All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

PURPOSE

Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA).

METHODS

An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS

The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care.

CONCLUSION

Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Tracheal tube introducer-associated airway trauma: a systematic review

BACKGROUND

Tracheal tube introducers are recommended in airway management guidelines and are used increasingly as videolaryngoscopy becomes more widespread. This systematic review aimed to summarise the published literature concerning tracheal tube introducer-associated airway trauma.

METHODS

PubMed, EMBASE and CINAHL databases were searched using pre-determined criteria. Two authors independently assessed search results and performed data extraction and risk of bias assessments.

RESULTS

We included 16 randomised controlled trials and five observational studies involving 10,797 patients. There was heterogeneity in patient characteristics, airway manipulation, and airway trauma definition and measurement. One study investigated hyperangulated videolaryngoscopy. The standard stylet was the most commonly reported introducer, followed by bougie and stylets with additional features such as video or lighted tip. Airway trauma resulted in low harm and most frequently involved injuries to the upper airway, followed by laryngeal and tracheobronchial injuries. Eighteen studies were comparative and reported a reduction in airway trauma incidence when an introducer was used, with the exception of the standard stylet. Median (IQR [range]) pooled incidence of airway trauma associated with standard stylets was 13.1% (4.2-31.4 [0.5-79.2])% and with bougies was 5.4% (0.4-49.9 [0.0-68.0])%. The risk of bias of included studies was variable and many randomised trials were found to be at high risk due to non-robust measurement of the outcome.

CONCLUSIONS

Stylets might be associated with an increased risk of airway trauma compared with other devices or when no stylet was used, though the quality of evidence is modest. However, other introducers appear to be safe and reduce the risk of airway trauma.

Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department

BACKGROUND

Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation.

METHOD

This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined.

RESULTS

The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%.

CONCLUSION

DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.

Current Status of Difficult Airway Information Dissemination at a Tertiary Pediatric Hospital

OBJECTIVE

Difficult airway is one of the most common potential risk factors for increased fatality in craniofacial/plastic surgery patients. To date, there is no well-established and all-around difficult airway notification system in China, which has recently been recommended by existing guidelines to improve the care of patients with known difficult airways. This study aimed to investigate the current status of critical information communication concerning difficult airway management in our institute.

METHODS

Vital information required to establish a difficult airway registry and notification system was collected through a literature review and expert suggestions. After approval by the Research Ethics Board, 3 online questionnaires were developed and sent to surgeons, anesthesiologists, and proxies of the patients. Knowledge of difficult airways, the willingness to be involved in the difficult airway notification system, and the way to disseminate the information were investigated in the 3 groups. The specific information that was disseminated, required, and available was investigated in the anesthesiologist group.

RESULTS

Compared with the surgeons and anesthesiologists, significantly fewer patients knew the definition of a difficult airway and thought it was a potential risk factor. There were no significant differences in the willingness to be informed of the difficulty encountered during airway management. Significant differences were detected in the willingness and way to disseminate the airway information when the participants communicated with different groups. Significantly more patients would disseminate the information to the surgeon and significantly more surgeons would disseminate the information to the patient and the other surgeon. Significantly more anesthesiologists would disseminate the information to the patient and the other anesthesiologists. A significant difference was observed between what was expected and what was available for the anesthesiologist to retrieve the airway information of a patient with known airway difficulty. Significantly more anesthesiologists would notify only the patient of the diagnosis of a difficult airway both oral and written, whereas significantly more anesthesiologists would notify the other anesthesiologist of the specific difficulties in oral only. Most participants agreed to be involved in the difficult airway notification system despite the significantly lower percentage in the patient group (89%).

CONCLUSIONS

Difficult airway information dissemination is, at the time of this writing, ineffective, which leads to a large gap between the expectation and practice of the anesthesiologist when caring for a patient with a difficult airway. Thus, a difficult airway registry and notification system should be developed, that has a solid foundation in all the participants.

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain.

METHODS

We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I2 statistics. All outcomes were submitted to random-effect models.

RESULTS

Our meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04-1.20; p < 0.01; I2 = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24-0.80; p < 0.01; I2 = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41-0.96; p = 0.03; I2 = 0%) compared to DL.

CONCLUSION

VL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients. Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685 . Registered 6 July 2023.

Management of the Difficult Airway: An Appraisal of Clinical Practice Guidelines

OBJECTIVE

Management of the difficult airway can be a challenging process, which necessitates actionable recommendations from well-established guidelines. Herein, clinical practice guideline (CPG) quality is evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

STUDY DESIGN

A systematic literature search was performed using Scopus, EMBASE, and MEDLINE via PubMed.

SETTING

Literature database.

METHODS

Data were abstracted from relevant guidelines and appraised by 4 expert reviewers in the 6 domains of quality defined by AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to quantify interrater reliability.

RESULTS

Twelve guidelines met the inclusion criteria. With a mean quality score of 83.1%, the highest quality guideline was authored by the American Society of Anesthesiologists (ASA). Low-quality content was observed in CPGs authored by the Japanese Society of Anesthesiologists (JSA) and the Chinese Collaboration Group for Emergency Airway Management (CCGEAM). Overall, deficits were most pronounced in domains describing the involvement of stakeholders, developmental rigor, and editorial independence. These findings were consistent among the panel of independent reviewers, with high ICC inter-rater reliability scores of 58.0% to 70.0% for the referenced domains.

CONCLUSION

By providing a comprehensive appraisal of guidelines, this report may serve as a reference for clinicians seeking to understand and improve upon the developmental quality of difficult airway management resources. According to AGREE II criteria for the quality of the guideline creation process, the 2022 ASA guideline outperforms its predecessors.

Current practice pattern among anaesthesiologists for difficult airway management: A nationwide cross-sectional survey

Background and Aims

The practice patterns for airway management vary among anaesthesiologists, depending on various setups and geographical divides. This survey assessed practice patterns in unanticipated difficult intubation and cannot intubate or cannot ventilate (CICV) situations/complete ventilation failure among Indian anaesthesiologists'.

Methods

A validated questionnaire of 22 items related to practice preferences for airway management among anaesthesiologists was sent to Indian Society of Anaesthesiologists members online through Google Forms and distributed manually to delegates in continuing medical education programme.

Results

A total of 535 responses were obtained and analysed. In unanticipated difficult laryngoscopy and intubation, the order of preference for alternative airway devices was video laryngoscope (VL, 60.1%), intubating laryngeal mask airway/laryngeal mask airway (23.5%), fibreoptic bronchoscope (13.5%) and optical stylets (1.2%). Advanced difficult airway devices were unavailable in most nursing homes and government non-teaching hospitals. Seventy per cent of respondents experienced CICV situations at least once, most during head and neck surgeries. In CICV situations, the order of choice for the front-of-neck airway access was cricothyroidotomy (CT) by narrow bore cannula (48.9%), tracheostomy by the surgeon (30%), Seldinger CT (12.5%), open surgical CT (5.4%) and scalpel bougie CT (3.2%).

Conclusion

The VL was the most preferred airway rescue device in unanticipated difficult intubation, and intravenous catheter cricothyroidotomy was the most selected technique in CICV situations.

Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults

BACKGROUND

Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.

METHODS

In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

RESULTS

The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.

CONCLUSIONS

Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195.).

Effectiveness of Face mask only oxygenation and apnoeic oxygenation in addition to face mask in sustaining PaO2 during rapid sequence induction - A randomized control trial

Background and Aims

Apnoeic oxygenation, although useful during elective intubations, has not shown consistent beneficial results during emergency intubations in critically ill patients. We aimed to study the effectiveness of adding apnoeic oxygenation to our routine practice of using facemask alone, in emergency laparotomy patients needing rapid sequence induction (RSI), for sustaining partial pressure of oxygen (PaO2).

Material and Methods

Seventy-two patients undergoing RSI for emergency laparotomy were randomly allocated to either receive pre-oxygenation with 5 L/min of oxygen (O2) with a facemask (Group-FM) or apnoeic oxygenation with 10 L/min of O2 through a nasal catheter in addition to pre-oxygenation (Group-NC). Apnoea (90 s) was allowed from the removal of the facemask before the resumption of ventilation. Arterial blood gas analysis was done at the baseline, following pre-oxygenation and after 90 s of apnoea to study the PaO2 and partial pressure of carbon dioxide (PaCO2). The circuit O2 concentrations (fraction of inspired [FiO2] and end-tidal [EtO2]) were also noted to ensure a steady state of O2 uptake was reached.

Results

The circuit O2 concentrations were 90 ± 4% in group FM and 93 ± 5% in Group-NC. The FiO2-EtO2 difference was 4% in both groups. During the 90 s apnoea following pre-oxygenation, there was a fall in the PaO2 by 38% in Group-FM and 12% in Group-NC (P = 0.000). Increase in PaCO2 was similar in both groups (Group-FM: 44 [range: 32-55] mmHg; Group-NC: 42 [range: 33-54] mmHg, P = 0.809).

Conclusion

Apnoeic insufflation of O2 using a nasopharyngeal catheter along with facemask oxygenation is more effective in sustaining PaO2 for 90 s during RSI than facemask-only oxygenation in patients undergoing emergency laparotomy.

Role of Point-of-Care Ultrasound in Emergency Airway Management Outside the Operating Room

Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.

Effect of etomidate and propofol on airway mechanics during induction - A prospective randomized trial

Background and Aims

Intravenous induction agents like propofol and etomidate change the airway mechanics and thus influence mask ventilation. These changes have an impact on the administration of muscle relaxant in a difficult mask ventilation scenario. The difference in dynamics of airway after administration of two different intravenous agents has been assessed in this study.

Material and Methods

After formal registry in clinical trials, patients undergoing general anesthesia were recruited and randomized into group P and E. Patients were induced with either of the intravenous agents, and mask ventilation was performed with a ventilator. After 60 s, rocuronium was administered and ventilation continued. Measurements of tidal volume, peak airway pressure, and compliance were taken from the anesthesia ventilator at different time points - induction, relaxant, and intubation.

Results

There was no statistically significant difference between the two groups with respect to demographics, airway parameters, and airway mechanics, as measured by tidal volume, peak airway pressure, and lung compliance. There was an improvement in the tidal volume and compliance following induction with propofol, with a P value of 0.007 and 0.032, respectively, obtained in within-group comparison.

Conclusion

Propofol and etomidate were comparable in airway mechanics, but compliance and tidal volumes improved with propofol, which facilitated face mask ventilation.

Comparative evaluation of C-MAC and McGrath MAC videolaryngoscopes with Macintosh direct laryngoscope for endotracheal intubation in adult patients undergoing elective surgeries

Background and Aims

Videolaryngoscopes have an undisputed role in difficult airway management, but their role in routine intubation scenarios remains underappreciated. McGrath MAC is a lightweight laryngoscope with a disposable blade. It remains to be proven if it performs as efficiently as the reusable videolaryngoscopes like C-MAC and whether it has an advantage over standard Macintosh laryngoscope in predicted normal airways.

Material and Methods

We recruited 180 adult patients and randomly divided them into three groups for intubation with either Macintosh laryngoscope (Group-A), C-MAC (Group-B), and McGrath (Group-C). The primary objective was to compare the first attempt success rate. Secondary objectives included Cormack-Lehane (CL) grades, laryngoscopy time, intubation time, ease of intubation, need for optimization manoeuver, and the number of passes to place the endotracheal tube.

Results

The two videolaryngoscopes provided a superior first attempt success rate as compared to Macintosh laryngoscope (P = 0.027). The CL grade-I was 100% in group B, 41.7% in group-A and 90% in group-C (B vs C; P = 0.037). Laryngoscopy time was 9.9 ± 2.5 s, 12.6 ± 0.8 s, and 13.1 ± 0.8 s for groups A, B, and C, respectively (B vs C; P = 0.001). Intubation time was 24.4 ± 12 s, 28.3 ± 1.9 s, and 37.3 ± 5.8 s for groups A, B, and C, respectively (P < 0.0001). The number of tube passes was highest in group C.

Conclusion

Videolaryngoscopes provided a superior glottic view and resulted in a superior first attempt success rate as compared to Macintosh laryngoscope. When comparing the two videolaryngoscopes, C-MAC resulted in better intubation characteristics (shorter intubation time, better glottic views, and higher first-attempt success rates) and should be preferred over McGrath for intubation in adult patients with normal airways.

Preventing unrecognized esophageal intubation in the emergency department

Tracheal intubation is a commonly performed procedure on critically ill patients in the emergency department. It is associated with many serious complications, one of the most dangerous being unrecognized esophageal intubation, which can result in anoxic brain injury, cardiac arrest, or death. It is the responsibility of the emergency physician to do everything possible to avoid this devastating complication. Preventing unrecognized esophageal intubation requires a two-pronged approach. First, the inadvertent placement of intended tracheal tubes into the esophagus must be reduced as much as is humanly possible. This can be achieved with the routine use of video laryngoscopes for emergency department intubations. Numerous studies have demonstrated that use of video laryngoscopes can significantly reduce the occurrence of esophageal intubation, presumably by providing an improved view of the larynx. Second, if an esophageal intubation inadvertently occurs, it must be rapidly identified and appropriately addressed. The cornerstone of rapid identification is the use of continuous waveform capnography to detect exhaled carbon dioxide. Capnography has been shown to be the most accurate method to determine tube placement after intubation. Standard clinical examinations, for example, auscultation of breath sounds, visualization of chest excursion, and observation of condensation in the tube, have all been demonstrated in studies to be unreliable and thus should not be used to exclude esophageal intubation. Recently, the Project for Universal Management of Airways, an international collaborative of airway experts from anesthesiology, critical care and emergency medicine, published evidence-based guidelines to specifically address the issue of preventing unrecognized esophageal intubation. These guidelines, which have received endorsement from several prominent airway societies, including the Society for Airway Management, the Difficult Airway Society, and the European Airway Management Society, will be briefly discussed in this review.

Randomized Clinical Trial Comparing the Success Rate of Blockbuster Intubating Laryngeal Mask Airway Versus Fastrach Intubating Laryngeal Mask Airway During Blind Endotracheal Intubation

Background A new piece of equipment, the Blockbuster (BB) Intubating Laryngeal Mask Airway (ILMA; Tuoren Medical India, Gurugram, India), was created in 2012. Dr. Chandy created the Fastrach (F) ILMA in 1997, which is another supraglottic airway equipment. The primary purpose of this study was to compare the success rate of intubation with BB-ILMA and F-ILMA. Methods In the chosen age category of >20 to <70 years, undergoing general anesthesia for intubation with ILMAs, 55 patients were in the BB-ILMA (group B), and 55 patients were in the F-ILMA (group F). These ILMAs were put in after the induction and checked to see if adequate ventilation was accomplished with either of these devices. Once ventilation had been attained, we proceeded with fiberoptic scope to visualize the glottis, followed by blind intubation. The primary objective was to compare the first pass successful intubation of BB-ILMA and F-ILMA. The secondary objectives were ease of LMA insertion, time taken for intubation, hemodynamic changes, glottis fiberoptic view, and complications. Results The first pass successful intubation of the BB-ILMA and F-ILMA are 94.5% and 87.3%, respectively, whereas the time taken for intubation in BB-ILMA and F-ILMA are 25.02 seconds (s) and 42.77 s with a p-value of 0.0001, indicating a statistically significant relationship. Conclusion When compared to the F-ILMA (group F), the BB-ILMA (group B) has a higher success rate for blind tracheal intubation, with lesser time taken for intubation and fewer complications.

Influence of airway trolley organization on efficiency and team performance: A randomized, crossover simulation study

BACKGROUND

Failed management of unanticipated difficult airway situations contributes to significant anesthesia-related morbidity and mortality. Optimization of design and layout of difficult airway trolleys (DATs) may influence outcomes during airway emergencies. The main objective of the current study was to evaluate whether a difficult airway algorithm-based DAT with integrated cognitive aids improves efficiency and team performance in difficult airway scenarios.

METHODS

In a crossover design, 16 teams (anesthetist, nurse anesthetist, assistant nurse) completed two high-fidelity simulated unanticipated difficult airway scenarios. Teams used both an algorithm-based DAT and a comparison, standard DAT, in the scenarios and were randomized to order of trolley type. Outcome measures included objective efficiency parameters, team performance assessment and subjective user-ratings. Linear mixed models ANOVA, including DAT type and order of condition as main factors, was utilized for the primary analyses of the team results.

RESULTS

Usage of the algorithm-based DAT was associated with fewer departures from the difficult airway algorithm (p = .010), and reduced number of unnecessary drawer openings (p = .002), but no significant differences in time to retrieval of airway devices or time to first effective ventilation, compared to the standard DAT. There were no significant differences in team performance, although participants expressed strong preference for the algorithm-based DAT (all user-rated measures p < .0001). Higher percentage of female members of the team improved adherence to the difficult airway algorithm (p = .043).

CONCLUSIONS

Algorithm-based DATs with integrated cognitive aids may improve efficiency in difficult airway situations, compared to traditional DATs. These findings have implications for improvement of anesthetic practice.

Multidisciplinary Difficult Airway Team Characteristics, Airway Securement Success, and Clinical Outcomes: A Systematic Review

Objective:

To investigate whether implementation of a multidisciplinary airway team was associated with improvement in (1) rate of successful airway securement at first attempt; (2) time to secure airway; and (3) overall complication rate in patients with a difficult airway, as compared with usual care.

Data Sources:

Ovid Medline, Embase, Scopus, Cochrane Central, and CINAHL databases.

Review Methods:

Systematic review of literature on inpatient multidisciplinary team management of difficult airways, including all studies performed in inpatient settings, excluding studies of ventilator weaning, flight/military medicine, EXIT procedures, and simulation or educational studies. DistillerSR was used for article screening and risk of a bias assessment to evaluate article quality. Data was extracted on study design, airway team composition, patient characteristics, and clinical outcomes including airway securement, complications, and mortality.

Results:

From 5323 studies screened, 19 studies met inclusion criteria with 4675 patients. Study designs included 12 quality improvement projects, 6 cohort studies, and 1 randomized controlled trial. Four studies evaluated effect of multidisciplinary difficult airway teams on airway securement; all reported higher first attempt success rate with team approach. Three studies reported time to secure the difficult airways, all reporting swifter airway securement with team approach. The most common difficult airway complications were hypoxia, esophageal intubation, hemodynamic instability, and aspiration. Team composition varied, including otolaryngologists, anesthesiologists, intensivists, nurses, and respiratory care practitioners.

Conclusion:

Multidisciplinary difficult airway teams are associated with improved clinical outcomes compared to unstructured emergency airway management; however, studies have significant heterogeneity in team composition, algorithms for airway securement, and outcomes reported. Further evidence is necessary to define the clinical efficacy, cost-effectiveness, and best practices relating to implementing difficult airway teams in inpatient settings.

Safety and ease of awake fiberoptic intubation with use of oxygen insufflation versus suction to clear secretions during procedure

Background and Aims

During awake fiberoptic intubation (AFOI), clearing secretions is usually done by suctioning. The study objectives were to assess the safety of AFOI with the use of oxygen insufflation versus suction to clear secretions from the field of vision during the procedure as assessed by incidence of desaturation <95%, ease of intubation, and time taken to secure the airway.

Material and methods

This prospective randomized study was conducted in 40 adult patients with difficult airways requiring AFOI. All patients received dexmedetomidine 0.5mcg/kg intravenously, and the airway was topicalized. In Group-S suction and in Group-O oxygen was connected to the suction port of the bronchoscope to clear the secretions by activating the suction knob during bronchoscopy. Ease of intubation was scored as easy, moderate, and hard.

Results

Incidence of desaturation to <95% and the need for oxygen supplementation were significantly high in Group S compared to Group O (60% vs. 10%). Incidence of easy intubation (80% vs. 75%) and time taken to intubate (50.1 ± 16.6 vs. 53.8 ± 21.0 s) were comparable. The number of times (median) suctioning was done in Group S was significantly high compared to the number of oxygen insufflations required in Group O [3 (1-6) vs. 2 (0-5), P 0.033]. Desaturation to <95% was significantly low in Group O compared to Group S during bronchoscopy (10% vs. 60%, P 0.002).

Conclusion

The use of oxygen insufflation to clear secretions from the field of vision during AFOI is a safer alternative to suctioning as this technique reduces the chance of desaturation during the procedure without affecting ease of intubation, number of attempts, time taken for it, or patient comfort.

Comparison of double lumen tube insertion using the McGrath MAC versus direct laryngoscopy in adult patients with a limited glottis view: A prospective interventional study

Background and Aims

Passage of double-lumen tubes (DLT) can be challenging in patients with limited glottis view. This study aims to determine the usefulness of McGrath® MAC videolaryngoscope (VL) in cases with limited glottis view on direct laryngoscopy with Macintosh blade.

Material and Methods

After study approval and registration of trial, consent was sought from all adult patients planned for elective DLT insertion for lung isolation during the course of general anesthesia. Patients not consenting, less than 18 years, with anticipated difficult mask ventilation or need for rapid sequence induction were excluded. Following routine anesthetic induction, laryngoscopy was attempted by an experienced anesthesiologist using Macintosh scope. If the view obtained was Cormack and Lehane (CL) view IIB and above or the attempt at intubation using DLT failed despite a CL I/IIA view, the patient was included in the trial. The laryngoscope was removed and after ensuring adequate oxygenation and depth of anesthesia, intubation was attempted using McGrath® MAC VL. The percentage of glottis opening (POGO) score was noted for both the scopes.

Results

DLT insertion was attempted in 76 patients in the study period. Eight patients were included in the trial on account of limited glottis view/failure with Macintosh scope. Insertion of DLT with McGrath MAC was tried only in six patients, in two patients, the VL was not available for use. The mean (standard deviation) POGO score with Macintosh scope was 9 (±20), which significantly improved with the use of VL to 71 (±24), P = 0.01.

Conclusion

McGrath MAC is helpful in inserting DLT in patients with limited glottis view with Macintosh scope.

Prevalence and commonality of non-technical skills and human factors in airway management guidelines: a narrative review of the last 5 years

The primary aim of this review was to identify, analyse and codify the prominence and nature of human factors and ergonomics within difficult airway management algorithms. A directed search across OVID Medline and PubMed databases was performed. All articles were screened for relevance to the research aims and according to predetermined exclusion criteria. We identified 26 published airway management algorithms. A coding framework was iteratively developed identifying human factors and ergonomic specific words and phrases based on the Systems Engineering Initiative for Patient Safety model. This framework was applied to the papers to delineate qualitative and quantitative results. Our results show that human factors are well represented within recent airway management guidelines. Human factors associated with work systems and processes featured more prominently than user and patient outcome measurement and adaption. Human factors are an evolving area in airway management and our results highlight that further considerations are necessary in further guideline development.

Tracheal intubation using the Airtraq video laryngoscope vs. Macintosh laryngoscope in patients with anticipated difficult intubation

Background

Various types of laryngoscopes have been invented to ameliorate the laryngoscopic view of the glottis, in normal and difficult airway, which helps anaesthesiologists to secure the airway during anaesthesia. In this prospective study, we aimed to compare the efficacy of the Airtraq video laryngoscope (AVL) and the Macintosh curved-blade laryngoscope (MBL), by using a common clinical assessment tool in patients with modified Mallampati class III and IV.

Methods

A total of 60 patients [group A (AVL) and group M (MBL)] with modified Mallampati class III and IV listed for general anaesthesia were included. Each patient was intubated with either of the laryngoscope based on the group allotted. Time taken for tracheal intubation, grade of visualisation of glottis and need for manoeuvres to optimise the glottic view were compared.

Results

The degree of the glottic view during successful intubation attempt was easily appreciated in group A (p < 0.0001). Difference in the requirement of manoeuvres for optimising the laryngeal view/assisting in intubation as assessed by manoeuvre score was easily appreciated in group A (p < 0.010). Rise in heart rate and mean arterial pressure 1 and 2 min after intubation was more in group M than in group A (p < 0.0001). No event of any airway trauma, as evidenced by visible trauma to lips or oral mucosa or blood on laryngoscope, was observed with either of the laryngoscope.

Conclusion

The novel AVL provides better intubation conditions with greater ease of intubation, better glottic view and lesser haemodynamic alterations during laryngoscopy than MBL.

Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study

Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/Fi_O2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).

Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial

Importance

Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain.

Objective

To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death.

Design, Setting, and Participants

This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021.

Interventions

Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527).

Main Outcomes and Measures

The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge.

Results

Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, -2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, -1.8% [95% CI, -7.9% to 4.3%]; P = .55).

Conclusions and Relevance

Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse.

Trial Registration

ClinicalTrials.gov Identifier: NCT03787732.

First-pass Success Rate and Number of Attempts Required for Intubation in Anticipated Difficult Airway: Comparison between Macintosh and Channeled King Vision Video Laryngoscopes

Background and Aims

Video laryngoscopy has been shown to improvise Cormack-Lehane grading and rate of successful tracheal intubation and is now incorporated in most of the difficult airway guidelines. Since there is scarce literature regarding the use of channeled blade of King Vision video laryngoscope (KVVL) in anticipated difficult intubation, we planned to undertake this randomized control trial to assess the performance of channeled blade of KVVL and Macintosh laryngoscope in patients with anticipated difficult intubation.

Design and Setting

This prospective randomized study was conducted in a tertiary care hospital.

Materials and Methods

Patients fulfilling the inclusion criteria were randomly assigned equally to the KVVL group or Macintosh group. The primary outcome of the study was intubation success in the first attempt and number of attempts required for intubation, and the secondary outcomes were Cormack-Lehane grading and time required to intubate in both the groups.

Results

The first-pass success of intubation was 88.6% in the KVVL group and 76.5% in the Macintosh group (P = 0.035). The second attempt of intubation was required in 11.4% and 20.6% of patients in the KVVL and Macintosh groups, respectively. Cormack Lehane Grade I was achieved in 100% of patients of the KVVL group as compared to 29.4% of patients in the Macintosh group. Moreover, the difference was statistically significant (P = 0.035). The mean duration of intubation was prolonged in the KVVL group as compared to the Macintosh group, and the difference was statistically significant (P = 0.04).

Conclusion

The channeled blade of KVVL had a higher first-pass success rate and required fewer attempts to intubate when used in patients with anticipated difficult intubation. Further, the KVVL was found to be significantly better than the Macintosh laryngoscope in terms of Cormack-Lehane grading, but the time taken to intubate the trachea was more in the KVVL group.

Efficacy of I- gel™ for airway management of neonates with Pierre Robin sequence undergoing glossopexy: A prospective study

This paper aims to review the utility of I- gel as a successful airway management device for infants with Pierre robin sequence (PRS) undergoing glossopexy. A prospective study was conducted on PRS neonates. The algorithm followed was putting a 'Tongue traction stitch' followed by the following sequence - two trials with direct laryngoscope intubation, two attempts with fiberoptic endoscope intubation followed by insertion of I-gel™ to manage difficult airway during glossopexy procedure. 6 patients were intubated with direct laryngoscope, 12 patients were intubated with fibreoptic endoscope and the rest 13 patients were intubated using I-gel™. Successful management of difficult airway was achieved with this airway management protocol during glossopexy and nil postoperative complications were encountered. Within the limitations of the study it seems that, I-gel™ is a relevant alternative toprovide a reliable and secure airway access to carry out glossopexy procedure in such patients.

Evaluation of Glottic View and Intubation Conditions with Sniffing Position Using Three Different Pillow Heights during Direct Laryngoscopy: A Prospective Analytical Study

Background

Limited studies are available for assessing the optimal pillow height for sniffing position to obtain the best glottic view during laryngoscopy and intubation in the Indian population.

Aims

This study was designed to evaluate laryngoscopic view and intubation conditions in sniffing position using three different pillow heights (without a pillow, 4 cm, and 7 cm) during direct laryngoscopy.

Settings and Design

This prospective analytical study was done in a tertiary care teaching institute.

Materials and Methods

In 60 patients, direct laryngoscopy was performed in the sniffing position first without a pillow (0 cm), followed by a 4-cm pillow, and then a 7-cm pillow to assess the glottic view after administration of anesthesia. The laryngoscopic views were graded using the percentage of glottic opening (POGO) score and Cormack and Lehane (CL) grade. The pillow with the best laryngoscopic view was subsequently used to intubate the patient. Intubation difficulty was assessed by the Intubation Difficulty Score (IDS). The patient was followed up for 24 h postoperatively to evaluate postoperative complications due to intubation.

Statistical Analysis

The categorical data were expressed in frequency and percentages and analyzed using the Chi-square test.

Results

With a 4-cm pillow, there are a lower CL grade and a higher POGO score compared to views without a pillow and a 7-cm pillow which was statistically significant. There is a significantly lesser IDS score with a 4-cm pillow.

Conclusions

The sniffing position with a 4-cm pillow provides a better laryngoscopic view and improved intubation condition than without a pillow and a 7-cm pillow in the study population.

Comparative Evaluation of C-MAC Videolaryngoscope with Macintosh Direct Laryngoscope in Patients with Normal Airway Predictors

Background

Video laryngoscopes (VL) assist in securing the airway faster and more accurately in difficult airways. However, data regarding its usefulness in patients with normal airways are sparse.

Aim

We designed this study to compare the ease and success of endotracheal intubation between C-MAC and Macintosh direct laryngoscope (DL) in adult patients with no anticipated airway difficulty.

Settings and Design

The design involves prospective randomized case - control study.

Subjects and Methods

One hundred and twenty adult patients with predicted normal airway were randomized into two groups and were intubated using VL (C-MAC VL) and DL (Macintosh DL), respectively. The Cormack-Lehane (CL) grade, time taken for intubation, attempts taken (number), and need for laryngeal maneuvers or stylets were recorded and analyzed for statistical significance.

Results

Thirty-eight patients in the DL group and 48 patients in the VL group had CL I view, 20 patients in the DL group and 16 patients in the VL group had CL II, and two patients in the DL group had CL III view. None of the patients in Group VL had CL III view. In seven out of 60 cases in the DL group, difficulty was experienced during insertion of the laryngoscope blade as compared to two cases out of 60 in the VL group. The mean time taken for intubation was lesser in Group DL (28.48 s) as compared to 39.3 s in Group VL. Nine patients in Group DL and 16 patients in Group VL required external laryngeal manipulation. Stylets were used, in seven patients in group DL and in 11 patients in group VL.

Conclusions

In patients with a predicted normal airway, C-MAC provides a better glottic view compared to Macintosh DL. Time taken for intubation using the C-MAC video laryngoscope was more. However, success rates on the first attempt at endotracheal intubation and the number of intubation attempts with either laryngoscope were similar.

Assessment of pre-anesthesia machine check and airway equipment preparedness: A cross-sectional study

Background

Anesthesia Equipment malfunction is one of the most common factors contributing to intraoperative surgical patient morbidity and mortality. It is impossible to give anesthesia without proper anesthesia machine checks and airway equipment preparation. Therefore, all anesthesia professionals should make sure that the anesthetic machine and equipment are working correctly.

Method

An institutional-based prospective observational study was conducted at the University Comprehensive Specialized Hospital, Operation rooms, from April 10, 2020 to May 10, 2020. About 90 anesthetists were working regularly in the operation theater both emergency and elective patients. Those include; 26 Msc holders, 17 MSc students, 7 BSc anesthetists, and 40 graduating BSc students. These descriptive data were presented with frequency, percentage, and table.

Result

The overall compliance rate was 87%. Whereas; 12.46% of clinicians have not met the standard. Out of standards that were not performed, 25.81% were not available from the setup.

Conclusion

The result shows that there was poor compliance with anesthesia machine check and equipment preparation before anesthesia in the operation theater according.

•

It is impossible to give anesthesia without proper anesthesia machine checks and airway equipment preparation.

•

Anesthesia Equipment malfunction is one of the most common factors contributing to intraoperative complications.

•

The overall compliance rate was (87%).

•

There was poor compliance of anesthesia machine check and airway equipment preparation.

The physiologically difficult airway: an emerging concept

PURPOSE OF REVIEW

The physiologically difficult airway is one in which physiologic alterations in the patient increase the risk for cardiorespiratory and other complications during tracheal intubation and transition to positive pressure ventilation. This review will summarize the recent literature around the emerging concept of the physiologically difficult airway, describe its relevance and various patient types in which this entity is observed.

RECENT FINDINGS

Physiologic derangements during airway management occur due acute illness, pre-existing disease, effects of anesthetic agents, and positive pressure ventilation. These derangements are especially recognized in critically ill patients, but can also occur in otherwise healthy patients including obese, pregnant and pediatric patients who have certain physiological alterations. Critically ill patients may have a physiologically difficult airway due to the presence of acute respiratory failure, hypoxemia, hypotension, severe metabolic acidosis, right ventricular failure, intracranial hypertension, and risk of aspiration of gastric contents during tracheal intubation.

SUMMARY

Understanding the physiological alterations and the risks involved in patients with a physiologically difficult airway is necessary to optimize the physiology and adopt strategies to avoid complications during tracheal intubation. Further research will help us better understand the optimal strategies to improve outcomes in these patients.

Evaluation of the use of the channeled King Vision video laryngoscope in improving glottic visualisation in patients with limited glottic view with the Macintosh laryngoscope: A prospective observational study

Background and Aims:

The role of King Vision videolaryngoscope (KVL) is well known in the anticipated difficult airway. However, its performance in patients with unanticipated restricted view of the glottis has never been investigated. The aim of this study was to evaluate the performance of KVL in patients with limited glottic view (POGO score <50%).

Methods:

Eighty-five patients fulfilling the inclusion criteria were included in this study. Laryngoscopy was performed in each patient with Macintosh blade followed by the channeled KVL. The laryngeal view obtained with each device was recorded using POGO score and Cormack--Lehane (CL) grade. After that, endotracheal intubation was attempted with the KVL. The haemodynamic parameters, the time taken for endotracheal tube placement and intubation, failure to intubate, modified intubation difficulty score and airway complications were also recorded.

Results:

There was a statistically significant improvement in the POGO scores with the use of KVL: 20 (0,40) vs 90 (40,100) (P < 0.001). The frequency of CL grade I and II increased from 63% with conventional laryngoscopy to 100% with the KVL. Although the time taken to obtain the best glottic view was significantly longer with the KVL as compared to the Macintosh blade (P < 0.001), the first attempt success rate was 97.65%.

Conclusion:

Channeled KVL when used by experienced operators provides superior laryngeal view as compared to Macintosh laryngoscope in patients with restricted glottic view (POGO score <50%) without any major airway complications.

Comparison between C-MAC and King Vision video laryngoscope (channelled blade) for tracheal intubation in aerosol-prevention intubation box for COVID-19 patients: A manikin-based study

Background and Aims

The risk of contracting infection while intubating a coronavirus disease 2019 (COVID-19)-positive patient can be reduced by the use of personal protective equipment (PPE), video laryngoscope (VL) and aerosol-preventing intubation box. We compared two VLs (C-MAC and King Vision laryngoscope [KVL]) for ease of intubation and time taken to intubate the manikin using an intubation box.

Methods

This randomised study involved healthcare workers having experience in using both C-MAC and KVL. After explaining the study and five practice sessions, a total of 63 volunteers were included; 61 participants gave consent and were enroled. The participants were allowed to intubate initially with one VL as per random sequence. Each participant performed three tracheal intubations with each device (C-MAC VL and KVL) on a manikin using an aerosol-prevention box over the head end at the time of intubation.

Results

Time taken, percentage of glottic opening (POGO) score and the number of attempts taken for successful intubation with C-MAC and KVL were comparable in any of the three attempts (P > 0.05). The participants reported more difficulty in using KVL compared to C-MAC, and insertion of laryngoscope blade into the mouth of manikin for intubation was easy in group C-MAC compared to KVL in all three intubations (P < 0.01).

Conclusion

C-MAC and KVL take comparable time for successful intubation under COVID-19 simulation conditions. But C-MAC is more user-friendly.

Effect of high fresh gas flow and pattern of breathing on rapid preoxygenation

Background and Aims:

Preoxygenation is supplementation of 100% oxygen prior to induction of general anaesthesia to increase the body’s oxygen stores. Efficacy of preoxygenation can be increased by optimising fresh gas flow (FGF) rate and pattern of breathing.

Methods:

Based on pattern of breathing—Tidal Volume Breathing (TVB) or Deep Breathing (DB) and FGF-10 L/min or 15 L/min—100 subjects of the American Society of Anesthesiologists physical status I/II posted for elective surgery were recruited and randomised into four groups: T10 - TVB with 10 L/min; D10 - DB with 10 L/min; T15 - TVB with 15 L/min; and D15 - DB with 15 L/min. A tight-fitting anaesthesia mask along with continuous positive airway pressure of 5 cm of H₂O with 20° head-up was used for preoxygenation. The total time taken and the total number of breaths required to achieve end tidal oxygen concentration (EtO₂) of 90% were noted. Exhaled tidal volume (Vte), end tidal carbon dioxide, fraction of inspired oxygen, and EtO₂ were recorded at each breath. Analysis of variance (ANOVA) was used for inferential statistics and Tukey’s honestly significant difference (HSD) test was used to calculate mean difference in total time and number of breaths amongst the groups.

Results:

Total time taken was significantly low (P < 0.001) in DB compared to TVB (D10: 70.2 ± 19.91, D15: 68.4 ± 20.27 vs T10: 112.28 ± 47.96, T15: 113.6 ± 48.57 seconds). Number of breaths was significantly high (P < 0.001) in TVB with 22.84 ± 8.73, 23.76 ± 11.64, 10.56 ± 3.69, and 8.32 ± 1.8 in T10, T15, D10 and D15, respectively. Vte was significantly low in TVB (P < 0.001).

Conclusion:

Rapid preoxygenation can be achieved by DB at high FGF of a minimum of 10 L/min.

Tracheal intubation practices and adverse events in trauma victims on arrival to trauma triage: A single centre prospective observational study

Background and Aims:

Trauma is one of the leading causes of global disease burden. Data on airway management in trauma patients from developing countries, particularly India is sparse. Hence, we planned a prospective observational study to assess the airway management practice patterns and associated complications.

Methods:

The study was conducted in trauma triage of a tertiary care hospital. Data was collected on all tracheal intubations occurring in trauma victims requiring definitive airway control, a detailed proforma including patient details, mode of injury, drugs used, intubation procedure, and complications were filled out for each patient.

Results:

We observed that the airway in trauma patients was primarily managed by non-anaesthesia speciality residents (426 patients); anaesthesia residents were primarily called for deferred or difficult intubations. The first attempt success rate of intubation by anaesthesia residents was significantly higher than speciality residents (P = 0.0001; 95% CI 9.02-24.66). Non-anaesthesia residents used midazolam in varying doses (3-12 mg) for intubation, whereas, rapid sequence intubation was the most common technique used by anaesthesia residents. Airway injuries were the most frequent complication observed in 32.8% of patients intubated by specialty residents compared to 5.9% of patients intubated by anaesthesia residents.

Conclusion:

The trauma triage is a high-volume area for frequent tracheal intubations which are manned by non-anaesthesia speciality teams. A number of factors related to the patient, staff, availability of airway equipment and unfavourable surroundings impact airway management and may explain the high incidence of airway complications, such as airway injuries in these trauma victims.

Biomarkers for oxidative stress and organ injury during Transnasal Humidified Rapid-Insufflation Ventilatory Exchange compared to mechanical ventilation in adults undergoing microlaryngoscopy: A randomised controlled study

BACKGROUND

Apnoeic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) during general anaesthesia prolongs the safe apnoeic period. However, there is a gap of knowledge how THRIVE-induced hyperoxia and hypercapnia impact vital organs. The primary aim of this randomised controlled trial was to characterise oxidative stress and, secondary, vital organ function biomarkers during THRIVE compared to mechanical ventilation (MV).

METHODS

Thirty adult patients, American Society of Anesthesiologists (ASA) 1-2, undergoing short laryngeal surgery under general anaesthesia were randomised to THRIVE, F_I O₂ 1.0, 70 L min^-1 during apnoea or MV. Blood biomarkers for oxidative stress, malondialdehyde and TAC and vital organ function were collected (A) preoperatively, (B) at procedure completion and (C) at PACU discharge.

RESULTS

Mean apnoea time was 17.9 (4.8) min and intubation to end-of-surgery time was 28.1 (12.8) min in the THRIVE and MV group, respectively. Malondialdehyde increased from 11.2 (3.1) to 12.7 (3.1) µM (P = .02) and from 9.5 (2.2) to 11.6 (2.6) µM (P = .003) (A to C) in the THRIVE and MV group, respectively. S100B increased from 0.05 (0.02) to 0.06 (0.02) µg L^-1 (P = .005) (A to C) in the THRIVE group. No increase in TAC, CRP, leukocyte count, troponin-T, NTproBNP, creatinine, eGFRcrea or NSE was demonstrated during THRIVE.

CONCLUSION

While THRIVE and MV was associated with increased oxidative stress, we found no change in cardiac, inflammation or kidney biomarkers during THRIVE. Further evaluation of stress and inflammatory response and cerebral and cardiac function during THRIVE is needed.

Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery

Haematoma after thyroid surgery can lead to airway obstruction and death. We therefore developed guidelines to improve the safety of peri‐operative care of patients undergoing thyroid surgery. We conducted a systematic review to inform recommendations, with expert consensus used in the absence of high‐quality evidence, and a Delphi study was used to ratify recommendations. We highlight the importance of multidisciplinary team management and make recommendations in key areas including: monitoring; recognition; post‐thyroid surgery emergency box; management of suspected haematoma following thyroid surgery; cognitive aids; post‐haematoma evacuation care; day‐case thyroid surgery; training; consent and pre‐operative communication; postoperative communication; and institutional policies. The guidelines support a multidisciplinary approach to the management of suspected haematoma following thyroid surgery through oxygenation and evaluation; haematoma evacuation; and tracheal intubation. They have been produced with materials to support implementation. While these guidelines are specific to thyroid surgery, the principles may apply to other forms of neck surgery. These guidelines and recommendations provided are the first in this area and it is hoped they will support multidisciplinary team working, improving care and outcomes for patients having thyroid surgery.

All India Difficult Airway Association guidelines in practice-A survey

Background and Aims:

The All India Difficult Airway Association (AIDAA) has come up with difficult airway (DA) guidelines to suit the Indian context. We conducted an online survey with the primary aim to find out the awareness about AIDAA guidelines and adherence to them in clinical practice. The secondary aims were to explore variations in practice with respect to experience or the type of the institute.

Methods:

An online web-based questionnaire survey was sent to all practising anaesthesiologists who attended an airway workshop. The validated and piloted questionnaire consisted of 23 questions and the practice patterns were asked to be graded on a Likert scale of four.

Results:

The response rate was 66%. Awareness about AIDAA guidelines was high (81%) but adherence varied. Apnoeic nasal oxygen insufflation was always practised by only 19.59%.Only 79.7%of the respondents always used capnography to confirm intubation. While 23.64% did not ensure a safe peripheral oxygen saturation (SpO₂) level of 95% to do repeat laryngoscopy, 64% chose supraglottic devices after three failed laryngoscopic attempts. A departmental debriefing of a DA event and issuing an alert card to the patient was practised by 58.78% and 52.7%, respectively. Although 50% had training to do cricothyrotomy, only 41% had ready access to a cricothyrotomy set in their workplace. The use of capnography was more prevalent in private institutions. The survey revealed a safety gap with some recommendations like debriefing of a DA event, alert card, nasal oxygenation etc.

Conclusion

Awareness about AIDAA guidelines is high among our practising anaesthesiologists, but adherence to the recommendations varied and there is room for improvement, especially for debriefing a DA event, issuing an alert card, the use of capnography and nasal oxygenation.

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies

Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

Current Recommendations for Airway Management Techniques in COVID-19 Patients without Respiratory Failure Undergoing General Anaesthesia: A Nonsystematic Literature Review

Summary Background

Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged, many articles have been published on airway management for coronavirus disease 2019 (COVID-19) patients. However, there is a lack of clear and concise conceptual framework for working with infected patients without respiratory failure undergoing general anaesthesia compared to noninfected patients. The aim of this article is to review current literature data on new challenges for anaesthesia providers, compare standard airway management techniques protocols with new data, and discuss optimisation potential.

Materials and methods

Literature search was performed in Google Scholar and PubMed databases using these keywords and their combinations: anaesthesia, preoxygenation, airway management, difficult airway, SARS-CoV-2, COVID-19. The following nonsystematic review is based on a comprehensive literature search of available data, wherein 41 articles were chosen for detailed analysis. Summarised and analysed data are presented in the article.

Results

SARS-CoV-2 has unique implications for airway management techniques in patients without respiratory failure undergoing general anesthesia. Main differences with the standard practice include: institutional preparedness, team composition principles, necessary skills, equipment, drugs, intubation and extubation strategies. Failed or difficult intubation is managed with predominance of emergency front of neck access (FONA) due to increased aerosol generation.

Conclusions

Airway management techniques in COVID-19 patients without respiratory failure are more challenging than in noninfected patients undergoing general anaesthesia. Safe, accurate and swift actions avoid unnecessary time delay ensuring the best care for patients, and reduce risk of contamination for staff. Appropriate airway strategy, communication, minimisation of time for aerosol generating procedures and ramped-up position aid to achieve these goals. During the pandemic, updated available literature data may change clinical practice as new evidence emerges.

A new approach to airway assessment-"Line of Sight" and more. Recommendations of the Task Force of Airway Management Foundation (AMF)

Assessment of airway is recommended by every airway guideline to ensure safe airway management. Numerous unifactorial and multifactorial tests have been used for airway assessment over the years. However, there is none that can identify all the difficult airways. The reasons for the inadequacy of these methods of airway assessment might be their dependence on difficult to remember and apply mnemonics and scores, inability to identify all the variations from the “normal”, and their lack of stress on evaluating the non-patient factors. Airway Management Foundation (AMF) experts and members have been using a different approach, the AMF Approach, to overcome these problems inherent to most available models of airway assessment. This approach suggests a three-step model of airway assessment. The airway manager first makes the assessment of the patient through focused history, focused general examination, and focused airway assessment using the AMF “line of sight” method. The AMF “line of sight” method is a non-mnemonic, non-score-based method of airway assessment wherein the airway manager examines the airway along the line of sight as it moves over the airway and notes down all the variations from the normal. Assessment of non-patient factors follows next and finally there is assimilation of all the information to help identify the available, difficult, and impossible areas of the airway management. The AMF approach is not merely intubation centric but also focuses on all other methods of securing airway and maintaining oxygenation. Airway assessment in the presence of contagion like COVID-19 is also discussed.

Role of videolaryngoscope in the management of difficult airway in adults: A survey

Background and Aims

A number of videolaryngoscopes (VLs) have flooded the Indian market. As per All India Difficult Airway Association 2016 guidelines, all anaesthesiologists should have access to a VL and must be trained to use it. We conducted an electronic survey to know the perception of Indian anaesthesiologists, who are members of the Indian Society of Anaesthesiologists (Karnataka State Chapter) towards the role of VL in the management of difficult airway (DA) and factors governing their use.

Methods

An electronic survey was sent to 2580 ISA members to know the availability, use and attitude towards VLs in the management of DA in adults. The survey was open for a period of 2 months and responses analysed.

Results

The response rate was 25.8% (666 out of 2580). A total of 280 (42%) respondents had access to VL. The respondents rated VL as 4^th preference for anticipated DA and 1^st for unanticipated DA (if available). The most widely used VLs were C-MAC, Airtraq, and Kingvision. As per 133 respondents (20%), access to VL in institutes was restricted only to consultants and the main reason being cost. The clarity of the image was the most important factor the respondents expected in a VL.

Conclusions

Less than half of respondents had access to VLs. Most of them having access to it worked in corporate hospitals. The high cost of the device and steep learning curve are still barriers against its widespread use. We conclude that low-cost devices, with increased clarity may make usage of VLs frequent and available to residents.