Acute Emergent Airway Issues in Sports

Emergent airway issues are rare in competitive sports. However, when airway compromise occurs, the sideline physician will be relied upon to manage the situation and the airway. . The sideline physician is tasked with not only the evaluation of the airway, but also management until the athlete can get to a higher level of care. Familiarity with the assessment of the airway and the various techniques for the management of airway compromise on the sideline are of the utmost importance in the unlikely event that an airway emergency should occur.

Postoperative airway morbidities in pediatric patients

Pediatric airway management is a huge challenge for anaesthetists, and airway-related complications should be actively addressed and focused on.

Flexible Fiberoptic Bronchoscopy in Non-ventilated Children in Pediatric Intensive Care Unit: Utility, Interventions and Safety

Objective

To study the utility of flexible fiberoptic bronchoscopy (FFB), and its effects on oxygenation and hemodynamics in children while on respiratory assist devices.

Materials and methods

The data of non-ventilated patients who underwent FFB during their stay in the PICU from January 2012 to December 2019 was retrieved from medical, nurses, and bronchoscopy records. The study parameters, demography, diagnosis, indication, and findings of FFB and interventions done after FFB, were noted, and also the oxygenation and hemodynamic parameters before, during and 3 hours after FFB.

Results

Data from the first FFB of 155 patients were analyzed retrospectively. About 54/155 (34.8%) children underwent FFB while on HFNC. About 75 (48.4%) patients were on conventional oxygen therapy (COT) before FFB. There were 51 (33%) patients who had received mechanical ventilation and were extubated successfully. The 98 (63.2%) children had primary respiratory diseases. Stridor and lung atelectasis were indications for FFB in 75 (48.4%) cases and the commonest bronchoscopic finding was retained secretions in the airways. Based on the FFB findings, 50 medical and 22 surgical interventions were done. The commonest medical and surgical interventions were changes in antibiotics (25/50) and tracheostomy (16/22) respectively. There was a significant fall in SpO₂ and a rise in hemodynamic parameters during FFB. All these changes were reversed after the procedure with no consequences.

Conclusion

Flexible fiberoptic bronchoscopy is a useful tool to diagnose and guide interventions in non-ventilated pediatric intensive care unit (PICU). There were significant but transient changes in oxygenation and hemodynamics with no serious consequences.

How to cite this article

Sachdev A, Gupta N, Khatri A, Jha G, Gupta D, Gupta S, et al. Flexible Fiberoptic Bronchoscopy in Non-ventilated Children in Pediatric Intensive Care Unit: Utility, Interventions and Safety. Indian J Crit Care Med 2023;27(5):358-365.

Predictors of difficult intubation when using a videolaryngoscope with an intermediate-angled blade during the first attempt: a prospective observational study

The curvature of a videolaryngoscope blade has been diversified from the standard macintosh-type to the hyperacute-angle-type, resulting in different performances. We aimed to determine the intubation success rate and identify predictors of difficult intubation when using an intermediate-angled videolaryngoscope in the first attempt of intubation under routine anaesthesia settings. We enrolled 808 patients between 19 and 79 years of age, scheduled for elective surgeries under general anaesthesia with orotracheal intubation from July 2017 to November 2018; patients who were candidates for awake intubation were excluded. We obtained patient demographic data and performed airway evaluation before induction of anaesthesia for elective surgeries. We used the UEScope for tracheal intubation with a hockey stick-shaped malleable stylet. The intubation time was defined as the total duration from the entry of the blade into the oropharynx to the detection of first end-tidal carbon dioxide capnogram; this duration was recorded along with the number of intubation attempts. Difficult intubation was defined as either > 60 s duration for tracheal intubation, or > 1 intubation attempt. The use of the UEScope demonstrated a 99.4% success rate for intubation; however, increased difficulties were observed in patients who were male, obese, had a short thyromental distance, limited mouth opening, and high upper-lip-bite test class. Despite the high intubation success rate using an intermediate-angled videolaryngoscope, we recommend preparing backup plans, considering the increased difficulty in patients with certain preoperative features.Clinical trial number and registry URL: Clinical Trials.gov Identifier: NCT03215823 (Date of registration: 12 July).

Assessment of Ratio of Height to Rhinion-Mentum Distance as a Predictive Tool for Difficult Tracheal Intubation

BACKGROUND

Difficult Intubation (DI) is a constant concern for anesthesiologists and being able to predict it will improve patient safety. Different tests have been presented in anesthesiology practice to increase the accuracy of the DI prediction. Since there is no single sensitive and specific test, most of the practitioners use a combination of them. Here we report a new and novel index of ratio of height to rhinion-mentum distance (RHRMD) to improve the prediction.

MATERIALS AND METHODS

Four hundred adult patients' candidate for elective surgery were enrolled into the study. Initially, patients' data such as weight, height and rhinion-mentum distance (RMD) were recorded by the first anesthesiologist. After anesthesia induction, the second anesthesiologist performed laryngoscopy and recorded the Cormack-Lehane (CL) score. CL score III or higher was considered as DI. Finally, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for RHRMD was calculated.

RESULTS

DI was reported in 7.75% of patients. RHRMD is related with CL grade: as the former increased, the latter decreased. RHRMD with cut-off point 25.4 has 90.6% sensitivity, 29.9% specificity, 10.1% PPV and 97.3% NPV in predicting DI.

CONCLUSION

RHRMD with 90.6% sensitivity and 97.3% NPV could be a valuable tool for prediction of DI.

Risk factors of complications during noninvasive mechanical ventilation -assisted flexible bronchoscopy

PURPOSE

Flexible bronchoscopy (FB) causes airway narrowing and may cause respiratory failure (RF). Noninvasive mechanical ventilation (NIV) is used to treat RF. Until recently, little was known about noninvasive mechanical ventilation assisted flexible bronchoscopy (NIV-FB) risk and complications.

MATERIALS AND METHODS

A retrospective analysis of NIV-FB performed in 20 consecutive months (July 1, 2018-February 29, 2020) was performed. Indications for: FB and NIV, as well as impact of comorbidities, blood gas results, pulmonary function test results and sedation depth, were analyzed to reveal NIV-FB risk. Out of a total of 713 FBs, NIV-FB was performed in 50 patients with multiple comorbidities, acute or chronic RF, substantial tracheal narrowing, or after previously unsuccessful FB attempt.

RESULTS

In three cases, reversible complications were observed. Additionally, due to the severity of underlining disease, two patients were transferred to the ICU where they passed away after >48h. In a single variable analysis, PaO₂ 69 ​± ​18.5 and 49 ​± ​9.0 [mmHg] (p ​< ​0.05) and white blood count (WBC) 10.0 ​± ​4.81 and 14.4 ​± ​3.10 (p ​< ​0.05) were found predictive for complications. Left heart disease indicated unfavorable NIV-FB outcome (p ​= ​0.046).

CONCLUSIONS

NIV-FB is safe in severely ill patients, however procedure-related risk should be further defined and verified in prospective studies.

Multivariate Analysis of the Failure Risk of First Tracheal Intubation Attempt in a Population of Patients Scheduled for Bariatric Surgery

BACKGROUND

Airway management during the administration of anesthesia to patients undergoing bariatric surgery is challenging. The goal is to avoid multiple intubation attempts because the risk of complications increases with the number of attempts. The objective of this study was to determine the failed first intubation attempt rate, as well as variables associated with this failure, in patients undergoing bariatric surgery.

METHODS

We enrolled patients scheduled for bariatric surgery in this prospective, observational, single-center study. We determined predictive criteria for difficult intubation at the preoperative anesthesia consultation. All patients were evaluated for obstructive sleep apnea by polygraphy. The primary study endpoint was a failed first intubation attempt.

RESULTS

We enrolled 519 patients between December 2012 and January 2015. The cohort consisted of 425 women (82%), with a median (interquartile range [IQR]) age of 39 (30-50) years and a body mass index of 42 (39-46) kg/m². The first intubation attempt failed in 60 patients, with an incidence rate of 11.5% (95% confidence interval [CI], 8.8-14.2%). We included nine variables in the final multivariate model. Two variables were associated with failed first intubation attempt: male sex (odds ratio [OR] [95% CI], 6.9% [2.5-18.7%]) and Mallampati score 3-4 (OR [95% CI], 2.2% [1.0-4.7%]).

CONCLUSIONS

In this morbidly obese population, the first intubation attempt failed in 11.5% of patients, and the risk factors for failure were male sex and a high Mallampati score.

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.

[Effectiveness of simplified predictive intubation difficulty score and thyromental height in head and neck surgeries: an observational study]

BACKGROUND AND OBJECTIVES

In this study, we aimed to investigate the predictive value of different airway assessment tools, including parts of the Simplified Predictive Intubation Difficulty Score (SPIDS), the SPIDS itself and the Thyromental Height Test (TMHT), in intubations defined as difficult by the Intubation Difficulty Score (IDS) in a group of patients who have head and neck pathologies.

METHODS

One hundred fifty-three patients who underwent head and neck surgeries were included in the study. The Modified Mallampati Test (MMT) result, Thyromental Distance (TMD), Ratio of the Height/Thyromental Distance (RHTMD), TMHT, maximum range of head and neck motion, and mouth opening were measured. The SPIDSs were calculated, and the IDSs were determined.

RESULTS

A total of 25.4% of the patients had difficult intubations. SPIDS scores > 10 had 86.27% sensitivity, 71.57% specificity and 91.2% Negative Predictive Value (NPV). The results of the Receiver Operating Curve (ROC) analysis for the airway screening tests and SPIDS revealed that the SPIDS had the highest area under the curve; however, it was statistically similar to other tests, except for the MMT.

CONCLUSIONS

The current study demonstrates the practical use of the SPIDS in predicting intubation difficulty in patients with head and neck pathologies. The performance of the SPIDS in predicting airway difficulty was found to be as efficient as those of the other tests evaluated in this study. The SPIDS may be considered a comprehensive, detailed tool for predicting airway difficulty.

[Evaluation of bedside tests and proposal of a model for predicting difficult laryngoscopy: an observational prospective study]

BACKGROUND AND OBJECTIVES

The prediction of difficult laryngoscopy is based on tests that assess anatomic characteristics of face and neck. We aimed to identify the most accurate tests and propose a multivariate predictive model.

METHODS

This prospective observational study included 1134 patients. Thyromental Distance (TMD), Sternomental Distance (STMD), Ratio of Height-to-Thyromental Distance (R-H/TMD), Neck Circumference (NC), Ratio of Neck Circumference-to-Thyromental Distance (R-NC/TMD), Hyomental Distance with head in Neutral Position (HMD-NP) and at Maximal Extension (HMD-HE), Ratio of Hyomental Distance at Maximal head extension-to-hyomental distance in neutral position (R-HMD), Mallampati Class (MLC), Upper Lip Bite Test (ULBT), Mouth Opening (MO) and Head Extension (HE) were assessed preoperatively. A Cormack-Lehane Grade ≥ 3 was defined as Difficult Laryngoscopy. Sensitivity, specificity, positive and negative predictive values were assessed for all tests. Multivariate analysis with logistic regression was used to create the predictive models.

RESULTS

A model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed high prognostic accuracy; x²(5)=109.12, p <0.001, AUC=0.86, p <0.001). Its sensitivity, specificity and negative predictive value were 82.3%, 74.8% and 97.4%, respectively. A second model including two measurements not requiring patient's cooperation (R-NC/TMD and HMD-HE) exhibited good prognostic performance; x²(2)=63.5, p <0.001, AUC=0.77, p <0.001. Among single tests, HE had the highest sensitivity (78.5%) and negative predictive value (96%).

CONCLUSIONS

A five-variable model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed satisfyingly high predictive value for difficult laryngoscopy. A model including R-NC/TMD and HMD-HE could be useful in incapable patients. The most accurate single predictor was HE.

Preoperative assessment organization in the time of the outbreak COVID-19

•

Maintaining the health of clinical workforce during COVID-19 pandemic is a top priority.

•

Extraordinary measures could greatly reduce the risk of cross-contamination for both staff and non-infected patients.

•

Airway assessment is a critical time for the consultant anesthetist.

•

Projecting the airway examination via a mirror can be a useful idea to minimizing viral contamination.

Anesthesia for meningioma surgery

Patients receiving treatment for a meningioma require anesthesia when undergoing open craniotomy and, in some cases, during preoperative tumor embolization and radiosurgery. Adequate anesthesia management is integral to patients' perioperative care, which consists of the three phases of preoperative assessment and optimization, intraoperative care, and postoperative recovery. The preoperative anesthesia evaluation focusses on the cardiorespiratory and neurologic systems, as well as the airway, but also extends to ensure the optimal treatment of significant comorbidities before surgical intervention. The goals of intraoperative care are maintenance of brain physiology, facilitating surgery, and correcting any adverse effects of surgery and underlying pathology to preserve general patient homeostasis. This requires adequate intraoperative patient monitoring, cardiorespiratory support, management of infusion therapy, and application of knowledge about the effects of anesthetic agents on brain physiology. The anesthesiologist's responsibilities for patient care extend well into the postoperative recovery period, with a focus on pain control, prevention, and treatment of postoperative nausea and vomiting (PONV), and, in some patients, intensive care therapy.

The usefulness of point of care ultrasound (POCUS) in preanaesthetic airway assessment

Background and Aims:

Point of care ultrasound has the potential to become reliable airway assessment tool by accurate prediction of difficult laryngoscopy. We aimed to determine the feasibility of ultrasound in preoperative airway assessment.

Methods:

This prospective, observational study was conducted on 200 patients requiring general anaesthesia and tracheal intubation. The thickness of anterior soft tissue neck at the level of hyoid bone (DSHB), epiglottis (DSEM), and Pre-E/E-VC[depth of the pre-epiglottic space (Pre-E)/distance from the epiglottis to the midpoint of the distance between the vocal cords (E-VC)] were measured sonographically. The hyomental distance ratio (HMDR) was measured utilising distances with head in neutral and extended position. The primary outcome was the efficacy of the parameters in predicting difficult laryngoscopy[Cormack Lehane 3,4]. The secondary outcome was to correlate the parameters to CL grading.

Results:

Utilising receiver operating curves, cutoff value of HMDR for predicting difficult laryngoscopy was ≤1.0870 with sensitivity of 65%, specificity of 77%. The cutoff value, sensitivity andspecificity for Pre-E/E-VC were ≥1.785, 82.8% and 83.8%., respectively. The cutoff value of DSHB was ≥0.99 with sensitivity of 48% and specificity of 82%. The cutoff, sensitivity and specificity for DSEM were ≥1.615, 89.7%, and 64.8%, respectively. There was moderate positive correlations of DSHB, DSEM, and Pre-E/E-VC (r = 0.551 and 0.701, 0.787: P = 0.00), whereas moderate negative correlation observed with HMDR (r = -.0671: P = 0.00).

Conclusion:

The strong positive correlation of Pre-E/E-VC, DSEM, and moderate negative correlation of HMDR makes these ultrasound parameters reliable predictors for difficult laryngoscopy.

Validation of age and height based formulae to predict paediatric airway distances - a prospective observational study

Background:

Preoperative airway evaluation in children is an important part of routine preanesthetic evaluation before surgery. External airway measurements, viz., thyromental, mentohyoid, and sternomental distances, while being growth dependent, could identify pediatric patients with potentially difficult airways.

Objectives:

This study was conducted to validate the age- and height-based formulae, derived from a previous study conducted in our institute, to predict thyromental distance, sternomental distance, and mentohyoid distance in relation with the height and age of pediatric patients.

Design:

Prospective cross-sectional single arm observational study.

Setting:

Tertiary level university teaching hospital from July 2015 to December 2016.

Patients:

Children (202) in the age group of 3-15 years with no obvious external airway anomaly scheduled for elective surgery under general anesthesia.

Outcomes Measured:

The thyromental, mentohyoid, and sternomental distances were measured preoperatively. The same parameters were then calculated based on age- and height-related formulae derived in the earlier study.

Results:

Bland-Altman analysis of the sample patients showed a mean difference (bias) between measured and calculated values ranging from 0.14 to –0.60 (3 - 13%). Overall agreement in terms of bias were found to be more with height-based equation for mentohyoid distance and thyromental distance and age-based equation for sternomental distance.

Conclusion:

Our study validates the formulae derived in the earlier study to predict thyromental, mentohyoid, and sternomental distances in children with no obvious external airway anomalies. Further studies are needed to extend the applicability of these formulae in obese children and those with craniofacial anomalies coming for general anesthesia and surgery.

Noninvasive Ventilation-Facilitated Bronchofiberoscopy in Patients with Respiratory Failure

Respiratory failure is one of the most important risk factors for diagnostic bronchofiberoscopy (BF), whereas therapeutic bronchoscopies are typically performed in intubated patients. Only a few published studies analyzed the outcomes of noninvasive mechanical ventilation (NIV)-facilitated BF. In this case series, we present our experiences with NIV-facilitated diagnostic and therapeutic BF performed in patients with respiratory failure that was associated with acute interstitial pulmonary disease, chronic obstructive pulmonary disease, cystic fibrosis exacerbation, foreign body aspiration, tracheal stenosis, pneumonia, and in a patient with a neuromuscular disease. All of the patients were initially hypoxic and some had PaO₂/FiO₂ < 200, which corresponded to moderate-to-acute respiratory distress syndrome (ARDS). NIV-facilitated BF were performed for the diagnostic or therapeutic purposes. The former consisted of bronchoalveolar lavage and bacterial sampling in a patient with impaired cough reflex, airway assessment in otherwise unexplained respiratory failure and hemoptysis, and the latter of mucous plugs resolution, foreign body removal, and assistance in weaning from mechanical ventilation. All procedures were carried out using NIV in the spontaneous timed (ST) or average volume assured pressure support (AVAPS) mode with oxygen supplementation. There were no procedure-related complications noticed during NIV-facilitated BF. We conclude that NIV is a useful and safe tool that facilitates the performance of BF in severe pulmonary diseases. Prospective studies are required to set the recommendations for the procedure and to define the optimum ventilatory modes to be used.

Airway Management for the Oral Surgery Patient

This article discusses anesthesia assessment concepts related to airway evaluation and airway maintenance for safe and reliable selection of either open system (entrainment of room air) or closed system (no entrainment of room air) airway devices, which can be used during office-based oral surgical procedures, depending on the needs of a patient. Dental facial and oral structures are integral to an anesthetist's preoperative patient evaluation prior to surgery. The preoperative medical history and physical examination as well as the nature of the oral surgical procedure affect the selection of a proper and safe airway device.

Predicting Difficult Intubation in Emergency Department by Intubation Assessment Score

BACKGROUND

The difficult intubation is associated with failure of emergency tracheal intubation. This study aimed to develop and validate a model for predicting difficult intubation in emergency department (ED).

METHODS

A cross-sectional study was conducted in the ED. We collected data from all consecutive adult patients who underwent emergency tracheal intubation. Patients were excluded if they were intubated by low experience intubator. The difficult intubation was defined by grade III or IV of Cormack and Lehane classification. We used multivariable regression model to identify significant predictors of difficult intubation and weighted points proportional to the beta coefficient values. The ability to discriminate was quantified by using the area under receiver operating characteristics curve (AuROC). The bootstrapping method was used to validate the performance.

RESULTS

A total of 1,212 intubations were analyzed. One hundred and fifty-seven intubations were enrolled in difficult intubation group. Five independence predictors were identified, and each was assigned a number of points proportional to its beta coefficient: male gender (one), large tongue (two), limit mouth opening (two), poor neck mobility (two), and presence of obstructed airway (three). Intubation assessment score model was created and applied to all subjects. The AuROC was 0.81 (95% confidence interval (CI): 0.77 - 0.85) for the development dataset, and 0.80 (95% CI: 0.76 - 0.85) for the validation dataset. We defined three risk groups: low risk (zero to one points), intermediate risk (two to three points), and high risk (above three points), and the difficult intubation rate was 4.7%, 22.5%, and 53.6%, respectively.

CONCLUSIONS

Intubation assessment score model was constructed from patients' simple characteristics and performed well in predicting difficult intubation and can discriminate between with and without difficult intubation.

Are physician assistant and patient airway assessments reliable compared to anesthesiologist assessments in detecting difficult airways in general surgical patients?

Background

Airway management remains one of the most important responsibilities of anesthesiologists. Prediction of difficult airway allows time for proper selection of equipment, technique, and personnel experienced in managing patients with difficult airway. Face to face preoperative anesthesia interviews are difficult to conduct as they necessitate patients traveling to the clinics, and, in practice, are usually conducted in the morning of the procedure by the anesthesiologist, when identification of predictors of difficult intubation may lead to schedule delays or case cancelations. We hypothesized that an airway assessment tool could be used by patients or physician assistants to accurately assess their airways.

Methods

We administered an airway assessment tool, which had been constructed in consultation with a psychometrician and revised after non-medical layperson feedback, to 215 patients presenting to the preoperative clinic for evaluation. Separately, patients had the airway exam performed by a physician assistant and an anesthesiologist. Agreement was compared using kappa.

Results

We found good agreement between observers only on "can you put three fingers in your mouth?" (three-way kappa = .733, p < 0.001) and poor agreement on Mallampati classification (three-way kappa = .195, p < 0.001) and "Can you fit three fingers between your chin and your Adam's Apple?" (three-way kappa = .216, p < 0.001). The agreements for the other questions were mostly fair. Agreements between patients and anesthesiologists were similar to those between physician assistants and anesthesiologists.

Conclusions

Neither the patients' self-assessments nor the physician assistants' assessments were adequate to substitute for the anesthesiologists' airway assessments.

Difficult Tracheal Intubation in Obese Gastric Bypass patients

BACKGROUND

Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation.

METHODS

This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients undergoing gastric bypass. Tracheal intubation was done preoperatively together with scoring of Intubation Score (IS), Mallampati (MLP), and Cormack-Lehane classification (CLC) and registration of the quantities of anesthetics and total attempts on cannulation.

RESULTS

The overall proportion of patients with DTI was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass index (BMI) <40, CLC >2, ASA scores >2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra-venous and intra-arterial cannulation was succeeded in first attempt in 85 and 86 % of the patients, respectively, and there were no association between BMI and difficult vascular access.

CONCLUSIONS

We found no association between increasing BMI and DTI.

Enhancing airway assessment of patients with head and neck pathology using virtual endoscopy

Studies have demonstrated that poor assessment and planning contribute to airway complications and that current airway assessment strategies have a poor diagnostic accuracy in predicting difficult intubation in the general population. Patients with head and neck pathology are at higher risk for difficulties during airway management and are more likely to need emergency surgical access. Therefore, thorough assessment of this group of patients is mandatory. The addition of virtual endoscopy (VE) to clinical history and computerised tomography imaging has been shown to improve diagnostic accuracy for supraglottic, glottic and infraglottic lesions and has a positive influence in formulating a more cautious and thorough airway management strategy in this high-risk group of patients. This article reviews whether VE can enhance airway assessment in patients with head and neck pathology and help reduce airway complications.

Preoperative Preparation and Planning of the Oral and Maxillofacial Surgery Patient

Every patient is different and has the potential to respond unfavorably to anesthetic and surgical intervention. Preparation is the key to optimizing patient outcome.

Paediatric haemoptysis and the otorhinolaryngologist: Systematic review

OBJECTIVES

Childhood haemoptysis is an uncommon presentation to the otolaryngologist but has a varied aetiology and can be life-threatening. We performed a systematic review of the literature to assess paediatric otolaryngologists' experience with haemoptysis, the aetiology involved, investigations performed and management provided. Using this, we produce an evidence-based treatment algorithm to guide clinicians.

METHODS

Systematic literature review of the PubMed, EMBASE and Cochrane Collaboration using the search terms 'paediatric', 'child', 'neonate', 'adolescent', 'haemoptysis', 'coughing blood', 'spitting blood' and 'otorhinolaryngology'.

RESULTS

Five articles were retrieved meeting the search criteria including 106 patients (age range 3 weeks to 18 years). The 3 most common aetiologies were bronchitis (n = 9), idiopathic/ no cause found (n = 9) and pneumonia (n = 7). Flexible bronchoscopy was the commonest investigation performed in non-active cases whilst rigid bronchoscopy was performed for active haemoptysis to provide therapeutic interventions. Chest x-ray was performed as a screening investigation rather than CT scan, which was reserved to assess pathology further, in recurrent cases and when x-ray is inconclusive. Management depended on aetiology. There was no difference in aetiology between age ranges.

CONCLUSIONS

Haemoptysis aetiology is varied and non-cancerous but is life-threatening in cases of pulmonary agenesis and vasculature abnormalities. No cause may be found. Clinicians' investigations and management plans should be based on the established care of haemoptysis. There is no difference between otolaryngologists and respiratory physicians' experience.

The diagnostic validity of clinical airway assessments for predicting difficult laryngoscopy using a grey zone approach

Objectives

The diagnostic validity of clinical airway assessment tests for predicting difficult laryngoscopy in patients requiring endotracheal intubation were evaluated using receiver operating characteristic (ROC) curve analysis and a grey zone approach.

Methods

In this prospective observational study, patients were evaluated during a pre-anaesthetic visit. Predictive airway assessment tests (i.e. Modified Mallampati [MMT] classification; upper lip bite test [ULBT]; mouth opening; sternomental distance; thyromental distance [TMD]; neck circumference; neck mobility; height to thyromental distance [HT/TMD]; neck circumference-to-thyromental distance [NC/TMD]) were performed on each patient and LEMON, Naguib, and MACOCHA scores were also calculated. In addition, laryngeal images were acquired and assessed for percentage of glottic opening (POGO) scores. A POGO score of zero was categorized as difficult laryngoscopy.

Results

The incidence of difficult laryngoscopy was 14.4% (35/243). Although seven predictive airway assessments (i.e. MMT classification, ULBT, mouth opening, HT/TMD, NC/TMD, and the LEMON and Naguib models) predicted difficult laryngoscopy by ROC analyses, a grey zone approach showed that the parameters were inconclusive in approximately 70% of patients. From all the tests, the HT/TMD ratio showed the highest sensitivity (80.0%) and ULBT had the highest specificity (95.2%).

Conclusion

Using the grey zone approach, all predictive airway assessment tests showed large inconclusive zones which may explain previous inconsistent results in the prediction of difficult laryngoscopy. Our results suggest that the usefulness of clinical airway evaluation tests for predicting difficult laryngoscopy remains controversial.

Clinical trial registration

ClinicalTrials.gov (NCT01719848)

Airway management in the hospital environment

In the hospital environment, patients can deteriorate rapidly and for many different reasons. Maintaining a patient's breathing is the main priority in any emergency situation, although achieving airway control can be difficult. All health professionals need to be able to undertake airway management safely. The key is a thorough assessment to ensure first of all whether the airway is patent (open and clear) or not. This article will discuss airway management, both acute and chronic, as well as associated nursing care.

Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy

Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures. Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation. Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function. Patients must retain their protective airway reflexes, and respond to and understand verbal communication. The drugs and techniques used must therefore carry a broad margin of safety.

Potential role of ultrasound in anesthesia and intensive care

One of the most exiting recent technological advances in the field of anesthesia to track the region of interest is the introduction of anatomical evaluation by ultrasound imaging. Widespread use of this modality depends on its proven clinical efficacy, cost effectiveness, and practicality as it allows anesthesiologist to evaluate complex and varied anatomy prior to needle insertion. Sound used in medicine is not significantly transmitted by air or bone but through fluids which make up the larger part of soft tissues in the body. Ultrasound has been shown to offer excellent guidance for difficult venous access, epidural space identification in cases of difficult anatomy, delineating nerve plexuses for chronic nerve blocks, for regional anesthesia, and in transesophageal echocardiography for cardiac imaging with blood flows or in an otherwise high-risk patient where interventional procedure is required. It has special application to assess the narrowest diameter of the subglottic upper airway. A systemic literature search was performed in PubMed and the Cochrane library. The search strategy was set up using either single text word or combinations. We also included the studies where in these techniques were compared with conventional methods . Despite the initial excitement of this technique, ultrasound visualization is still indirect and images are subject to individual interpretation. It is gradually becoming routine in daily practice at our institution due to its reliability and safety. Though ultrasound is much safer, exposure in terms of intensity and time should be limited as far as possible, as high-energy ultrasound can cause heating and damage to tissues. In this review, we discuss established and future areas of ultrasound imaging and emphasize the use of B-mode ultrasound to improve the efficacy of interventional techniques. We have also illustrated potential uses with reference to cross-sectional B-mode images which visually represent a slice of tissues and are the easiest images for interpretation by clinicians.

Airway management

In this article, recent literature related to airway management in the ambulatory surgery setting is reviewed. Practical pointers to improve clinical success and avoid complications of newer airway management techniques are provided.

Cephalometric Evaluation of Airway Changes Following Mandibular Distraction in Patients with Nocturnal Desaturations During Sleep Secondary to TMJ Ankylosis

OBJECTIVES

The objective of this study was to cephalometrically evaluate the changes in the oro-pharyngeal airway and its correlation to the clinical outcome following mandibular distraction in patients with sleep disordered breathing secondary to tempero-mandibular joint (TMJ) ankylosis.

METHODS

Five patients diagnosed as having nocturnal desaturations during sleep secondary to TMJ ankylosis were evaluated in this study. They were evaluated pre and post mandibular distraction using cephalometry, to determine changes in their oro-pharyngeal airway space and, upper and lower airway dimensions. An attempt was made to correlate these changes to the clinical outcome of the procedure by over-night pulse-oximetry.

RESULTS

The patients showed a mean increase of 31.33 % in the oro-pharyngeal airway space with a 3.8 % increase in the oxygen saturation levels. The change in the airway space dimensions and area was directly proportional to the oxygen saturation observed in the patients.

CONCLUSION

The patients in this series did not show a very high apnoea hypopnoea index but had a compromised airway which resulted in sub-optimal sleep patterns. Mandibular distraction in these patients not only improved their esthetics but also proved to aid their functional rehabilitation by significantly increasing their oro-pharyngeal space and reducing their sleep disturbances.

Diagnostic value of the upper lip bite test in predicting difficulty in intubation with head and neck landmarks obtained from lateral neck X-ray

Background:

Unanticipated difficult tracheal intubation remains a primary concern of anaesthesiologists and upper lip bite test (ULBT) is one of the assessments used in predicting difficult intubation. In this study, we aimed to check the utility of lateral neck X-ray measurements in improving the diagnostic value of the ULBT.

Methods:

In a prospective study conducted from January 2007 until December 2010, we recorded personal and demographic data of 4500 patients who entered the study and subjected them to standard lateral neck radiography. Before the induction of anaesthesia, clinical examination and ULBT results were recorded and during induction of anaesthesia laryngoscopic grading was evaluated and recorded in questionnaires. All the compiled data were analysed by SPSS 14.0 (SPSS Inc., Chicago, IL, USA) software. Diagnostic value for each test was calculated and compared.

Results:

Negative predictive values (NPVs) were high in all tests. ULBT had the highest specificity and NPV compared with the other tests. The positive predictive value for all the tests had been low, but marginally high in the ULBT.

Conclusion:

Although all the tests used had relatively acceptable predictive values, combination of tests appeared to be more predictive. Highest sensitivities were observed with ULBT, mandibulohyoid distance and thyromental distance respectively. Use of radiological parameters may not be suitable as screening tools, but may help in anticipating and preparing for a difficult scenario.

Prediction of difficult intubations using conventional indicators: Does rapid sequence intubation ease difficult intubations? A prospective randomised study in a tertiary care teaching hospital

BACKGROUND

Endotracheal intubations performed in the Emergency Department.

AIMS

To assess whether conventional indicators of difficult airway can predict a difficult intubation in the Emergency Setting and to investigate the effect of rapid sequence intubation (RSI) on ease of intubation.

SETTINGS AND DESIGN

A prospective randomized study was designed involving 60 patients requiring intubation, over a period of 4 months.

MATERIALS AND METHODS

Demographic profile, details of methods used, airway assessment, ease of intubation, and Cormack and Lehane score were recorded. Airway assessment score and ease of intubation criteria were devised and assessed.

STATISTICAL ANALYSIS

Descriptive statistical analysis was carried out. Chi-square/2 × 2, 2 × 3, 3 × 3, Fisher Exact test have been used to find the significance of study parameters on categorical scale between two or more groups.

RESULTS

Patients with a Mallampatti score of three or four were found to have worse laryngoscopic views (Cormack-Lehane score, 3 or 4). Of all airway indicators assessed, an increased Mallampatti score was found to have significant correlation with increased difficulty in intubation. The use of RSI was associated with better laryngoscopic views, and easier intubations.

CONCLUSIONS

An airway assessment using the Mallampatti score is invaluable as a tool to predict a difficult airway and should be performed routinely if possible. RSI aids intubation ease. If not otherwise contraindicated, it should be performed routinely for all intubations in the ED.