Difficult Airway Research Articles

BACKGROUND Fiberoptic bronchoscopy-guided intubation (FOI) is a reliable method for managing difficult airways, typically requiring a 2-operator technique using jaw thrust. This study introduces a novel 3D-printed transoral guiding device (TGD) enabling single-operator FOI without jaw thrust. The aim was to assess the feasibility and effectiveness of TGD compared to a modified oropharyngeal airway (MOA) with assistant-applied jaw thrust. MATERIAL AND METHODS A total of 218 patients undergoing elective orotracheal intubation were randomized into 2 groups: TGD and MOA. After anesthesia induction, Group TGD underwent FOI using the TGD without jaw thrust, while Group MOA used the MOA combined with jaw thrust. Outcome measures included time to successful intubation, first-attempt success rate, number of attempts or device adjustments, and airway visibility (epiglottis and bronchoscope view). RESULTS Successful FOI was achieved in all patients in the TGD group versus 95.4% in the MOA group (P=0.024). The TGD group had significantly shorter times to visualize the vocal cords and tracheal carina (both P<0.001) and to complete intubation (P<0.001). First-attempt success was higher in the TGD group (99.1%) than in the MOA group (67.0%; P<0.001). Fewer attempts and device adjustments were needed in the TGD group. CONCLUSIONS The 3D-printed transoral guiding device (TGD) facilitates faster, more effective single-operator FOI without jaw thrust, offering a promising alternative to traditional 2-operator techniques.

Introduction: Provision of safe perioperative care in remote theatre locations has many challenges. NAP 4 identified airway management in remote sites is associated with increased risk of morbidity and mortality [1]. Simulation training can aid preparedness to manage infrequent but highly critical events. Simulation training is often recommended following a critical events [2]. Insitu Simulation (ISS) undertaken in a clinical team’s own workplace provides a safe learning environment, improves team work and performance and identifies latent safety threats [3]. We organised ISS training in our dental DPU for the clinical team after review of learning needs and following recommendations from a critical event. Methods: Protected time for ISS was secured through list cancellation in dental DPU. Scenarios were built around agreed learning outcomes (LOs) and specific critical events. Mannequins and portable simulation patient monitors were used. An eFONA workshop was also delivered. The ISS organised session was run twice, morning and afternoon to facilitate smaller groups and reflective of healthcare team working in theatre and recovery on a standard day. Each group rotated though scenarios in main DPU theatre, dental chair theatre and recovery. Scenarios included CICO, anaphylaxis, choking under sedation, post op bleeding in oral cavity and emergency airway management in recovery. Communications systems were tested to seek assistance from main hospital site. Each scenario was preceded by team brief and followed by structured debrief. Feedback questionnaire was distributed to team members after event. Results: Received an 80% response to the feedback survey. Those who responded 100% agreed or strongly agreed ISS was a psychologically safe learning environment.100% agreed or strongly agreed improved communication, team work, confidence, clinical skills and feeling of preparedness. Team members were able to identify areas for improvement and deficits in resources. 83% suggested ISS should be delivered more frequently, 50% indicated at least twice yearly. Discussion: Feedback indicates ISS was valuable to the clinical team in our dental DPU. Debrief sessions helped identify areas of latent safety threats and areas for improvement. Familiarising with airway drills and eFONA skills with the clinical team may be helpful in difficult airway management or CICO situation for any anaesthetist working alone in a remote setting. Time pressures in clinical environments impede ISS which leads to difficulty in showing improvement in patient outcomes. However, if recommended in a critical event report this is a powerful tool for stakeholders to secure protected time for ISS training. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable.

Orofacial malformations, especially when associated with syndromes, may complicate airway management in children. However, only a few studies have addressed the airway management in children undergoing cleft lip and/or palate surgery. To report on perioperative airway management and complications in children undergoing cleft lip or palate surgery over an 8-year retrospective period. We performed a retrospective analysis of patients younger than 2 years of age who underwent surgery for cleft lip or palate at the Department of Oral and Cranio-Maxillofacial Surgery of a German university hospital between 2016 and 2023. The study assessed patient demographics, airway management techniques, airway management difficulties, and adverse events. During the observation period, 274 cases were included. Difficult laryngoscopy occurred in 16 cases (6%). Direct laryngoscopy failed in five cases (1.9%), leading to successful video-laryngoscopic intubation. There was a noticeable higher incidence of difficult laryngoscopy (16.7% vs. 5.3%) and failed direct laryngoscopy (11.1% vs. 1.2%) in cleft patients with a syndrome association. In eight cases (2.9%) with an expected difficult airway, a primary hybrid technique was used for intubation due to a proven syndromic disorder. Airway complications were significantly more common in patients associated with a syndromic disorder (40.7% vs. 23.5%; p = 0.049, φ = 0.12). Airway management in children undergoing cleft lip or palate surgery presents unique challenges, with an increased incidence of difficult and failed direct laryngoscopy and a significantly higher rate of complications in patients with a syndromic disorder. Video laryngoscopy and, if a difficult airway is anticipated, a hybrid technique for intubation is a safe and effective approach to airway management in these patients. However, the postextubation period can be very challenging, particularly in patients with associated syndromes. Epinephrine inhalation may prevent reintubation and ventilated admission to the intensive care unit. Cleft lip and palate significantly complicate airway management, especially in infants with syndromic conditions. It was already known that these children are at higher risk for difficult intubation and respiratory complications. The new findings of this study, analyzing 274 procedures in children under 2 years, found that the hybrid technique (video laryngoscopy combined with flexible bronchoscopy) is highly effective for anticipated difficult airways and highlights the importance of an individualized, stepwise approach to ensure safe anesthesia in cleft surgery. Additionally, the study identified a higher incidence of postextubation stridor, particularly in syndromic patients, pointing to the need for tailored postoperative care.

Artificial intelligence in airway management: A systematic review and meta-analysis.

Achondroplasia is the most common cause of disproportionate dwarfism and is associated with multiple systemic abnormalities that pose unique challenges to anaesthetic management. Characteristic features such as hypotonia, delayed motor development and obesity often complicate perioperative care. Craniofacial anomalies, including midface hypoplasia, macrocephaly and craniocervical junction compression, increase the likelihood of a difficult airway. Additionally, skeletal deformities such as thoracolumbar kyphosis, spinal canal stenosis and abnormal vertebral anatomy make neuraxial anaesthesia technically challenging. Fluid and electrolyte imbalances, hypovolemia and altered pharmacokinetics further complicate drug dosing and anaesthetic selection. Present case is of a 13-year-old child with achondroplasia who sustained extensive thermal burns following accidental kerosene exposure and subsequently required split-thickness skin grafting under general anaesthesia. This case highlights the importance of anticipating anaesthetic complications in patients with achondroplasia and burns and of adopting an individualised, multidisciplinary approach to ensure safe outcomes. Ultrasound guidance was used to facilitate intravenous access. The anticipated difficult airway was managed with video laryngoscopy to minimise cervical spine movement. Muscle relaxation was achieved with rocuronium and reversed with sugammadex. The intraoperative course was uneventful and the patient was discharged the following day.

In the United States, over a quarter of outpatient pediatric procedures take place in ambulatory surgery centers (ASCs). Previous studies have identified substantial variability in clinical staffing, pediatric-specific training, and policy development among ASCs that provide pediatric care. To characterize and compare the exclusion criteria currently used in ASCs affiliated with pediatric hospital systems across the continental United States. In this descriptive study, we solicited exclusion guidelines from the 30 largest pediatric hospitals representing each geographic region in the continental United States. Additionally, we surveyed each institution regarding the physical configuration of its ambulatory surgery center, as well as the availability of ancillary site support and the center's proximity to the parent institution. While there was general consistency in excluding children with a history of congenital heart disease, pulmonary conditions, and difficult airway, we found considerable heterogeneity in minimum age thresholds, obesity criteria, and recent respiratory infection. Additionally, there was variation in ambulatory surgery center proximity to its parent institution, resources available at the facility, and capacity for extended observation beyond same-day discharge. These findings highlight the need for standardized, evidence-based guidelines that balance consistency with site-specific flexibility to ensure safe and efficient care for pediatric patients in ambulatory surgery settings.

Massive multinodular goiter causing airway compression: A case series.

Eagle’s syndrome is a rare condition characterised by elongation of the styloid process or ossification of the stylohyoid ligament, which may result in facial or cervical pain, dysphagia, and restricted jaw movement. The normal length of the styloid process ranges from 20 to 30 mm; elongation can cause impingement on adjacent anatomical structures, leading to significant discomfort. Diagnosis is radiological, and symptomatic cases often require surgical intervention. A 38-year-old male presented with restricted mouth opening for six to seven months, along with sharp, intermittent pain triggered by eating and yawning. The pain radiated to the ear, neck, and back. He also reported two previous episodes of jaw locking that resolved spontaneously. Clinical examination revealed restricted and painful Temporomandibular Joint (TMJ) movements, deviation of the jaw to the right on opening, and bilateral hypertrophy of the masseter and temporalis muscles. Airway assessment showed Mallampati class II with slight limitation in neck extension. Imaging with Orthopantomogram (OPG) and Cone Beam Computed Tomography (CBCT) confirmed bilateral styloid process elongation, measuring 46.44 mm on the right and 48.13 mm on the left. The patient was scheduled for bilateral styloidectomy under general anesthesia. Multiple nasal intubation attempts were required due to poor laryngeal visibility, ultimately successful with the use of a bougie and a smaller Endotracheal Tube (ETT). Postoperative evaluation indicated that calcified stylohyoid ligaments may have contributed to the difficult airway management.

OBJECTIVES:Tracheal intubation in critically ill patients is associated with significant morbidity and mortality. Point-of-care ultrasound (POCUS) may help with hemodynamic optimization and customization of management plans to the patient’s tenuous physiology to prevent cardiopulmonary collapse. We report the integration of POCUS in the emergency airway management (EAM) of critically ill patients at a tertiary care academic medical center.DESIGN:Our study is a retrospective, exploratory research project. We evaluated the feasibility of using Echocardiography Assessment using Subcostal-only-view in Physiologically Difficult Airway (EASy-PDA) protocol to prevent peri-intubation hemodynamic compromise during EAM.SETTING:This study took place at a tertiary academic medical center where requests for EAM were answered by anesthesiologists.SUBJECTS:The EASy-PDA protocol was performed on 30 patients with PDA outside of the operating room in need of EAM.INTERVENTIONS:The EASy-PDA protocol included the acquisition of subcostal four-chamber (SC4C) and inferior vena cava (IVC) images, supplemented by focused lung and gastric ultrasonography. Trained anesthesiology residents performed EASy-PDA examinations before airway management, and subsequently assigned hemodynamic phenotypes based on qualitative assessment of biventricular chamber size, myocardial wall thickness and function, and IVC size and collapsibility. Management was then tailored based on hemodynamic phenotyping.MEASUREMENTS AND MAIN RESULTS:The mean time to complete the EASy-PDA examination was 2.40 minutes. SC4C image could not be obtained in one patient due to severe abdominal pain. Images obtained solely via the EASy-PDA examination were sufficient to inform further patient management in 26 patients (86.7%), with one patient requiring emergent pericardial window creation and two patients requiring gastric decompression before intubation based on examination findings.CONCLUSIONS:We were able to show the feasibility of integrating the EASy-PDA protocol into the management of emergent airways. In our case series, we observed that the EASy-PDA examination findings guided hemodynamic optimization before EAM in critically ill patients. This approach may help reduce intubation-associated morbidity and mortality. Further studies are needed to assess the impact of integration of EASy protocol during EAM on patient outcomes.

Can Current Artificial Intelligence and Large Language Models Aid in Difficult Airway Management?

BackgroundAirway management is critical in prehospital care. This study quantified first pass success (FPS) for endotracheal intubation (ETI) in a Swiss emergency medical service (EMS) and identified factors associated with success.MethodsAll adult (≥ 18 years) ETI attempts documented in the EMS database between 1 January 2021 and 31 December 2024 were reviewed. Devices [direct laryngoscopy, standard-geometry videolaryngoscope (VL), hyperangulated VL], adjuncts [bougie, stylet], operators [critical-care paramedic (CCP), emergency physician (EP)] and setting were analyzed. The primary outcome was FPS; predictors were evaluated with univariate and multivariable logistic regression.ResultsETI was attempted in 270 patients (mean age 67.9 ± 16.4 year; 64.8% male); 55.6% intubations occurred during cardiopulmonary resuscitation. Overall FPS was 92.6% (250/270). Bougie use achieved 100% (49/49) FPS versus 91.0% (201/221) with a stylet (p = 0.03). Device-specific FPS was 94.3% (33/35, direct laryngoscopy), 94.0% (173/184, standard-geometry VL) and 86.3% (44/51, D-BLADE VL). FPS was significantly associated with D-BLADE VL use in patients with an anticipated difficult intubation (89,7% FPS, p < 0.001). CCP showed higher odds for FPS for CCP compared to EP (OR 3.61, 95% CI 1.14 to 11.45).ConclusionsBougie-assisted laryngoscopy was significantly associated with higher first pass success rates. When a difficult airway was anticipated, the hyperangulated D-BLADE videolaryngoscope showed higher odds for first pass success. Critical-care paramedics achieved first pass success rates comparable to those of emergency physicians.Trial registrationClinical Trials.gov: NCT06653166 (19 October 2024).Supplementary InformationThe online version contains supplementary material available at 10.1186/s13049-025-01489-x.

The anesthetic challenges encountered in separating heteropagus conjoined twins are unique for each case. The rarity of these surgeries and the unique anatomical variations make every separation procedure a distinct experience. This case report details the anesthetic management and the challenges faced during the separation of a heteropagus twin attached at the occiput in a 3-year, 9-month-old girl who presented for excision at a parasitic site at our tertiary care hospital. The challenges associated with our child were anticipated difficult airway, prone positioning, shared airway, the possibility of blood loss, hypothermia, hemodynamic instability, need for neuromonitoring, prolonged surgical duration of surgery with anticipation of postoperative mechanical ventilation and intensive care. Using appropriate positioning aids, airway management strategy, monitoring of depth of anesthesia, and utilization of dynamic indices for hemodynamic monitoring and post-operative intensive care ensured a safe perioperative course. Multidisciplinary collaboration, identification of perioperative challenges, and meticulous planning help in the successful management of such cases.

Airway management in trauma patients: A seven-year review of emergency department intubations.

IntroductionDifficult intubation is one of the most challenging scenarios to deal with due to increased morbidity and mortality. Machine learning systems can help predict this process in advance. This study aimed to predict whether patients had difficult intubation using machine learning programs for anthropometric and ultrasonographic measurements taken for preoperative airway assessment.MaterialmethodPatients over 18 years of age with American Society of Anesthesiologists (ASA) scores I–III who underwent general anesthesia were included. Patients with a history of head/neck surgery, planned thyroidectomy, congenital or acquired airway anomalies morbidly obese patients with BMI > 40 or a known difficult airway were excluded. Preoperative modified mallampati test score and other anthropometric measurements (thyromental distance, neck circumference, mouth opening, sternomental distance) were recorded. Ultrasonographic measurements included the distance from skin to hyoid bone, skin to epiglottis, skin to vocal cords (anterior commissure), skin to trachea, MTT and hyomental distances in neck extension and neutral positions. The dataset was analyzed via eight different machine learning algorithms.ResultsWe obtained data from 329 patients (62 difficult intubation cases). The Support Vector Machine algorithm achieved the highest performance, with an accuracy of 89.39%, a negative predictive value of 92.7%, and a positive predictive value of 72.7%. Among all evaluated parameters, the modified mallampati score, neck circumference, skin to epiglottic distance and tongue thickness were the strongest predictors of difficult intubation.ConclusionThe ability of individual bedside tests, which are commonly used, to predict difficult intubations is limited. Our study demonstrates that incorporating ultrasonographic measurements into a machine learning model, in addition to clinical airway assessments, improves predictive accuracy. Integrating our predictive model into a mobile app could provide a rapid and objective tool for preoperative airway assessment to identify difficult airways and improve patient safety in anesthesia settings.Trial registrationProspective Observational.

Supraglottic airway devices (SGAs) have emerged as effective alternatives to endotracheal intubation for airway management, especially in difficult airway scenarios. This study compared the ease of insertion, insertion time, and oropharyngeal leak pressure (OLP) between the i-gel and the laryngeal mask airway (LMA) protector in adult patients with simulated difficult airway undergoing elective laparoscopic procedures. Sixty adult patients (American Society of Anesthesiologists I-II), aged 18-60 years, scheduled for elective laparoscopic surgeries under general anesthesia, were randomized into two groups: Group I (i-gel) and Group P (LMA Protector). SAD was inserted in a simulated airway scenario made more difficult by using a cervical collar to limit mouth opening and neck movement. Insertion time and ease of insertion were recorded. OLP was measured 5 min after device insertion and pneumoperitoneum. Statistical significance was set at P < 0.05. I-gel showed shorter insertion time (18.16 ± 3.62 vs. 29.65 ± 7.39 s; P < 0.0001) and greater ease of insertion (P < 0.0001). LMA protector had significantly higher OLP than i-gel, both 5 min postinsertion (37.5 ± 2.86 vs. 27.33 ± 4.69 cm H2O; P < 0.0001) and after pneumoperitoneum (34.83 ± 3.34 vs. 22.83 ± 4.49 cm H2O; P < 0.0001). While the i-gel is associated with quicker and easier insertion, the LMA protector offers superior airway sealing pressures. Both devices are effective, but the choice should be tailored to procedural demands and clinician preference.

PurposeDental injury is a known complication of endotracheal intubation during general anesthesia (GA), yet data on its incidence and associated risk factors remain limited. This study aimed to evaluate the incidence, risk factors, and outcomes of dental injury in patients undergoing GA.Patients and MethodsThis retrospective case-control study was conducted between January 2021 and June 2024. A total of 42,826 patients underwent GA during the study period; 72 cases of dental injury were identified from the departmental database. Controls were time-matched patients who underwent surgery in the same anatomical region, using a case-to-control ratio of 1:4. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors for dental injury.ResultsThe incidence of dental injury was 0.17%. Univariate analysis identified the following factors as associated with dental injury: age ≥ 60 years, pre-existing dental pathology, Mallampati classification ≥ 3, anticipated difficult intubation, and difficult airway. In the multivariable logistic regression analysis, pre-existing dental pathology (adjusted OR 3.87, 95% CI: 1.92–7.81, p < 0.001), anticipated difficult intubation (adjusted OR 4.99, 95% CI: 1.84–13.50, p = 0.002), and difficult intubation (laryngoscopic view grade ≥ 3) (adjusted OR 10.56, 95% CI: 4.24–26.29, p < 0.001) remained significant independent predictors of dental injury during GA. The most common complication was bleeding.ConclusionDental injury during GA is uncommon, with an incidence of 0.17%. Pre-existing dental pathology, anticipated difficult intubation, and poor laryngoscopic view (grade ≥ 3) were identified as independent risk factors. Awareness and thorough preoperative assessment of these factors may help reduce the risk of dental injury and related complications.

BackgroundVideolaryngoscopy has significantly improved the management of unanticipated difficult airways and replaced other intubation techniques. The goal of this study was to identify the indications for using videolaryngoscopy and fiberoptic bronchoscopy for adult patients, where direct laryngoscopy is the standard intubation technique.MethodsOver a one-year period from January to December 2018, anesthesiologists were surveyed on their reasons for using a videolaryngoscope or fiberoptic bronchoscope for tracheal intubations. Additionally, retrospective data on all direct laryngoscopy intubations were collected for the same period from the anesthesia information management system.ResultsOut of 6251 tracheal intubations with direct laryngoscopy and 502 with videolaryngoscopy or fiberoptic bronchoscopy, data from 450 (89.6%) cases were collected. We excluded 46 cases where videolaryngoscopy and fiberoptic bronchoscopy were used for non-airway management reasons, resulting in 404 cases for analysis. Videolaryngoscopy was initially used in 356 (88.1%) patients. The primary reasons for using videolaryngoscopy or fiberoptic bronchoscopy were anticipated difficult intubation (218, 54.0%) and cervical pathology (109, 27.0%). Among the 42 cases of unanticipated failed direct laryngoscopy, videolaryngoscopy was used in 41 cases and fiberoptic bronchoscopy in 1 case. The overall rate of unanticipated failed direct laryngoscopy was 0.7%.ConclusionsThe routine use of videolaryngoscopy and fiberoptic bronchoscopy for anticipated difficult tracheal intubations led to a very low incidence of unanticipated failed tracheal intubations with direct laryngoscopy. Therefore, routinely using more expensive videolaryngoscopes for all intubations would prevent only very small numbers of unanticipated failed direct laryngoscopic intubations and is not financially justified.

Difficult airway (DA) remains a challenge in anesthetic practice, particularly in patients with head and neck pathologies leading to anatomical alterations. We report the case of a 40-year-old male with severe cardiac comorbidities and craniofacial malformations (cleft palate and macrognathia), undergoing transfemoral amputation. Two attempts at orotracheal intubation failed, requiring successful nasotracheal intubation with videolaryngoscope. This case highlights the importance of detailed pre-anesthetic assessment, individualized planning, and the use of advanced devices such as videolaryngoscope, bougie and fiberscope for safe management of DA. We conclude that early recognition of risk factors and the adoption of alternative strategies are essential to reduce complications and ensure patient safety.

Introduction. Endotracheal intubation is one of the most important technical skills in neonatal resuscitation. However, it can be challenging in various situations. The use of the laryngeal mask (LM) may be an alternative. However, its use is not yet standardized in current neonatal resuscitation algorithms. The study aimed to evaluate whether the standardized use of an LM in difficult airway (DAW) situations reduces the time to achieve effective ventilation (EVT) in a clinical simulation setting. Population and methods. This was a blinded, randomized, simulation-based study. A modified algorithm was developed that emphasized the early use of LM in cases of DAW. Two groups of neonatologists were randomly assigned to receive training in two different resuscitation algorithms (standard and modified). After training, the physicians participated in two simulation scenarios, one with a normal airway and one with a difficult airway. Results. Sixty-nine neonatologists participated in the study, 36 in the intervention group. No significant differences in EVT were observed between the two groups. However, when we analyzed those participants who used the LM on the first attempt, regardless of the training received, a shorter time was observed: 9.5 seconds (IQR 7-11) versus 63 seconds (IQR 42-89); p <0.01. Conclusions. Standardized use of LM in DAW situations could reduce the time to achieve effective ventilation.

Video laryngoscopes (VLs) offer benefits by improving visualization and first-attempt success and decreasing failed intubations. This study examined the perceived usefulness and perceived ease of using VLs by certified registered nurse anesthetists (CRNAs) utilizing the Technology Acceptance Model published by Fred Davis in 1989. The study further investigated the influence of patient airway types, provider characteristics (age, years of practice, intubation frequency), and clinical factors (hospital size and technology availability) on subsequent selection and usage. The cross-sectional design included a one-time national survey using a purposive 3,000-CRNA sample. Data analysis included univariate, bivariate, and multivariate methodologies with multiple linear and binary logistic regression models. Approximately 71% of CRNAs were extremely likely to find VLs useful and easy to use and approximately 60% reported their selection and use when confronting difficult airways. Additionally, CRNAs selecting VLs for routine airways 50% to 100% of the time reported 4.49 times greater odds of always using VLs (100%) for difficult airways compared with CRNAs using this technology infrequently. This study provides current usage data by CRNAs and represents a first-ever assessment exploring CRNA perceptions of usefulness and ease in utilizing VLs in the operating room setting.