Complex Airway Management Research Articles

Rates of tracheostomy in patients with complex skeletal dysplasia: A 32-year institutional experience

ObjectiveRespiratory failure secondary to multilevel airway compromise may present complex airway challenges in patients with specific skeletal dysplasia diagnoses. This study sought to identify and characterize subgroups of skeletal dysplasia diagnoses that more frequently undergo operative airway evaluations and tracheostomy placement. MethodsRetrospective electronic medical record review of pediatric patients with an ICD-10 associated skeletal dysplasia diagnosis and CPT-specified airway intervention at a tertiary pediatric hospital from 1990 to 2022. Patients without a defined skeletal dysplasia diagnosis, subjects with craniosynostosis syndromes, and those with limited clinical data were excluded. Collected variables included demographics, age at diagnosis, comorbidities, operative procedures, and airway interventions. Descriptive statistical analysis was utilized to evaluate data distribution. ResultsFrom the initial population of 313 patients, 41 subjects were confirmed to have clinical features and/or genetic testing consistent with a skeletal dysplasia diagnosis. A tracheostomy was placed in 19/41 subjects and these patients’ records were further analyzed. Skeletal dysplasia groups with more frequent tracheostomy placement included Filamins and related disorders, Sulfation disorders, and Chondrodysplasia punctata. In the patients with a tracheostomy, skeletal dysplasia was diagnosed at a median age of 0.3 years (IQR 4.8 years), and tracheostomy was initiated at a median age of 1.8 years (IQR 2.2 years). Only four of these patients were successfully decannulated, and two subjects are deceased. ConclusionOver 32 years, nearly half of the skeletal dysplasia patients who underwent airway interventions eventually had a tracheostomy placed. Respiratory insufficiency and complex airway management challenges are common manifestations of skeletal dysplasia.

Airway Management in Pan Facial Fracture: An Outcome Analysis of Elective Tracheostomy and Submental Endotracheal Intubation

Background and Aims. Pan facial fractures are complex and often requiring complex airway management. Elective tracheostomy (ET) and submental endotracheal intubation (SEI) are the two major techniques for airway management. The aim of this article is to compare the management outcome between these techniques. Methods. This study was done in a tertiary care hospital from Jan 2019 to Dec 2019. Data were retrieved for all patients from hospital admission-discharge reports, operation room records, follow-up notes, and clinical photograph records which was recorded prospectively after ethical clearance. Total 38 patients were included in the study after the exclusion criteria into two groups: submental endotracheal intubation (SEI) and elective tracheostomy (ET). Demographic data, intraoperative time (IOT), length of hospital stay (LOHS), postoperative pain score at three and seven days, and Vancouver Scar Score (VSS) at 4 and 12 weeks was compared between the two groups. Results. SEI consisted of 23 patients (60%) while ET had 15 (40%) patients. The mean age was 32.77±8.24 years in the SEI and 29.36±7.32 years in the ET. The IOT in SEI was 15.36±1.53 min and 24.60±1.40 min in the ET which was statistically significant (p = 0.00001). The LOHS was 11±3.87 days in SEI and 25.2±3.88 days in ET (p = 0.0001). The mean VSS at 4 and 12 weeks for SEI were moderate and mild respectively and for the ET was moderate and mild respectively. Both were statistically significant with a p = 0.003 and p = 0.006. Conclusion. Submental intubation is a safe airway management technique in pan facial fracture. It provides the surgeon with an excellent operative field for achieving the proper dental occlusion. Both short- and long-term outcomes are better compared to the alternative airway method of elective tracheostomy.

Carinal Resections

Carinal resections are consistently described in the literature as one of the most challenging procedures in thoracic surgery. Depending on the underlying disease and its extent, different resection forms and reconstruction techniques are required. From a surgical point of view, the complex anatomy, and the technique of reconstruction of the central airway are particularly challenging. However, complex airway management and extensive postoperative follow-up demonstrate that these procedures require a multidisciplinary team effort beyond surgical expertise. This article reviews the most important pre-, intra-, and post-operative aspects of these challenging procedures.

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.

Difficult Tracheal Intubation and Airway Outcomes after Radiation for Nasopharyngeal Carcinoma.

The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT). The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group). One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p = 0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p < 0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%. NPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor. 4 Laryngoscope, 134:120-126, 2024.

Complex Airway Management in Patients with Tracheal Cartilaginous Sleeves.

A tracheal cartilaginous sleeve (TCS) is a rare anomaly characterized by anterior fusion of tracheal cartilages. TCS is associated with syndromic craniosynostoses including Apert, Crouzon and Pfeiffer syndromes and FGFR2, FGFR3, and TWIST1 variants. This study presents a 30-year review of patients with syndromic craniosynostosis and TCS and describes diagnostic methods, genetic variants, surgical interventions, and long-term outcomes. Retrospective, single-institution review. This review included patients with syndromic craniosynostosis and TCS treated at Seattle Children's Hospital from 1990 to 2020. Tracheostomy, genetic variants, and additional surgery were primary measures. Fisher's exact test compared need for tracheostomy in patients with proposed high-risk (FGFR2 p.W290 or FGFR2 p.C342) versus low-risk genetic variants. Thirty patients with TCS were identified. Average age at diagnosis was 12 months (range 2-weeks to 7.9-years; standard deviation 19.8 months). Syndromes included Pfeiffer (37%), Apert (37%), and Crouzon (26%). Severe obstructive sleep apnea was present in 76% of patients. Tracheostomy was performed in 17 patients (57%); five were successfully decannulated. Additional interventions included adenotonsillectomy (57%), nasal (20%), laryngeal (17%), and craniofacial skeletal surgery (87%). All patients with Pfeiffer syndrome and FGFR2 p.W290C variants and 83% of patients with FGFR2 p.C342 variants required tracheostomy, differing from other variants (P=.02, odds ratio 33, 95% confidence interval 1.56-697.96). One patient (3%) died. TCS contributes to multilevel airway obstruction in patients with syndromic craniosynostosis. Genetic testing in patients with FGFR2-related syndromic craniosynostoses may identify those at risk of TCS and facilitate early intervention. A better understanding of this patient population may foster individualized airway management strategies and improve outcomes. 4 Laryngoscope, 132:215-221, 2022.

Essential Spine Surgery During the COVID-19 Pandemic: A Comprehensive Framework for Clinical Practice from a Specialty Orthopedic Hospital in New York City.

During the March 18, 2020, White House Coronavirus Task Force Press Briefing, representatives from the Centers for Medicare and Medicaid Services (CMS) and the US Surgeon General’s office announced a plan for all “elective” and “non-essential” surgeries and procedures to be delayed in order to enhance response to coronavirus disease 2019 (COVID-19) [21]. In the three-tiered CMS hierarchy, spine surgery was included in tier 2a, along with a recommendation to “consider postponing surgery” for “non-urgent spine” and “elective spine” procedures [8]. Deferring these services conserves beds, ventilators, personal protective equipment (PPE), and essential workforce and was therefore a priority for hospitals preparing for or experiencing a surge of patients with COVID-19. Postponing elective surgeries may have minimized additional risk of exposure through social distancing, further protecting patients and healthcare workers. The CMS recommendations outlined several factors that surgeons may consider, including patient risk, availability of beds, staff and equipment, and the urgency of the procedure, but they lacked a clear framework to assist operative decision-making. Translating the CMS recommendations into practical management and triaging of patients for surgical vs. non-surgical treatment have carried significant clinical and ethical challenges for spine surgeons. Which cases were “essential”? Which could wait? How could we temporize the condition of patients waiting for surgery during the surge of critically ill patients in the pandemic? Conversely, the decision to operate required comprehensive anesthetic and peri-operative protocols for patients with known or suspected COVID-19. Such protocols had to achieve dual goals of protecting patients and practitioners, while conserving PPE and hospital resources. Although evidence had accumulated from countries afflicted earlier in the pandemic, these protocols needed to be evaluated and adapted to suit the local hospital environment and they often raised more questions than they answered [7, 13, 22, 31]. How could we protect the vital medical workforce and ensure the safety of COVID-19-negative patients admitted for urgent-emergent surgery? How could we screen for disease when testing capability lagged testing demand, and how could we safely reintegrate essential staff after a period of quarantine or illness? Every surgery was accompanied by specific anesthetic risks which needed to be mitigated for optimal outcomes. However, unique additional challenges had to be addressed when caring for spine surgery patients during the surge phase of the pandemic. How could pre-operative evaluation and optimization be achieved while respecting social distancing orders? Could we safely use steroids and non-steroidal anti-inflammatories (NSAIDs) in COVID-19 patients? How could we safely intubate and extubate, particularly when spine surgery patients frequently require complex airway management? Finally, several issues surrounded the practical and ethical distribution of resources during the surge crisis. How could we consistently allocate peri-operative resources when planning for post-operative care and/or complications? This included not only intensive care unit (ICU) services and ventilators but also blood management in a time of progressive shortages, and allied physical therapy, nursing, and pain management services. As spine surgeons and anesthesiologists at a specialty orthopedic surgery hospital in New York City, we were confronted with these questions early in the pandemic. Here, we share our experiences in developing the Hospital for Special Surgery (HSS) Spine Care Institute’s response to the challenge of providing care at the leading edge of the COVID-19 pandemic. Key institutional, surgical, and anesthetic aspects of the response are presented and which when implemented together addressed the important questions raised here.

Perspectives in surgical and anaesthetic management of lung cancer in the era of coronavirus disease 2019 (COVID-19).

Early in 2020, coronavirus disease 2019 (COVID-19) quickly spread globally, giving rise to a pandemic. In this critical scenario, patients with lung cancer need to continue to receive optimal care and at the same be shielded from infection with the potentially severe acute respiratory syndrome coronavirus 2. Upgrades to the prevention and control of infection have become paramount in order to lower the risk of hospital contagion. Aerosol-generating procedures such as endotracheal intubation or endoscopic procedures may expose health care workers to a high risk of infection. Moreover, thoracic anaesthesia usually requires highly complex airway management procedures because of the need for one-lung isolation and one-lung ventilation. Therefore, in the current pandemic, providing a fast-track algorithm for scientifically standardized diagnostic criteria and treatment recommendations for patients with lung cancer is urgent. Suggestions for improving existing contagion control guidelines are needed, even in the case of non-symptomatic patients who possibly are responsible for virus spread. A COVID-19-specific intraoperative management strategy designed to reduce risk of infection in both health care workers and patients is also required.

Using critical care physicians to deliver anesthesia and boost surgical caseload in austere environments: the Critical Care General Anesthesia Syllabus (CC GAS)

BackgroundDespite an often severe lack of surgeons and surgical equipment, the rate-limiting step in surgical care for the nearly five billion people living in resource-limited areas is frequently the absence of safe anesthesia. During disaster relief and surgical missions, critical care physicians (CCPs), who are already competent in complex airway and ventilator management, can help address the need for skilled anesthetists in these settings. MethodsWe provided a descriptive analysis that CCPs were trained to provide safe general anesthesia, monitored anesthesia care (MAC), and spinal anesthesia using a specifically designed and simple syllabus. ResultsSix CCPs provided anesthesia under the supervision of a board-certified anesthesiologist for 58 (32%) cases of a total of 183 surgical cases performed by a surgical mission team at St. Luc Hospital in Port-au-Prince, Haiti in 2013, 2017, and 2018. There were no reported complications. ConclusionsGiven CCPs’ competencies in complex airway and ventilator management, a CCP, with minimal training from a simple syllabus, may be able to act as an anesthesiologist-extender and safely administer anesthesia in the austere environment, increasing the number of surgical cases that can be performed. Further studies are necessary to confirm our observation.

The value of preoperative endoscopic airway examination in complex airway management of a patient with supraglottic cancer

The standard bedside airway assessment tests are poorly predictive for difficult tracheal intubation, and do not assess the presence of the inside pathology of the upper airway, such as base of the tongue lesions, glottic and vallecular lesions, pyriform sinus pathology, supraglottic tumors, etc. The preoperative endoscopic airway examination, also commonly called nasal endoscopy, or nasendoscopy, is the only technique that assesses the upper airway in its entirety, under dynamic conditions prior to induction of anesthesia, and is recommended for routine use by NAP4 even for high acuity cases. We present a case of a patient with a malignant partial upper airway obstruction and largely normal external airway exam where preoperative endoscopic airway examination findings were used in real-time to devise successful ventilation and intubation strategies.

Royal Perth Hospital airway &amp; head and neck anesthesiology fellowship

Royal Perth Hospital airway &amp; head and neck anesthesiology fellowship

Editorial introductions

Current Opinion in Otolaryngology & Head and Neck Surgery was launched in 1993. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of otolaryngology and head and neck surgery are divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Jacqui E. AllenJacqui E. AllenJacqui E. Allen, MBChB, FRACS, is a Consultant Otolaryngologist in the Department of Otolaryngology – Head and Neck Surgery at North Shore Hospital, Auckland, New Zealand, and a Senior Lecturer in the Department of Surgery at the University of Auckland, New Zealand. Dr Allen's practice includes voice, laryngology with complex airway management, swallowing disorders, reflux management, and head and neck cancer. She earned her medical degree from the University of Auckland Medical School and completed ORL residency in New Zealand, followed by a fellowship at the University of California, Davis, USA, in the Voice and Swallowing Centre. She is a member of the New Zealand Society of Otolaryngology, Head and Neck Surgery, the American Bronchoesophagological Association, the RACS Academy of Surgical Educators, and a Fellow of the Royal Australasian College of Surgeons. Dr Allen's research interests include airway stenosis, cough and reflux, and novel dysphagia management. Her publications have appeared in journals such as Laryngoscope, Otolaryngology Head and Neck Surgery, Head and Neck, and Dysphagia. Lisa BuckmillerLisa BuckmillerDr Lisa Buckmiller is the Chief of Pediatric Otolaryngology at the Children's Hospital of San Antonio, USA, and is an Associate Professor with Baylor College of Medicine, USA. She has also been named Director of the Global Health rotation for the Pediatric Residency at Children's Hospital of San Antonio. Dr Buckmiller completed her undergraduate training in molecular biology & biochemistry at the University of California, Santa Cruz, USA, and went on to do her medical training at the University of California, Irvine College of Medicine, and her residency in otolaryngology at the University of California, Davis in Sacramento. She then accomplished her fellowship training in pediatric otolaryngology at Arkansas Children's Hospital, USA, and continued on as faculty from 2002-2012. Dr Buckmiller directed two multidisciplinary teams, including the Cleft Lip & Palate Team as well as the Vascular Anomalies Team, while on faculty at Arkansas Children's Hospital. In 2005, she was awarded the Benjamin & Milton Endowed Chair in Pediatric Facial Plastic & Reconstructive Surgery for her work to better the lives of children with facial deformities. She is also dedicated to serving overseas on medical missions several times a year, and performs surgeries for both cleft lip/palate as well as hemangiomas and vascular malformations on these trips. She is board certified and is an active member of the American Academy of Otolaryngology, International Society for the Study of Vascular Anomalies, American Cleft Palate Association, and the American Society of Pediatric Otolaryngology. Dr Buckmiller's research interests are in the areas of vascular anomalies as well as treatment of velopharyngeal insufficiency and primary rhinoplasty for cleft patients Taylor FordhamTaylor FordhamDr Taylor Fordham is an Assistant Professor of Pediatric Otolaryngology at the Children's Hospital of San Antonio, Baylor College of Medicine, USA. He completed his undergraduate education at Wake Forest University and subsequently stayed in Winston-Salem, NC to attend Wake Forest University School of Medicine where he received his medical degree. He completed his residency training at the Medical University of South Carolina in Charleston, South Carolina, and then moved to Washington, D.C. to complete a pediatric otolaryngology fellowship year at Children's National Hospital. He joined the team in San Antonio in 2014.

Emergency in the clinic: a simulation curriculum to improve outpatient safety

Emergency response skills are essential when events such as seizure, anaphylaxis, or hemorrhage occur in the outpatient setting. As services and procedures increasingly move outside the hospital, training to manage complications may improve outcomes. The objective of this study was to evaluate a simulation-based curriculum in outpatient emergency management skills with the outcome measures of graded objective performance and learner self-efficacy. This pre- and postcurriculum study enrolled residents and fellows in Obstetrics and Gynecology and Family Medicine in a simulation-based, outpatient emergency management curriculum. Learners completed self-efficacy questionnaires and were videotaped managing 3 medical emergency scenarios (seizure, over-sedation/cardiopulmonary arrest, and hemorrhage) in the simulation laboratory both before and after completion of the curriculum. Evaluators who were blinded to training level scored the simulation performance videotapes using a graded rubric with critical action checklists. Scenario scores were assigned in 5 domains and globally. Paired t-tests were used to determine differences pre- and postcurriculum. Thirty residents completed the curriculum and pre- and postcurriculum testing. Subjects' objective performance scores improved in all 5 domains (P<.05) in all scenarios. When scores were stratified by level of training, all participants demonstrated global improvement. When scores were stratified by previous outpatient simulation experience, subjects with previous experience improved in all but management of excess sedation. Pre-and postcurriculum self-efficacy evaluations demonstrated improvement in all 7 measured areas: confidence, use of appropriate resources, communication skills, complex airway management, bag mask ventilation, resuscitation, and hemorrhage management. Self-efficacy assessment showed improvement in confidence managing outpatient emergencies (P=.001) and ability to communicate well in emergency situations (P<.001). A simulation-based curriculum improved both self-efficacy and objectively rated performance scores in management of outpatient medical emergencies. Simulation-based curricula should be incorporated into residency education.

Human factors in complex airway management

### Key points Human factors have been defined as ‘the environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety’1 and have been described with particular relevance to anaesthesia in the Anaesthetists Non-Technical Skills Framework.2 When dealing with a patient with a complex airway, exceptional attention to human factors is vital to success. This has been noted extensively in the literature after two high profile cases.3,4 Recently, there has been adoption of human factors in healthcare at the highest level with the signing of a Concordat from the National Quality Board by organizations such as the General Medical Council, The Care Quality Commission, and Health Education England.5 The Fourth National Audit Project of the Royal College of Anaesthetists (NAP4) examined major complications in airway management and concluded that poor human factors could have contributed to 40% of the cases reported. In 25% of these cases, inadequate human factors were felt to be a major contributor to a poor outcome.6 Further analysis specifically looking at human factors in cases reported to NAP4 reported that there …

Endotracheal intubation in the ICU.

Endotracheal intubation in the ICU is a high-risk procedure, resulting in significant morbidity and mortality. Up to 40% of cases are associated with marked hypoxemia or hypotension. The ICU patient is physiologically very different from the usual patient who undergoes intubation in the operating room, and different intubation techniques should be considered. The common operating room practice of sedation and neuromuscular blockade to facilitate intubation may carry significant risk in the ICU patient with a marked oxygenation abnormality, particularly when performed by the non-expert. Preoxygenation is largely ineffective in these patients and oxygen desaturation occurs rapidly on induction of anesthesia, limiting the time available to secure the airway. The ICU environment is less favorable for complex airway management than the operating room, given the frequent lack of availability of additional equipment or additional expert staff. ICU intubations are frequently carried out by trainees, with a lesser degree of airway experience. Even in the presence of a non-concerning airway assessment, these patients are optimally managed as a difficult airway, utilizing an awake approach. Endotracheal intubation may be achieved by awake direct laryngoscopy in the sick ICU patient whose level of consciousness may be reduced by sepsis, hypercapnia or hypoxemia. As the patient’s spontaneous respiratory efforts are not depressed by the administration of drugs, additional time is available to obtain equipment and expertise in the event of failure to secure the airway. ICU intubation complications should be tracked as part of the ICU quality improvement process.

Advanced Practice Nursing Simulation for Neonatal Skill Competency: A Pilot Study for Successful Continuing Education

Skill readiness remains a challenge for all health care professionals who are involved in direct patient care. Researchers suggest that skill retention may decrease within 6 months of an educational session. The purpose of this study was to explore competency retention for high-risk, low-frequency procedures, specifically, managing a difficult airway and placing a laryngeal mask airway, using a web-based content refresher. The pilot study was conducted in two sessions. Session one established clinical skill competency. Six months later, the advanced practice RNs were randomized into two groups. Group 1 reviewed didactic content and participated in a complex airway management simulation. Group 2 participated only in a complex airway management simulation. This study showed a positive trend in maintaining competency for a low-frequency procedure for which complex airway management was given, using web-based content review. It is feasible to maintain competency for low-frequency procedures using web-based content refreshers. This pilot study benefited advanced practice nurses by providing them with the potential to maintain competency in this high-risk, low-frequency procedure. Continuing education is an important consideration for health care organizations.

Airway management: a survey of training and practices of Nigerian anesthetists.

Airway management is an integral part of anesthetist's training and clinical practice. Studies have suggested that opportunities for anesthesia trainees to learn and practice endotracheal intubation have decreased over time. We sought to examine the current training and practices of airway management by anesthetists practicing in Nigeria. A structured questionnaire was administered to delegates at an annual conference of the Nigerian Society of Anaesthetists. A total of 49 respondents participated in the survey. The data were analyzed using Statistical Package for Social Sciences (SPSS) version 16.0, the results are presented in appropriate statistical tools, and the findings discussed. The response rate was 82%. Majority of the respondents (61%) had attended a course on airway management. Many of the respondents (54%) had less than 10 years of experience in anesthesia. Majority (69%) of the respondents were from teaching hospitals. All the respondents had access to laryngeal mask airways (LMAs) and 85% of respondents could use them very well. Fiberoptic bronchoscope (FOB) was available to 51% of the respondents and only 22% of them were conversant with its use, while 31% admitted that they needed more training. Majority (71%) of the respondents had received formal training in airway management, some of a short duration (47%). Majority of our respondents had good knowledge of routine airway management using LMAs. Though FOBs may be available in some of the teaching hospitals, very few anesthetists are conversant with its use. There is increased use of simple airway devices with deskilling in complex airway management. Resource limitation means that very few individuals have access to training with novel airway techniques. There is need to increase funding of anesthesia training and services in order to improve skill acquisition and practice of airway management.

Editorial introductions

Current Opinion in Otolaryngology & Head and Neck Surgery was launched in 1993. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of otolaryngology and head and neck surgery are divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Jacqui E. AllenJacqui E. AllenJacqui E. Allen, MBChB, FRACS is a Consultant Otolaryngologist in the Department of Otolaryngology – Head and Neck Surgery at North Shore Hospital, Auckland, New Zealand and an Honorary Senior Lecturer in the Department of Surgery at the University of Auckland, New Zealand. Dr Allen's practice includes voice, laryngology with complex airway management, dysphagia and head and neck cancer. She earned her medical degree from the University of Auckland Medical School and completed ORL residency in New Zealand, followed by a fellowship at the University of California, Davis, USA, in the Voice and Swallowing Centre. She is a member of the New Zealand Society of Otolaryngologists Head and Neck Surgeons, the RACS Academy of Surgical Educators and a Fellow of the Royal Australasian College of Surgeons. Dr Allen's research interests include airway stenosis, cough and reflux, and novel dysphagia management. Her publications have appeared in journals such as Laryngoscope, Otolaryngology Head and Neck Surgery, Head and Neck and Dysphagia. Lisa BuckmillerLisa BuckmillerDr Lisa Buckmiller is a Pediatric Otolaryngologist at the Children's Hospital of San Antonio, Texas, USA. Dr Buckmiller completed her undergraduate training in molecular biology and biochemistry at the University of California, Santa Cruz, USA, and went on to do her medical training at the University of California, Irvine College of Medicine, USA, and her residency in otolaryngology at the University of California, Davis, USA in Sacramento. She then accomplished her fellowship training in pediatric otolaryngology at Arkansas Children's Hospital, USA, and continued on as faculty from 2002–2012. Dr Buckmiller directed two multidisciplinary teams, including the Cleft Lip and Palate Team as well as the Vascular Anomalies Team while on faculty at Arkansas Children's Hospital. In 2005, she was awarded the Benjamin and Milton Endowed Chair in Pediatric Facial Plastic and Reconstructive Surgery for her work to better the lives of children with facial deformities. She also is dedicated to serving overseas on medical missions several times a year and performs surgeries for both cleft lip and palate as well as hemangiomas and vascular malformations on these trips. She is board certified and is an active member of the: American Academy of Otolaryngology; International Society for the Study of Vascular Anomalies; American Cleft Palate Association; and the American Society of Pediatric Otolaryngology. Dr Buckmiller's research interests are in the areas of vascular anomalies as well as treatment of velopharyngeal insufficiency and primary rhinoplasty for cleft patients.

Effect Of The Provision Of An Airway Training Module On The Acquisition Of Complex Airway Skills

Questionnaires were sent to anaesthetists working in two regions in the United Kingdom: South Wales, without formal airway training module, and Oxford, with established airway training module. Replies were received from 68% and 64% of anaesthetists in the South Wales and in Oxford regions respectively. The results of experience with patients showed differences between the Oxford and South Wales regions in the use of the intubating laryngeal mask (64% and 26% respectively, p<0.001) and fibreoptic intubation via the intubating laryngeal mask (31% and 3% respectively, p< 0.001) and via the laryngeal mask (56% and 20% respectively, p<0.001). The results of experience with manikins show similar differences. Our findings suggest that the provision of an airway training module has important effect on the acquisition of complex airway management skills. The time has now arrived for airway management issues to take more a central place in the overall training of anaesthetists.

Quantitative description of the workload associated with airway management procedures

Study Objectives: To measure the workload associated with specific airway management tasks. Setting and Intervention: Written survey instrument. Patients: 166 Stanford University and 75 University of California, San Diego, anesthesia providers. Measurements and Main Results: Subjects were asked to use a seven-point Likert-type scale to rate the level of perceived workload associated with different airway management tasks with respect to the physical effort, mental effort, and psychological stress they require to perform in the typical clinical setting. The 126 subjects completing questionnaires (overall 52% response rate) consisted of 43% faculty, 26% residents, 23% community practitioners, and 8% certified registered nurse-anesthetists (CRNAs). Faculty physicians generally scored lower workload measures than residents, whereas community practitioners had the highest workload scores. Overall, workload ratings were lowest for laryngeal mask airway (LMA) insertion and highest for awake fiberoptic intubation. Airway procedures performed on sleeping patients received lower workload ratings than comparable procedures performed on awake patients. Direct visualization procedures received lower workload ratings than fiberoptically guided procedures. Conclusions: These kinds of data may permit more objective consideration of the nonmonetary costs of technical anesthesia procedures. The potential clinical benefits of the use of more complex airway management techniques may be partially offset by the impact of increased workload on other clinical demands.