difficult airway scenario and whether correct practice by experienced anesthesiologist can reduce trauma. Methodology: Eighty-nine adult patients with anticipated difficult airway who were intubated using GVL by experienced anesthesiologists in a tertiary care setting were studied. The time to visualize, the time to intubate, the difficulties encountered at intubation were documented, the incidence of trauma was reported. The factors associated with trauma were analyzed using PSPP software (psppire. exe 0.8.4-g012d99). Results: The incidence of airway trauma was 11.2%. It was higher in the group with technical difficulties (Gtd) (P &lt; 0.001) and was less in the hands of an experienced anesthesiologist (P = 0.02). Conclusion: GVL intubation in anticipated difficult airway cases by experienced anesthesiologists using the right technique has lesser incidence of trauma, lesser than that is seen with Macintosh intubations in anticipated difficult airway scenario. Knowledge on techniques to troubleshoot technical difficulties with GVL may reduce the incidence of trauma further and needs to be studied more.