Difficulty Of Tracheal Intubation Research Articles

Utility of the Pentax-AWS ® without interruption of chest compression: Comparison of the Macintosh laryngoscope with the Pentax-AWS ® in manikin model

Background Emergency airway management in suboptimal conditions can result in difficulties in tracheal intubation. The video laryngoscope (Pentax-AWS ®) has potential advantages during difficult tracheal intubations. According to the 2005 guidelines for cardiopulmonary resuscitation (CPR), all rescuers should minimize interruption of chest compressions. Our hypothesis is that tracheal intubation using the Pentax-AWS ® is possible without interruption of chest compressions. We tested this using tracheal intubation performed by less experienced medical personnel in a manikin model. Methods Thirty-two less experienced (<10 tracheal intubations) medical interns performed intubation using the Pentax-AWS ® and the Macintosh laryngoscope in an ALS simulator (Laerdal, Stavanger, Norway) in each of three scenarios. The three scenarios were: (1) normal airway without chest compression, (2) normal airway with continuous chest compression, and (3) difficult airway with continuous chest compression. The success rate, time required to complete tracheal intubation and to visualize vocal cords, POGO (percentage of glottic opening) score, dental compression and the ease of intubation were recorded. Results All participants performed successful intubation with the Pentax-AWS ® in the three scenarios. In the two continuous chest compression scenarios (scenarios 2 and 3), the success rate was significantly higher with the Pentax-AWS ® than with the Macintosh laryngoscope. Conclusions The Pentax-AWS ® was an effective tool for endotracheal intubation during chest compression performed by less experienced medical personnel in a manikin model simulating cardiac arrest, both under conditions of normal and difficult airways.

Randomized controlled trial of the Pentax AWS®, Glidescope®, and Macintosh laryngoscopes in predicted difficult intubation

The purpose of this study was to determine the potential for the Pentax AWS and the Glidescope to reduce the difficulty of tracheal intubation in patients at increased risk for difficult tracheal intubation, in a randomized, controlled clinical trial. Seventy-five consenting patients presenting for surgery requiring tracheal intubation, and who were deemed to possess characteristics indicating an increased risk for difficult tracheal intubation, were randomly assigned to undergo intubation using a Macintosh, AWS, or Glidescope laryngoscope (n=25 patients per group). All patients were intubated by one of three anaesthetists experienced in the use of each laryngoscope. Both the Glidescope and the AWS significantly reduced the intubation difficulty score compared with the Macintosh. The rate of successful tracheal intubation was lower with the Macintosh (84%) compared with the Glidescope (96%) or the AWS (100%). There were no differences in the duration of tracheal intubation attempts between the devices. Both the Glidescope and the AWS significantly reduced the need for additional manoeuvres and improved the Cormack and Lehane view obtained at laryngoscopy, compared with the Macintosh. Tracheal intubation with the AWS but not the Glidescope reduced the degree of haemodynamic stimulation compared with the Macintosh laryngoscope. The AWS and the Glidescope laryngoscopes reduced the difficulty of tracheal intubation to a similar extent compared with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation.

Videolaryngoskope für die endotracheale Intubation – Neue Entwicklungen für das Management des schwierigen Atemweges

Difficulties in tracheal intubation are the major causes of anaesthesia related morbidity and mortality. Novel videolaryngoscopes facilitate endotracheal intubation by indirect visualisation of glottic structures through optical systems. In this review, differences and the advantages and disadvantages of videolaryngoscopes are discussed.

Optimizing preoxygenation in adults

Preoxygenation increases oxygen reserves and duration of apnea without desaturation (DAWD), thus it provides valuable additional time to secure the airway. The purpose of this Continuing Professional Development (CPD) module is to examine the various preoxygenation techniques that have been proposed and to assess their effectiveness in healthy adults and in obese, pregnant, and elderly patients. The effectiveness of preoxygenation techniques can be evaluated by measuring DAWD, i.e., the time for oxygen saturation to decrease to <90%. Clinically, preoxygenation is considered adequate when end-tidal oxygen fraction is >90%. This is usually achieved with a 3-min tidal volume breathing (TVB) technique. As a rule, asking the patient to take four deep breaths in 30 sec (4 DB 30 sec) yields poorer results. Eight deep breaths in 60 sec (8 DB 60 sec) is equivalent to TVB 3 min. The DAWD is decreased in obese patients, pregnant women, and patients with increased metabolism. Obese patients may benefit from the head-up position and positive pressure breathing. A TVB technique is preferable in the elderly. Failure to preoxygenate is often due to leaks, which commonly occur in edentulous or bearded patients. In cases of difficult preoxygenation, directly applying the circuit to the mouth might be a useful alternative. Supplying extra oxygen in the nasopharynx during apnea might increase DAWD. Since ventilation and tracheal intubation difficulties are unpredictable, this CPD module recommends that all patients be preoxygenated. The TVB 3 min and the 8 DB 60 sec techniques are suitable for most patients; however, the 4 DB 30 sec is inadequate.

Bilateral guided cervical block for Zenker diverticulum excision in a patient with ankylosing spondylitis

Patients with severe ankylosing spondylitis (AS) have difficulties in tracheal intubation. An 87-year-old man with severe AS was scheduled for Zenker diverticulum (ZD) excision. It was decided to proceed with combined bilateral cervical plexus blockade using a nerve stimulator. The surgery lasted about 3 h, with stable hemodynamics, ECG, and oxygen saturation. The use of a nerve stimulator-guided cervical block minimizes the risk of severe respiratory and/or airway compromise secondary to phrenic nerve or recurrent laryngeal nerve palsy, because it can elicit diaphragmatic muscle response, which helps to avoid the administration of local anesthetic directly to the area of the phrenic nerve, and guides correct needle placement. In conclusion, the nerve stimulatorguided bilateral cervical block in our ZD patient with AS was shown to be a safe and successful alternative anesthetic option.

Airway Scope®‐assisted nasotracheal intubation

The Airway Scope® (AWS) (Pentax Corporation, Tokyo, Japan) is only available for orotracheal intubation [1, 2]. We describe its use in the management of a patient with difficult nasotracheal intubation. A middle-aged man scheduled for repair of a mandible fracture required nasotracheal intubation. The patient had a history of surgery for a mesopharyngeal tumour. He could open his mouth without pain, and the oropharyngeal view was Mallampati Class II. On pre-operative examination, epiglottis and vocal cords were clearly observed on flexible laryngoscopy, suggesting that there would be no particular difficulty in tracheal intubation under general anaesthesia. In the operating room, propofol, vecuronium and fentanyl were given, face mask ventilation was easy and oxygen saturation maintained at 100% during oxygen and sevoflurane anaesthesia. After preparation of the nasopharynx with 8% lidocaine spray, a fibre-optic scope (FI-16RBS; Pentax, Tokyo, Japan) was introduced into the more patent nostril. This was gently advanced, but we failed to see the glottis or epiglottis. Laryngoscopy using a Macintosh blade did not improve the view. Fibre-optic intubation alone was abandoned after multiple attempts over 20 min. To obtain a wider laryngeal view, an AWS was inserted into the pharynx. A deformed epiglottis was seen, with severe deviation caused by scarring. The tip of the fibre-optic scope was observed with the AWS. The deformed epiglottis interrupted the view by the fibre-optic scope. Using the AWS view of the larynx, the fibre-optic scope was advanced into the trachea and a tracheal tube, mounted on the fibre-optic scope was successfully placed. The combination with the laryngeal view provided by the AWS and the ability to manipulate the fibre-optic scope as a guide wire for the tracheal tube finally permitted nasotracheal intubation.

Factors affecting the difficulty of tracheal intubation with a lightwand

Anesthesia and Pain Medicine, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea

Evaluation of new laryngoscope blade for tracheal intubation, Truview EVO2©;

Difficult airways present a clinical challenge for anaesthetists. The Truphatek Truview EVO2 (Truphatek International Ltd, Netanya, Israel) is a new laryngoscope blade used for endotracheal intubation that could be used where there is difficulty in visualizing the laryngeal inlet. Twenty anaesthetists (12 trainees and eight consultants) compared the Truphatek Truview EVO2 with a conventional Macintosh size 3 blade. The Trucorp Airsim Bronchi (Trucorp Ltd, Belfast, Northern Ireland, UK) manikin was intubated under normal conditions and under simulated difficult conditions such as tongue inflation and neck rigidity. In each scenario, the Cormack-Lehane grade, time needed for successful intubation, perceived difficulty of tracheal intubation and personal preference of blade were compared. The results were analysed with t-test (time of intubation), Wilcoxon signed-rank sum (Cormack-Lehane grade, ease of manoeuvre, preferred blade) and analysis of variance with Bonferroni correction (augmentation of difficulties in different scenarios). The Truview EVO2 blade allowed the best laryngeal view as judged by the Cormack-Lehane grade (P < 0.05) in two separate situations: under simulated tongue inflation and under simulated neck rigidity. However, this blade did not reduce the intubation time or the ease of tracheal tube placement with respect to conventional Macintosh blade. Compared with the classical Macintosh blade, the Truview EVO2 blade allowed a better view of the larynx, but did not facilitate endotracheal intubation in any of the difficult scenarios created with the adjustable manikin and in most scenarios in fact prolonged the intubation time.

Evaluation of the Airtraq® and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation*

The Airtraq, a novel single use indirect laryngoscope, has demonstrated promise in the normal and simulated difficult airway. We compared the ease of intubation using the Airtraq with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation, in a randomised, controlled clinical trial. Forty consenting patients presenting for surgery requiring tracheal intubation, who were deemed to possess at least three characteristics indicating an increased risk for difficulty in tracheal intubation, were randomly assigned to undergo tracheal intubation using a Macintosh (n = 20) or Airtraq (n = 20) laryngoscope. All patients were intubated by one of three anaesthetists experienced in the use of both laryngoscopes. Four patients were not successfully intubated with the Macintosh laryngoscope, but were intubated successfully with the Airtraq. The Airtraq reduced the duration of intubation attempts (mean (SD); 13.4 (6.3) vs 47.7 (8.5) s), the need for additional manoeuvres, and the intubation difficulty score (0.4 (0.8) vs 7.7 (3.0)). Tracheal intubation with the Airtraq also reduced the degree of haemodynamic stimulation and minor trauma compared to the Macintosh laryngoscope.

Oculoauriculovertebral spectrum in two siblings

Oculoauriculovertebral spectrum (OAVS) is a rare congenital malformation consisting of epibulbar dermoids, lid colobomas, auricular deformities, hypoplasia of the soft and bony tissues of the face, associated oral deformities and vertebral anomalies. This report presents a child with a choroid of the right eye, coloboma of the upper eyelid, epibulbar dermoid of the left eye, mandibular hypoplasia, facial asymmetry, bilateral complete cleft lip and palate, hypoplasia of the left alar cartilage, appendage of the left nose, butterfly vertebral defects of Th-1, Th-2 and abnormality of rib XI. Widened sulci of frontal and parietal lobes, bilateral white matter density decrease and calcifications of falx cerebelli were noted. Axial hypotony and delayed psycho-motor development were apparent. This rare case presents a range of severe clinical manifestations of oculoauriculovertebral spectrum. Despite a normal cervical vertebral column, tracheostenosis was present. It caused difficulties in tracheal intubation, creating the need for a tracheostomy, and death after a failed attempt at decannulation. This case indicates that in patients with clinical manifestations including cerebral anomalies, a risk of respiratory insufficiency should be always taken under consideration, when planning surgery.

Case series: The McGrath® videolaryngoscope — an initial clinical evaluation

To document tracheal intubation success rates and airway instrumentation times using the newly designed McGrath videolaryngoscope. We prospectively recorded factors associated with difficult tracheal intubation, factors causing actual difficulty in tracheal intubation, as well as complications arising from use of the new McGrath videolaryngoscope in a series of adult patients with normal preoperative airway examinations. All patients were undergoing scheduled or elective surgery. In the first 75 patients (phase I), experience with airway instrumentation was documented, while in the second 75 patients (phase II), the time required to obtain an optimal view of the larynx was recorded, as well as the time to complete tracheal intubation. Ninety-eight percent of all tracheal intubations were successful using the McGrath videolaryngoscope. Cormack and Lehane grade I views were obtained in 143 patients (95%) and grade II views were achieved in six (4%). In phase II, the median time required to obtain an adequate view was 6.3 sec [interquartile range 4.7-8.7 (range 2-26.3)], and to complete tracheal intubation was 24.7 sec [18.5-34.4 (11.4-286)]. Fortynine (65%) of the tracheal intubations were completed within 30 sec, and 72 (96%) were completed within one minute. No complications were encountered in any patient. The McGrath videolaryngoscope is an effective aid to airway management in patients with normal airways, based upon intubation success rates and the ability to rapidly secure the airway. Its potential advantages of convenience and portability warrant further evaluation in comparison with other airway devices and in patients with difficult airways.

Comparison of the GlideScope® video laryngoscope vs. the intubating laryngeal mask for females with normal airways

In this randomized clinical study, we compared the intubation success rates of the intubating laryngeal mask airway with the GlideScope in patients with normal airways. The primary hypothesis was that the intubating laryngeal mask airway was equally effective as the GlideScope in terms of successful intubation times. Sixty ASA I and II adult patients undergoing elective gynaecological surgery were randomly allocated into either the intubating laryngeal mask airway group or the GlideScope group. After a standard anaesthetic intravenous induction, orotracheal intubation was performed. Time taken for successful tracheal intubation, ease of device insertion, difficulty of tracheal intubation, manoeuvres needed to aid tracheal intubation, number of intubation attempts, haemodynamic changes every 2.5 min interval for 5 min and complications during tracheal intubation were recorded. Time to successful intubation was longer (mean 68.4 s +/- 23.5 vs. 35.7 s +/- 10.7; P < 0.05), mean difficulty score was higher (mean 16.7 +/- 16.3 vs. 7.3 +/- 13.1; P < 0.05) and more intubation attempts were required in the intubating laryngeal mask airway group. The GlideScope improved intubation time and difficulty score for tracheal intubation when compared with the intubating laryngeal mask airway in our patients. Blind intubation through the intubating laryngeal mask airway offers no advantages over the GlideScope in patients with normal airways. Despite its limitations, the intubating laryngeal mask airway is a valuable adjunct, especially in cases of difficult airway management when it can provide ventilation in between intubation attempts.

Airway training in the UK

Dr Cook has made some important points about airway training [1]. He makes a case for the adoption of the Difficult Airway Society (DAS) guidelines on airway management [2]. It is noteworthy that within 10 years from its inception the DAS is being put forward in a leading editorial as an authority for airway training, not just for difficult cases. There is some irony here because the DAS considered changing its name to ‘The Airway Society’ a few years ago, but decided against this. It is worth noting that the guidelines refer to unanticipated difficulty in tracheal intubation for adults. As explicitly stated in the paper [2], the guidelines were limited to adult, non-pregnant patients. Obstetric and paediatric practice were excluded. Additionally, and importantly, management of patients with airway obstruction, an ongoing source of morbidity and mortality, was also excluded. The guidelines took about 5 years to produce, backed up with over 300 references. Adoption or modification of guidelines beyond their intended scope deserves careful consideration and whoever takes on these tasks may be unable to devote sufficient time or the effort necessary. Dr Cook calls upon the Royal College of Anaesthetists to adopt a pro-active role in setting training standards for airway management. I would go further and suggest that the DAS, College and Association of Anaesthetists join forces on this crucial issue. There is a pressing need for airway management issues, be they about training, equipment or skill assessment to take centre stage. This requires a major change in attitudes and behaviours away from ‘high risk strategies as a consequence of a low range of skills’[3]. This is neither quick, nor easy. Consider the ‘10 year rule’[4]. What separates the expert from the ordinary is ‘effortful study’, pushing to learn and teach. It takes about a decade of sustained effort to gain expert status. This effort applies to institutions as well as individuals. Dr Cook is right: patient demand and expectation is changing quickly. What was deemed acceptable clinical practice previously may not be acceptable now. These changes affect all aspects of our work. Airway management is a high consequence, risk intolerant activity and mandates an expert approach. As such, it should be at the centre of our practice, not at the sideline. There is no room for complacency. Like Dr Cook, I am a member of the DAS and gave advice before publication of the guidelines. These views are my own.

Retrograde tracheal intubation

Cook et al. report airway rescue using a Proseal™ laryngeal mask airway paired with fibrescope-guided placement of an Aintree intubation catheter®[1]. They recognised that their patient had the ‘full house’ for airway problems, with recognised difficulties in facemask ventilation, tracheal intubation and subglottic cannulation. Their creative pairing of equipment is to the authors' credit, especially in the setting of airway rescue for a hypoxic, unstable patient. We suggest that there would have been a good case for awake definitive airway management in addition to the precautionary cricothyroidotomy given the anticipated airway difficulties noted. The authors mention that an awake, transnasal fibreoptic approach had failed on a previous occasion. This, we surmise, influenced the authors in their choice of cricothyroidotomy with jet ventilation under general anaesthesia as their first management option. We suggest a retrograde technique, a method that has received little recent attention in the realm of airway management. Retrograde approaches are fairly simple to perform under local or general anaesthesia, have a high safety profile and can succeed when other techniques fail. A retrograde approach, however, needs sufficient space around the patient's neck to allow airway cannulation via the cricothyroid membrane. Sanchez & Morrison give a useful description of the range of retrograde options available [2], including a method by which a retrograde approach is used with a fibrescope [3], which we describe below. After patient consent and preparation, including topical airway anaesthesia, a 16 G epidural needle is used to cannulate the airway through the cricothyroid membrane with the bevel facing rostrally. An angiographic guidewire of sufficient length (we use a Teflon coated wire, diameter 0.889 mm and 145 cm long; Medtronic Vascular, Danvers, MA) is threaded into the airway through the needle and usually protrudes out from the patient's mouth. A sufficient length of wire is pulled through the mouth, taking care not to pull the wire completely into the neck (a clip applied to the wire near the neck will prevent this). The guidewire is then passed into the working channel of a lubricated fibrescope loaded with a suitable tracheal tube. The guidewire allows the fibrescope to traverse the upper airway into the larynx until the fibrescope abuts the larynx at the level of the cricothyroid membrane. At this stage the guidewire can be pulled out, either rostrally or caudally through the neck. Choosing the former option may reduce lower airway contamination from the oral cavity. Once the fibrescope is no longer constrained by the guidewire it falls into the airway, allowing further advancement of the fibrescope into the tracheal lumen and subsequent passage of the tracheal tube. A modification to guidewire removal is to pull the guidewire rostrally until it lies in the trachea, when it can be advanced into the trachea, preserving a pathway for any further airway instrumentation. This method results in orotracheal intubation. Should nasotracheal intubation be required, an additional step prior to use of the fibrescope is needed to re-direct the guidewire from the oral to the nasal route. A suitable gastric tube is inserted into the patient's nose and lifted from their pharynx either digitally or by Magill's forceps so the tip now exits from the mouth. The guidewire is threaded into the tip of the gastric tube, re-directing the guidewire from mouth to nose, at which time the gastric tube can be removed from the patient. Retrograde techniques using a guidewire require that the wire be of sufficient length to traverse a patient's airway and the length of a fibrescope and central venous catheter wire are not suitable. Whilst there are other retrograde techniques available, we feel that pairing of guidewire to fibrescope has great merit, allowing visualisation of the intubation sequence.

The use of the GlideScope® for tracheal intubation in patients with ankylosing spondylitis

The GlideScopeVideo Laryngoscope is a new intubating device. The aim of the study was to investigate the use of the GlideScopefor tracheal intubation in patients with ankylosing spondylitis (AS) undergoing general anaesthesia. Twenty AS patients were chosen to undergo tracheal intubation by the GlideScope. Preoperative airway assessments were carried out to predict the difficulty of tracheal intubation. Before intubation all patients were given a modified Cormack and Lehane (MCLS) grade and percentage of glottic opening (POGO) score by a separate anaesthetist using a Macintosh size 3 blade. The patients were then intubated, using the GlideScope, by a different anaesthetist during which the larynx was inspected and given another MCLS grade and POGO score. Twelve of the AS patients were judged to have had difficult intubation by preoperative airway assessment. Eleven of the twelve patients had MCLS grades III or IV by direct laryngoscopy and were considered to have had a difficult laryngoscopy. Naso-tracheal intubations by the GlideScope were successful on 17/20 occasions, including 8 of the 11 difficult laryngoscopy. The GlideScope improved the MCLS grade and POGO score in the majority of AS patients compared with direct laryngoscopy (P<0.01). The GlideScope provides a better laryngoscopic view than that of direct laryngoscopy. Most of the AS patients presenting with MCLS grade III or IV by direct laryngoscopy can be intubated successfully by the GlideScope. In elective patients with AS, awake fibreoptic intubation offers a higher level of security because it can be applied while maintaining spontaneous breathing. The use of GlideScope for tracheal intubation may be an alternative option in these patients who prefer their airway management under anaesthesia.

Evaluation of dental injury following endotracheal intubation using the Periotest® technique

The hazards of damage to teeth and their periodontal attachment during tracheal intubation are well known. Dental trauma represents the commonest single reason for complaints against anesthesiologists. In order to predict the possible risk of perianesthetic iatrogenic tooth luxation we evaluated the use of a measuring method (Periotest technique), being well established for the diagnosis of periodontal disease. In 120 patients undergoing elective surgery, we compared the amount of tooth mobility before and after general anesthesia to different scores assessing the difficulty of tracheal intubation. Furthermore, the level of work experience of the intubating anesthetist was compared with the degree of postoperative tooth mobility. Changes of periodontal attachment could not be detected by the Periotest technique. The Periotest technique does not seem to have the ability to detect early periodontal changes associated with endotracheal intubation.

Risk Factors Assessment of the Difficult Airway: An Italian Survey of 1956 Patients

Over the last decade, there has been a heightened awareness and an increase in the amount of literature being published on recognition and prediction of the difficult airway. During the preoperative evaluation of the airway, a thorough history and physical specifically related to the airway should be performed. Various measurements of anatomic features and noninvasive clinical tests can be performed to enhance this assessment. In this study we correlated the Mallampati modified score and several other indexes with the laryngoscopic view to identify anatomical and clinical risk factors related to the difficult airway. We prospectively collected data on 1956 consecutive patients scheduled to receive general anesthesia requiring endotracheal intubation for elective surgery. The Mallampati classification versus the Cormack-Lehane (C-L) linear correlation index was 0.904. A Mallampati Class 3 correlated with a C-L Grade 2 (0.94), whereas a Mallampati Class 4 correlated with a C-L Grade 3 (0.85) and a C-L Grade 4 (0.80). Operator evaluation, performed by a simplified tracheal intubation difficulty scale, showed a linear correlation of 0.96 compared with the C-L groups. Although there is a correlation between oropharyngeal volume and difficult intubation, the Mallampati score by itself is insufficient for predicting difficult endotracheal intubation.

Management of unanticipated difficult intubation: a survey of current practice in the Oxford region.

Unanticipated difficulty in tracheal intubation in an anaesthetized patient has always been a cause of concern to anaesthesiologists. This difficulty may lead to morbidity and mortality. This survey was carried out to determine the technique commonly favoured in centres in the Oxford region in the UK for the management of unanticipated difficult intubation. We conducted a clinical scenario-based questionnaire survey of 181 anaesthesiologists in the Oxford region. In this scenario, difficulty in endotracheal intubation is recognized only after induction of anaesthesia. A number of options were available to deal with this situation. We used this scenario as a tool to gain insight into the training and the training needs of anaesthesiologists at various levels of training. Of the 181 questionnaires sent, we received 143 (79%) completed replies. The vast majority (141/143 (99%)) of anaesthesiologists would use a gum-elastic bougie together with head and neck positioning and optimal external laryngeal manipulation to gain the best attempt at intubation. If intubation still failed, overall 129/143 (90%) had a back-up plan, while 14/143 (10%) had no plan. Flexible fibreoptic techniques were more commonly planned by 92/143 (64%) anaesthesiologists compared to blind techniques which were less commonly planned by 37/143 (26%) anaesthesiologists. Differences in choice of technique among anaesthesiologists in teaching and district general hospitals were not significant (P = 0.87). Overall, trainees were less likely to choose fibreoptic techniques compared to consultants (P = 0.0009) and would use blind techniques or ask a more experienced colleague to take over. The main reason for the choice was previous experience with the technique. Although fibreopric techniques were most commonly planned, these were less often chosen by trainees than consultants due to lack of experience/training, while unavailability of intubating laryngeal mask airway (Intavent) was an additional issue precluding its use as an adjunct to intubation.

'Airway Alerts'. How UK anaesthetists organise, document and communicate difficult airway management.

A questionnaire on organisation, documentation and communication of airway problems during anaesthesia was sent to 271 anaesthetic college tutors in the UK. Their responses were compared with three published recommendations. There was a 72% response rate (195/271). The recommendations of the American Society of Anaesthesiologists Task Force on the Management of the Difficult Airway were met by 71% of respondents; 2% met those suggested by the Canadian Airway Focus Group and 2% met those suggested in a standard UK textbook on difficulties in tracheal intubation. Guidelines for management of the difficult airway were available in 142 departments (73%), but only 41 (21%) had guidelines for communication and dissemination of information. We present an 'Airway Alert' scheme which has since been adopted by the Difficult Airway Society.

Anaesthetic approach in a case of Goldenhar's syndrome

Anaesthetic approach in a case of Goldenhar's syndrome