Syllabus updates

The AOD syllabus is constantly evolving with the literature. When new material is added to the syllabus, push notifications will alert you to visit this page.

Updates

Recent literature Updates

Added April 26

Emergency front-of-neck access in pediatric anesthesia: A narrative review

Anna-Katharina Haag ¹, Alberto Tredese ², Martina Bordini ³, Alexander Fuchs ^1 2, Robert Greif ^4 5, Clyde Matava ³, Thomas Riva ¹, Tommaso Scquizzato ⁶, Nicola Disma ²

Abstract

added March 25, 2024

Mediastinal Masses, Anesthetic Interventions and Airway Compression in Adults: A Prospective Observational Study

Philip M. Hartigan, M.D., Sergey Karamnov, M.D., et al      Anesthesiology 2022; 136:104–14

NOTE by William Rosenblatt, MD 

This observational study is an example of how it has taken more than 30 years for evidence to catch up with practice. This study contradicts a long held belief in the management of the patient with a mediastinal mass, though most clinicians working with these patients knew that there was a "myth" around the dogma that all of these patients were at particular risk.

ABSTRACT

Background: Central airway occlusion is a feared complication of general

anesthesia in patients with mediastinal masses. Maintenance of spontaneous

ventilation and avoiding neuromuscular blockade are recommended to reduce

this risk. Physiologic arguments supporting these recommendations are controversial

and direct evidence is lacking. The authors hypothesized that, in

adult patients with moderate to severe mediastinal mass–mediated tracheobronchial

compression, anesthetic interventions including positive pressure

ventilation and neuromuscular blockade could be instituted without compromising

central airway patency.

Methods: Seventeen adult patients with large mediastinal masses requiring

general anesthesia underwent awake intubation followed by continuous video

bronchoscopy recordings of the compromised portion of the airway during

staged induction. Assessments of changes in anterior–posterior airway diameter

relative to baseline (awake, spontaneous ventilation) were performed using

the following patency scores: unchanged = 0; 25 to 50% larger = +1; more

than 50% larger = +2; 25 to 50% smaller = −1; more than 50% smaller = −2.

Assessments were made by seven experienced bronchoscopists in side-by-side

blinded and scrambled comparisons between (1) baseline awake, spontaneous

breathing; (2) anesthetized with spontaneous ventilation; (3) anesthetized with

positive pressure ventilation; and (4) anesthetized with positive pressure ventilation

and neuromuscular blockade. Tidal volumes, respiratory rate, and inspiratory/

expiratory ratio were similar between phases.

Results: No significant change from baseline was observed in the mean

airway patency scores after the induction of general anesthesia (0 [95% CI, 0

to 0]; P = 0.953). The mean airway patency score increased with the addition

of positive pressure ventilation (0 [95% CI, 0 to 1]; P = 0.024) and neuromuscular

blockade (1 [95% CI, 0 to 1]; P < 0.001). No patient suffered airway

collapse or difficult ventilation during any anesthetic phase.

Conclusions: These observations suggest a need to reassess prevailing

assumptions regarding positive pressure ventilation and/or paralysis and

mediastinal mass–mediated airway collapse, but do not prove that conventional

(nonstaged) inductions are safe for such patients.

(ANESTHESIOLOGY 2022; 136:104–14)

March 19

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating RoomK A Cluster Randomized Clinical Trial

Kurt Ruetzler, MD; Sergio Bustamante, MD; Marc T. Schmidt; Federico Almonacid-Cardenas, MD;

Andra Duncan, MD; Andrew Bauer, MD; Alparslan Turan, MD; Nikolaos J. Skubas, MD; Daniel I. Sessler, MD;

for the Collaborative VLS Trial Group

JAMA. doi:10.1001/jama.2024.0762  Published online March 18, 2024.

IMPORTANCE Endotracheal tubes are typically inserted in the operating room using direct

laryngoscopy. Video laryngoscopy has been reported to improve airway visualization;

however, whether improved visualization reduces intubation attempts in surgical patients

is unclear.

OBJECTIVE To determine whether the number of intubation attempts per surgical procedure is

lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy.

DESIGN, SETTING, AND PARTICIPANTS Cluster randomized multiple crossover clinical trial

conducted at a single US academic hospital. Patients were adults aged 18 years or older

having elective or emergent cardiac, thoracic, or vascular surgical procedures who required

single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from

March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat.

INTERVENTIONS Two sets of 11 operating roomswere randomized on a 1-week basis to perform

hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt.

MAIN OUTCOMES AND MEASURES The primary outcomewas the number of operating room

intubation attempts per surgical procedure. Secondary outcomes were intubation failure,

defined as the responsible clinician switching to an alternative laryngoscopy device for any

reason at any time, or by more than 3 intubation attempts, and a composite of airway and

dental injuries.

RESULTS Among 8429 surgical procedures in 7736 patients, the median patient age was 66

(IQR, 56-73) years, 35%(2950) were women, and 85%(7135) had elective surgical

procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures

(1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%)

randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the

number of intubation attempts of 0.20 (95%CI, 0.14-0.28; P < .001). Intubation failure

occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016

surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95%CI, 0.03-0.14;

P < .001) with an unadjusted absolute risk difference of −3.7%(95%CI, −4.4%to −3.2%).

Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries

[0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).

CONCLUSION AND RELEVANCE In this study among adults having surgical procedures who

required single-lumen endotracheal intubation for general anesthesia, hyperangulated video

laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation

compared with direct laryngoscopy at a single academic medical center in the US. Results

suggest that video laryngoscopymay be a preferable approach for intubating patients

undergoing surgical procedures.

Updated Sept 6

Video versus Direct Laryngoscopy for Tracheal Intubation of

Critically Ill Adults

Matthew E. Prekker, M.D., M.P.H., Brian E. Driver, M.D., et al 

BACKGROUND Whether video laryngoscopy as compared with direct laryngoscopy increases the

likelihood of successful tracheal intubation on the !rst attempt among critically ill adults is uncertain.

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 videolaryngoscope

group or the direct-laryngoscope group. The primary outcome was successful intubation

on the !rst attempt. The secondary outcome was the occurrence of severe complications during

intubation; severe complications were de!ned as severe hypoxemia, severe hypotension, new or

increased vasopressor use, cardiac arrest, or death.

The trial was stopped for e$cacy at the time of the single preplanned interim analysis.

Among 1417 patients who were included in the !nal analysis (91.5% of whom underwent intubation that

was performed by an emergency medicine resident or a critical care fellow), successful intubation on the

!rst 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 di,erence, 14.3 percentage

points; 95% con!dence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the videolaryngoscope

group and 149 patients (20.9%) in the direct-laryngoscope group had a severe

complication during intubation (absolute risk di,erence, 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.

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

!rst attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE

ClinicalTrials.gov number, NCT05239195.)

RESULTS

CONCLUSIONS

likelihood of successful tracheal intubation on the !rst attempt among critically ill adults is uncertain.

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 videolaryngoscope

group or the direct-laryngoscope group. The primary outcome was successful intubation

on the !rst attempt. The secondary outcome was the occurrence of severe complications during

intubation; severe complications were de!ned as severe hypoxemia, severe hypotension, new or

increased vasopressor use, cardiac arrest, or death.

The trial was stopped for e$cacy at the time of the single preplanned interim analysis.

Among 1417 patients who were included in the !nal analysis (91.5% of whom underwent intubation that

was performed by an emergency medicine resident or a critical care fellow), successful intubation on the

!rst 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 di,erence, 14.3 percentage

points; 95% con!dence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the videolaryngoscope

group and 149 patients (20.9%) in the direct-laryngoscope group had a severe

complication during intubation (absolute risk di,erence, 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.

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

!rst attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE

ClinicalTrials.gov number, NCT05239195.)

 Updated Sept 6

Transnasal Videoendoscopy for Preoperative AirwayRisk Stratification: Development and Validation of a Multivariable Risk Prediction Model

Alexander!Barclay-Steuart, MD, MBA,* Hanna L.!Großhennig,* Phillip!Sasu, MD,*

Viktor A.!Wünsch, MD,* Rupert!Stadlhofer, MD,† Joanna!Berger, MD,† Maria!Stark, MSc‡

Susanne!Sehner, MSc,‡ Christian!Zöllner, MD,* and Martin!Petzoldt, MD*

(Anesth Analg 2023;136:1164–73)

BACKGROUND: Transnasal "exible videoendoscopy (TVE) of the larynx is a standard of care

for the detection and staging of pharyngolaryngeal lesions in otorhinolaryngology. Patients frequently

present with existing TVE examinations before anesthesia. Although these patients

are considered high risk, the diagnostic value of TVE for airway risk strati#cation is currently

unknown. How can captured images or videos be used for anesthesia planning, and which

lesions are most concerning? This study aimed to develop and validate a multivariable risk prediction

model for dif#cult airway management based on TVE #ndings and to determine whether

the discrimination of the Mallampati score can be improved by adding this new TVE model.

METHODS: This retrospective single-center development and validation study assessed 4021

patients who underwent 4524 otorhinolaryngologic surgeries at the University Medical Centre

Hamburg-Eppendorf between January 1, 2011, and April 30, 2018, with electronically stored

TVE videos and included 1099 patients who underwent 1231 surgeries. TVE videos and anesthesia

charts were systematically reviewed in a blinded fashion. The Least Absolute Shrinkage

and Selection Operator (LASSO) regression analysis was used for variable selection, model

development, and cross validation.

RESULTS: The prevalence of dif#cult airway management was 24.7% (304/1231). Lesions at

the vocal cords, epiglottis, or hypopharynx were not selected by the LASSO regression, while

lesions at the vestibular folds (ß-coef#cient 0.123), supraglottic region (ß-coef#cient 0.161),

arytenoids (ß-coef#cient 0.063), and viewing restrictions on the rima glottidis that cover $50%

of the glottis area (ß-coef#cient 0.485) and pharyngeal secretion retention (ß-coef#cient 0.372)

were relevant risk factors for dif#cult airway management. The model was adjusted for sex, age,

and body mass index. The area under the receiver operating characteristic curve (95% con#-

dence interval) of the Mallampati score was 0.61 (0.57–0.65) and 0.74 (0.71–0.78) of the TVE

model combined with Mallampati (P < .001).

CONCLUSIONS: Stored images and videos from TVE examinations can be reused for the purpose

of predicting risk associated with airway management. Vestibular fold, supraglottic, and

arytenoid lesions are most concerning, especially if they are accompanied by secretion retention

or restrict the glottic view. Our data indicate that the TVE model improves discrimination of

the Mallampati score and might, therefore, be a useful addition to traditional bedside airway risk

examinations.

Updated Sept 6

Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and operating theatre environments (Review)

White LD, Vlok RA, Thang CY, Tian DH, Melhuish TM. Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and operating theatre environments. Cochrane Database Syst Rev. 2023;8(8):CD013558.

A B S T R A C T

Background

Apnoeic oxygenation is the delivery of oxygen during the apnoeic phase preceding intubation. It is used to prevent respiratory

complications of endotracheal intubation that have the potential to lead to significant adverse events including dysrhythmia,

haemodynamic decompensation, hypoxic brain injury and death. Oxygen delivered by nasal cannulae during the apnoeic phase

of intubation (apnoeic oxygenation) may serve as a non-invasive adjunct to endotracheal intubation to decrease the incidence of

hypoxaemia, morbidity and mortality.

Objectives

To evaluate the benefits and harms of apnoeic oxygenation before intubation in adults in the prehospital, emergency department, intensive

care unit and operating theatre environments compared to no apnoeic oxygenation during intubation.

Search methods

We used standard, extensive Cochrane search methods. The latest search date was 4 November 2022.

Selection criteria

We included randomized controlled trials (RCTs) and quasi-RCTs that compared the use of any form of apnoeic oxygenation including

high flow and low flow nasal cannulae versus no apnoeic oxygenation during intubation. We defined quasi-randomization as participant

allocation to each arm by means that were not truly random, such as alternation, case record number or date of birth. We excluded

comparative prospective cohort and comparative retrospective cohort studies, physiological modelling studies and case reports.

Data collection and analysis

We used standard Cochrane methods. Our primary outcomes were 1. hospital stay and 2. incidence of severe hypoxaemia. Our secondary

outcomes were 3. incidence of hypoxaemia, 4. lowest recorded saturation of pulse oximetry (SpO2), 5. intensive care unit (ICU) stay, 6. first

pass success rate, 7. adverse events and 8. mortality. We used GRADE to assess certainty of evidence.

Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and

operating theatre environments (Review)

Main results

We included 23 RCTs (2264 participants) in our analyses. Eight studies (729 participants) investigated the use of low-flow (15 L/minute

or less), and 15 studies (1535 participants) investigated the use of high-flow (greater than 15 L/minute) oxygen. Settings were varied and

included the emergency department (2 studies, 327 participants), ICU (7 studies, 913 participants) and operating theatre (14 studies, 1024

participants). We considered two studies to be at low risk of bias across all domains.

None of the studies reported on hospital length of stay. In predominately critically ill people, there may be little to no diGerence in the

incidence of severe hypoxaemia (SpO2 less than 80%) when using apnoeic oxygenation at any flow rate from the start of apnoea until

successful intubation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.66 to 1.11; P = 0.25, IN = 0%; 15 studies, 1802 participants; lowcertainty

evidence).

There was insuGicient evidence of any eGect on the incidence of hypoxaemia (SpO2 less than 93%) (RR 0.58, 95% CI 0.23 to 1.46; P = 0.25, IN

= 36%; 3 studies, 489 participants; low-certainty evidence). There may be an improvement in the lowest recorded oxygen saturation, with

a mean increase of 1.9% (95% CI 0.75% to 3.05%; P < 0.001, IN = 86%; 15 studies, 1525 participants; low-certainty evidence). There may be

a reduction in the duration of ICU stay with the use of apnoeic oxygenation during intubation (mean diGerence (MD) O1.13 days, 95% CI

O1.51 to O0.74; P < 0.0001, IN = 46%; 5 studies, 815 participants; low-certainty evidence). There may be little to no diGerence in first pass

success rate (RR 1.00, 95% CI 0.93 to 1.08; P = 0.79, IN = 0%; 8 studies, 826 participants; moderate-certainty evidence). There may be little

to no diGerence in incidence of adverse events including oral trauma, arrhythmia, aspiration, hypotension, pneumonia and cardiac arrest

when apnoeic oxygenation is used. There was insuGicient evidence about any eGect on mortality (RR 0.84, 95% CI 0.70 to 1.00; P = 0.06,

IN = 0%; 6 studies, 1015 participants; low-certainty evidence).

Authors' conclusions

There was some evidence that oxygenation during the apnoeic phase of intubation may improve the lowest recorded oxygen saturation.

However, the diGerences in oxygen saturation were unlikely to be clinically significant. This did not translate into any measurable eGect on

the incidence of hypoxaemia or severe hypoxaemia in a group of predominately critically ill people. We were unable to assess the influence

on hospital length of stay; however, there was a reduction in ICU stay in the apnoeic oxygenation group. The mechanism for this is unclear

as there was little to no diGerence in first pass success or adverse event rates.

Updated June 17

Updated June 16

Updated May 29

Updated May 20

Updated May 15

2023 Anaesthesia May 5.

Updated May 15

Updated March 25, 2023

The incidence of awake tracheal intubation in anesthetic practice is decreasing: a historical cohort study of the years 2014–2020 at a single tertiary care institution

J. Adam Law, MD, FRCPC . Apiraami Thana, MD . Andrew D. Milne, MD

Abstract Purpose Awake tracheal intubation (ATI) is recommended in airway management guidelines when significant difficulty is predicted with airway management. Use of the technique may be declining, which may have implications for patient safety or for skills acquisition and maintenance. This historical cohort database study sought to determine if the use of ATI was decreasing in our adult tertiary care center. Methods With institutional research ethics board approval, we queried our anesthesia information management system for cases with ATI descriptors for each year from 2014 to 2020. Records of the retrieved cases were independently reviewed by all three authors to verify they met inclusion criteria for the ATI cohort prior to analysis for the primary outcome. Secondary outcome measures included airway device and route used for ATI, first attempt and ultimate success rates, and reported adverse issues recorded in cases of failed ATI or those requiring more than one attempt. Results A total of 692 cases of ATI were identified between 2014 and 2020. There was a statistically significant decrease in yearly ATIs over the seven-year study period (Chi square goodness of fit, P\0.001), with ATI use decreasing by about 50%. First attempt success was significantly greater with use of flexible bronchoscopy vs video laryngoscopy to facilitate ATI (84% vs 60%; P\ 0.001), while there was no difference in first attempt success with the oral vs nasal route (82% vs 82%; P = 1.0). Conclusion In this single-center historical cohort study, the use of ATI decreased significantly from 2014 to 2020. Whether this decrease will result in morbidity or mortality related to airway management is currently unclear. Regardless, it has implications for training opportunities and maintenance of competence in performing the procedure.

Updated March 6

Updated Feb 27

Success and Time to Oxygen Delivery for Scalpel-Finger-

Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated “Can’t Intubate, Can’t Oxygenate” Scenario in a Manikin Model With Impalpable Neck Anatomy

Jinbin Zhang, et al 

August 2022 • Volume 135 • Number 2

BACKGROUND: Emergency front-of-neck access (FONA) is particularly challenging with impal- pable neck anatomy. We compared 2 techniques that are based on a vertical midline neck incision, followed by finger dissection and then either a cannula or scalpel puncture to the cricothyroid membrane.

METHODS: A manikin simulation scenario of impalpable neck anatomy and bleeding was cre- ated. Sixty-five anesthesiologists undergoing cricothyrotomy training performed scalpel-finger- cannula (SFC) and scalpel-finger-bougie (SFB) cricothyrotomy in random order. Primary outcomes were time to oxygen delivery and first-attempt success; data were analyzed using multilevel mixed-effects models.

RESULTS: SFC was associated with a shorter time to oxygen delivery on univariate (median time difference, −61.5 s; 95% confidence interval [CI], −84.7 to −38.3; P < .001) and mul- tivariable (mean time difference, −62.1 s; 95% CI, −83.2 to −41.0; P < .001) analyses. Higher first-attempt success was reported with SFC than SFB (47 of 65 [72.3%] vs 18 of 65 [27.7%]). Participants also had higher odds at achieving first-attempt success with SFC than SFB (odds ratio [OR], 10.7; 95% CI, 3.3–35.0; P < .001). Successful delivery of oxy- gen after the “can’t intubate, can’t oxygenate” (CICO) declaration within 3 attempts and 180 seconds was higher (84.6% vs 63.1%) and more likely with SFC (OR, 5.59; 95% CI, 1.7–18.9; P = .006). Analyzing successful cases only, SFC achieved a shorter time to oxygen delivery (mean time difference, −24.9 s; 95% CI, −37.8 to −12.0; P < .001), but a longer time to cuffed tube insertion (mean time difference, +56.0 s; 95% CI, 39.0–73.0; P < .001). After simulation training, most participants preferred SFC in patients with impalpable neck anatomy (75.3% vs 24.6%).

CONCLUSIONS: In a manikin simulation of impalpable neck anatomy and bleeding, the SFC approach demonstrated superior performance in oxygen delivery and was also the preferred technique of the majority of study participants. Our study findings support the use of a cannula- based FONA technique for achieving oxygenation in a CICO situation, with the prerequisite that appropriate training and equipment are available. (Anesth Analg 2022;135:376–84)

Updated Jan 2, 2023

Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes

Kelsey A. Miller, MD, EdM*; Andzelika Dechnik, MD; Andrew F. Miller, MD; et al 

Study objective: To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where

laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes.

Methods: We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the

National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education

collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed

multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the

association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes.

Results: The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11

participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds

of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse

airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites

varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of videoassisted

laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient

laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95).

Conclusion: Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes

for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy,

and the high use is associated with increased odds of first-attempt success. [Ann Emerg Med. 2022;-:1-10.]

Updated December 27, 2022

Emergency Department Intubations in Patients With Angioedema: A Report from the National Emergency Airway Registry

Benjamin J. Sandefur MD, Xiao-Wei Liu MD, Amy H. Kaji MD, PHD, Ronna L. Campbell MD, PhD, Brian E. Driver MD, Ron M. Walls MD, Jestin N.

Carlson MD, MSC and Calvin A. Brown MD

Journal of Emergency Medicine, 2021-11-01, Volume 61, Issue 5, Pages 481-488,

Abstract

Background

Angioedema, a localized swelling of subcutaneous and submucosal tissues, may involve the upper airway. A subset of patients

presenting for emergent evaluation of angioedema will require intubation. Little is known about airway management practices in

patients with angioedema requiring intubation in the emergency department (ED).

Objective

To describe airway management practices in patients intubated for angioedema in the ED.

Methods

We analyzed data from the National Emergency Airway Registry. All patients with an intubation attempt for angioedema between

January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted

95% confidence intervals.

Results

Of 19,071 patient encounters, intubation was performed for angioedema in 98 (0.5%). First-attempt success was achieved in 81%,

with emergency physicians performing the procedure in 94% of encounters. The most common device used was a flexible endoscope

(49%), and 42% of attempts were via a nasal route. Pharmacologic methods included sedation with paralysis (61%), topical

anesthesia with or without sedation (13% and 13%, respectively), and sedation only (10%). Among 19 (19%) patients requiring

additional attempts, intubation was achieved on second attempt in 10 (53%). The most common adverse events were hypotension

(13%) and hypoxemia (12%). Cricothyrotomy occurred in 2 patients (2%). No deaths were observed.

Conclusions

Angioedema was a rare indication for intubation in the ED setting. Emergency physicians achieved first-attempt success in 81% of

encounters and used a broad range of intubation devices and methods, including flexible endoscopic techniques. Cricothyrotomy was

rare, and no ED deaths were reported. © 2021 Elsevier Inc.

Updated Nov 22, 2022

The impact of head and neck radiation on airway management: a retrospective data review

Can J Anesth/J Can Anesth (2022) 69:1562–1564 https://doi.org/10.1007/s12630-022-02331-z

Updated Nov 2, 2022

Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review  of current evidence

M. D. Wiles

Anaesthesia 2022, 77, 1120-1128

Around 1 million people sustain a spinal cord injury each year, which can have significant psychosocial, physical

and socio-economic consequences for patients, their families and society. The aim of this review is to provide

clinicians with a summary of recent studies of direct relevance to the airway management of patients with

confirmed or suspected traumatic spinal cord injury to promote best clinical practice. All airway interventions

are associated with some degree of movement of the cervical spine; in general, these are very small and

whether these are clinically significant in terms of impingement of the spinal cord is unclear. Manual in-line

stabilisation does not effectively immobilise the cervical spine and increases the likelihood of difficult and failed

tracheal intubation. There is no clear evidence of benefit of awake tracheal intubation techniques in terms of

prevention of secondary spinal cord injury. Videolaryngoscopy appears to cause a similar degree of cervical

spine displacement as flexible bronchoscope-guided tracheal intubation and is an appropriate alternative

approach. Direct laryngoscopy does cause a slightly greater degree of cervical spinal movement during

tracheal intubation than videolaryngoscopy, but this does not appear to increase the risk of spinal cord

compression. The risk of spinal cord injury during tracheal intubation appears to be minimal even in the

presence of gross cervical spine instability. Depending on the clinical situation, practitioners should choose the

tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical

spine movement.

Updated Oct 5, 2022

Has the time really come for universal videolaryngoscopy?

Tim M. Cook1,2,* and Michael F. Aziz3

This editorial accompanies: Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic

review and meta-analysis update by Hansel et al., Br J Anaesth 2022:129:612e623, doi: 10.1016/j.bja.2022.05.027

and

Videolaryngoscopy as a first-intention technique for tracheal intubation in unselected surgical patients: a before and after observational

study by De Jong et al., Br J Anaesth 2022:129:624e634, doi: 10.1016/j.bja.2022.05.030

Summary

Recent evidence, highlighted in this editorial, creates a strong argument for universal use of videolaryngoscopy in

anaesthesia to improve efficiency and safety of tracheal intubation. In a recent study published in the British Journal of

Anaesthesia, the authors implemented widespread (66%) use of videolaryngoscopy as first choice in one hospital and

compared this with a control hospital, in which this was not implemented. Increased videolaryngoscopy use was

associated with a significant fall in the rate of difficult airways, use of airway rescue techniques, and operator-reported

difficulty, whilst in the control hospitals no such changes were seen. Locations outside the operating theatre might also

benefit from universal laryngoscopy, but the evidence base is less robust, most notably in pre-hospital emergency

medicine. The extent to which variation in results in different locations is attributable to different patient factors or

organisational and operator factors is considered.

British Journal of Anaesthesia, 129 (4): 474e477 (2022)

Updated Oct 2, 2022

Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence

M.D. Wiles

Anaesthesia 2022 77 1120-8

Around 1 million people sustain a spinal cord injury each year, which can have significant psychosocial, physical

and socio-economic consequences for patients, their families and society. The aim of this review is to provide

clinicians with a summary of recent studies of direct relevance to the airway management of patients with

confirmed or suspected traumatic spinal cord injury to promote best clinical practice. All airway interventions

are associated with some degree of movement of the cervical spine; in general, these are very small and

whether these are clinically significant in terms of impingement of the spinal cord is unclear. Manual in-line

stabilisation does not effectively immobilise the cervical spine and increases the likelihood of difficult and failed

tracheal intubation. There is no clear evidence of benefit of awake tracheal intubation techniques in terms of

prevention of secondary spinal cord injury. Videolaryngoscopy appears to cause a similar degree of cervical

spine displacement as flexible bronchoscope-guided tracheal intubation and is an appropriate alternative

approach. Direct laryngoscopy does cause a slightly greater degree of cervical spinal movement during

tracheal intubation than videolaryngoscopy, but this does not appear to increase the risk of spinal cord

compression. The risk of spinal cord injury during tracheal intubation appears to be minimal even in the

presence of gross cervical spine instability. Depending on the clinical situation, practitioners should choose the

tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical

spine movement.

Updated 8-15-22

Preventing unrecognised oesophageal intubation: a consensus guideline 

Anaesthesia 2022, Chrimes, N and the PUMA working group 

Summary

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised

oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the

hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised

oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated

approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the

rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The

detection of `sustained exhaled carbon dioxide´ using waveform capnography is the mainstay for excluding

oesophageal placement of an intended tracheal tube. Tube removal should be the default response when

sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous,

urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with

evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely

restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions,

strategies are required to address cognitive biases and the deterioration of individual and team performance

in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for

preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of

geography, clinical location, discipline or patient type.

Updated 7-14-22

Videolaryngoscopes versus direct laryngoscopes in children: Ranking systematic review with network meta-analysesof randomized clinical trials

Clístenes C. de Carvalho et al 

Pediatric Anesthesia. 2022;00:1–15.

AbstractBackground: Videolaryngoscopes improve tracheal intubation in adult patients, but we currently do not know whether they are similarly beneficial for children. We de-signed this ranking systematic review to compare individual video and direct laryngo-scopes for efficacy and safety of orotracheal intubation in children.Methods: We searched PubMed and five other databases on January 27, 2021. We in-cluded randomized clinical trials with patients aged ≤18 years, comparing different la-ryngoscopes for the outcomes: failed first intubation attempt; failed intubation within two attempts; failed intubation; glottic view; time for intubation; complications. In addition, we assessed the quality of evidence according to GRADE recommendations.Results: We included 46 studies in the meta-analyses. Videolaryngoscopy reduced the risk of failed first intubation attempt (RR = 0.43; 95% CI: 0.31–0.61; p= .001) and failed intubation within two attempts (RR = 0.33; 95% CI: 0.33–0.33; p< .001) in chil-dren aged <1 year. Videolaryngoscopy also reduced the risk of major complications in both children aged <1 year (RR = 0.33; 95% CI: 0.12–0.96; p= .046) and children aged 0–18 years (RR = 0.40; 95% CI: 0.25–0.65; p= .002). We did not find significant difference between videolaryngoscopy and direct laryngoscopy for time to intuba-tion in children aged <1 year (MD = −0.95 s; 95% CI: −5.45 to 3.57 s; p= .681), and children aged 0–18 years (MD = 1.65 s; 95% CI: −1.00 to 4.30 s; p= .222). Different videolaryngoscopes were associated with different performance metrics within this meta-analysis. The overall quality of the evidence ranged from low to very low.Conclusion: Videolaryngoscopes reduce the risk of failed first intubation attempts and major complications in children compared to direct laryngoscopes. However, not all videolaryngoscopes have the same performance metrics, and more data is needed to clarify which device may be better in different clinical scenarios. Additionally, care must be taken while interpreting our results and rankings due to the available evi-dence's low or very low quality. 

Updated 7-8-22

Updated 6-16-22

E D I T O R I A L COMMENT  The role of Scalpel-bougie cricothyroidotomy in managing emergency Front of Neck Airway access. A review and technical update for ENT surgeons

In October 2016, an editorial was published jointly in Clinical Otolaryngology and the British Journal of Anaesthesia concerning the

appropriate management of the difficult airway in a situation of “Can’t Intubate Can’t Oxygenate” (CICO).1 It highlighted the importance of joint working between surgeons and anaesthetists and also made a case for the wider use of the scalpel-bougie cricothyroidotomy technique in securing a Front of Neck Airway (FONA), especially in an emergency. Almost all cases of an unexpectedly difficult airway are encountered by anaesthetists without the presence of an ENT surgeon.2,3 The Difficult Airway Society (DAS) has developed guidelines for the management of such situations (Figure 1) based on research that suggests that scalpel-bougie cricothyroidotomy is the safest way of securing an airway in emergency situations.4 Custom and practice in ENT surgery dictate that a surgical tracheostomy is the appropriate immediate technique for securing an airway when intubation is impossible. However, surgical tracheostomy should be seen as just one technique available to ENT surgeons in this situation. Firstly, the scalpel-bougie cricothyroidotomy technique is recommended by DAS as the first line management in the CICO situation and is the primary intervention expected of those attending with surgical expertise. Secondly, the number of open surgical tracheostomies performed both by trainees and substantive ENT staff is declining such that confidence in performing an emergency tracheostomy in a timely manner cannot be guaranteed by all ENT surgeons undertaking on-call duties. Approximately twothirds of tracheostomies performed in the United Kingdom at present are performed percutaneously (mostly by non-surgeons) and there may be a relative reduction in complications using this technique in appropriate patients.5,6 With regards to open tracheostomies, the 2014 UK NCEPOD report found 41% of the procedures were carried out by senior trainees, and the most senior surgeon was a consultant in 47% (although trainees were present for 84% of these).6 This reduction in exposure to performing these procedures means that confidence and competence to perform them in a high-pressure situation is likely to be adversely affected. The joint editorial notes that the DAS algorithms are guidelines. Ultimately, the decision as to the type of surgical airway performed is at the discretion of the surgeon which should be based on their own experience and skill set.

 Clinical Otolaryngology. 2018;43:791–794.

6-3-22

Upper airway pressure distribution during nasal high-flow therapy

• Rutger H.J., Hebbink Marieke L. Duiverman, Peter J. Wijkstra and Rob Hagmeijer
• Medical Engineering and Physics, 2022-06-01, Volume 104, Article 103805,

Abstract

Two working mechanisms of Nasal High-Flow Therapy (NHFT) are washout of anatomical dead space and provision of positive end-expiratory pressure (PEEP). The extent of both mechanisms depends on the respiration aerodynamics and the corresponding pressure distribution: at end-expiration the onset of uniform pressure indicates the jet penetration length, and the level of the uniform pressure is the PEEP. The clinical problem is that adequate measurements in patients are presently impossible. In this study, the respiratory pressure distribution is therefore measured in 3D-printed anatomically correct upper-airway models of an adult and an infant. Assuming that elastic fluctuations in airway anatomy are sufficiently small, the aerodynamics in these rigid models will be very similar to the aerodynamics in patients. It appears that, at end-expiration, the jet penetrates into or slightly beyond the nasal cavity, hardly depending on cannula size or NHFT flow rate. PEEP is approximately proportional to the square of the flow rate: it can be doubled by increasing the flow rate by 40%. In the adult model, PEEP is accurately predicted by the dynamic pressure at the prong-exits, but in the infant model this method fails. During respiration, large pressure fluctuations occur when the cannula is relatively large compared to the nostrils.

5-11-22

Tube Cuff Location and Perhaps a Call to Reconsider the Use of Uncuffed Tracheal Tubes

Malaak Isa, MD,* Josef Holzki, MD, PhD,† Anna Hagemeier, MSc,‡ Markus A. Rothschild, MD, PhD,*

and Charles J. Coté, MD§  (Anesth Analg XXX;XXX:00–00)2021

BACKGROUND: Some in vivo studies question the traditional “funnel-shaped” infant larynx; further

anatomic examinations were warranted. Examination of fixative free fresh autopsy laryngeal

and upper tracheal specimens and multiple measurements was needed to determine consistency

between current tracheal tube designs and anatomic observations.

METHODS: Larynges from 19 males and 11 females (Caucasian term newborn to 126 months)

were examined by the same forensic pathologist. Measurements included anterior/posterior

(A/P) and transverse (T) diameters of the cricoid outlet (CO), interarytenoid diameter (IAD), cricothyroid

membrane (CTM), distance from the vocal cords (VC) to CO (VC-CO), and calibration of

the larynx lumen with uncuffed tracheal tubes as measuring rods. Assessment of “safe tracheal

tube placement” was assessed using manufacturer recommended cuffed Microcuff (Kimberly-

Clark, Koblenz, Germany) tubes.

RESULTS: In 77% (95% confidence interval [CI], 58-90) of specimens, the proximal end of the

cuff was within the CO and in 23% even with or close to the CO. The VC-CO varied from 9.1

to 13.17 mm in infants, 11.55 to 15.17 mm in toddlers, and 13.19 to 18.34 mm in children.

The AP/T ratio of the CO was nearly 0.99 in most larynges; the IAD was greater than CO in all

specimens. The CTM could be minimally distended in all specimens.

CONCLUSIONS: First, despite being marketed as a safer tracheal tube design, the proximal

end of the Microcuff cuff rested within or close to the cricoid cartilage theoretically increasing

potential cuff-induced injury when using the VC markings for positioning. Our data suggest that

the optimal cuff free distance (VC-CO) would be ~13.5 mm for a Microcuff internal diameter (ID)

size 3.0, ~15 mm for size 3.5, and ~16 to 19 mm for greater sizes.

Second, the CO was virtually circular in all specimens, suggesting that appropriately sized

uncuffed tubes should provide an adequate seal in most neonates and toddlers, thus avoiding

the potential for cuff-related necrosis injury.

Third, the IAD was always greater than CO confirming that the narrowest point of the infant larynx

is the nondistensible cricoid cartilage and not the easily distended glottis.

Fourth, appropriately sized Microcuff tubes with the cuff deflated completely filled the lumen of

the CO and proximal trachea in all specimens. Our data suggest the need for all manufacturers

to further evaluate tracheal tube cuff locations and lengths in relation to the VC safe insertion

markings, particularly for neonates and toddlers.

Fifth, the CTM is minimally distensible, thus having important implications for emergency surgical

airway access with most currently available emergency airway devices.

5-1-22

Extubation of the potentially difficult airway in the intensive care unit

Joffe A, Barnes CR. Extubation of the potentially difficult airway in the intensive care unit. Curr Opin Anaesthesiol. 2022;35(2):122-129.

Purpose of review

Extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10– 20% patients further associated with significant morbidity and mortality. This review serves to highlight recent advancements and guidance on approaching extubation for patients at risk for difficult or failed extubation (DFE).

Recent findings

Recent literature including closed claim analysis, meta-analyses, and national society guidelines demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an extubation strategy have been described as potential methods to decrease occurrence of DFE.

Summary

Extubation in the ICU remains an elective decision and patients found to be at risk should be further optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be operationalized utilizing easily reproducible strategies, with airway experts present to guide decision making and assist in reintubation if needed.

4/27/22

Videolaryngoscopy vs. direct Macintosh laryngoscopy in tracheal intubation in adults: a ranking systematic review and network meta-analysis

C. C. de Carvalho,1 D. M. da Silva,2 V. M. Lemos,3 T. G. B. dos Santos,4 I. C. Agra,5

G. M. Pinto,6 I. B. Ramos,7 Y. S. C. Costa8 and J. M. Santos Neto9

Summary

Videolaryngoscopes are thought to improve glottic view and facilitate tracheal intubation compared with the

Macintosh direct laryngoscope. However, we currently do not know which one would be the best choice in most

patients undergoing anaesthesia. We designed this systematic review with network meta-analyses to rank the

different videolaryngoscopes and the Macintosh direct laryngoscope.We conducted searches in PubMed and a

further five databases on 11 January 2021.We included randomised clinical trials with patients aged ≥16 years,

comparing different videolaryngoscopes, or videolaryngoscopes with the Macintosh direct laryngoscope for the

outcomes: failed intubation; failed first intubation attempt; failed intubation within two attempts; difficult

intubation; percentage of glottic opening seen; difficult laryngoscopy; and time needed for intubation. We

assessed the quality of evidence according to GRADE recommendations and included 179 studies in the metaanalyses.

The C-MAC and C-MAC D-Blade were top ranked for avoiding failed intubation, but we did not find

statistically significant differences between any two distinct videolaryngoscopes for this outcome. Further, the CMAC

D-Blade performed significantly better than the C-MAC Macintosh blade for difficult laryngoscopy. We

found statistically significant differences between the laryngoscopes for time to intubation, but these differences

were not considered clinically relevant. The evidence was judged as of low or very low quality overall. In

conclusion, different videolaryngoscopes have differential intubation performance and some may be currently

preferred among the available devices. Furthermore, videolaryngoscopes and the Macintosh direct

laryngoscope may be considered clinically equivalent for the time taken for tracheal intubation. However,

despite the rankings from our analyses, the current available evidence is not sufficient to ensure significant

superiority of one device or a small set of them over the others for our intubation-related outcomes.

4/11/22

Extubation of the potentially difficult airway in the intensive care unit

Aaron Joffea,b and Christopher R. Barnesa

Current Opinion  Volume 35 ! Number 2 ! April 2022

Purpose of review

Extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10–

20% patients further associated with significant morbidity and mortality. This review serves to highlight

recent advancements and guidance on approaching extubation for patients at risk for difficult or failed

extubation (DFE).

Recent findings

Recent literature including closed claim analysis, meta-analyses, and national society guidelines

demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at

optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an

extubation strategy have been described as potential methods to decrease occurrence of DFE.

Summary

Extubation in the ICU remains an elective decision and patients found to be at risk should be further

optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be

operationalized utilizing easily reproducible strategies, with airway experts present to guide decision

making and assist in reintubation if needed.

Keywords

difficult extubation, failed extubation, high flow nasal cannula, noninvasive ventilation

4/2/22

Tracheal intubation using intubating laryngeal tube iLTS-D™ and LMA Fastrach™ in 99 adult patients: A prospective multicentric randomised non-inferiority study

M. Zuercher, MD a,*, G. Casso, MD b, V. Krugel, MD c, A. Poti!e, MD a, M.P. Barry, PhD a, P. Schoettker, PhD

JCA 2022 78, 110671   

Laryngeal Tube Suction-Disposable (iLTS-D™, VBM, Sulz a. N., Germany) compared to the Laryngeal Mask Airway (LMA) Fastrach™ (Teleflex, Athlone, Ireland). We hypothesised that the iLTS-D™ would be non-inferior to the LMA Fastrach™ for tracheal intubation and ventilation. Design􀀧 Multicentric, non-inferiority, randomised controlled study. Setting􀀧 Operating rooms from two tertiary and one secondary centre in Switzerland from January 2017 to July 2019. The investigators were trained anaesthetists with extensive experience with laryngeal masks but limited to laryngeal tubes. The study was discontinued after the planned interim analysis. 􀀩atients􀀧 Ninety-nine adult patients were included after randomisation. The inclusion criteria were American Society of Anesthesiologists physical status 1 to 3 in patients scheduled for elective surgery requiring tracheal intubation. Patients with a history of difficult intubation were excluded. Intervention􀀪s􀀫􀀧 After anaesthesia induction and once neuromuscular blockade was obtained, ventilation was initiated, and tracheal intubation was performed through the randomised device with the flexible endoscope tip placed proximally to the tip of the tracheal tube (visualised blind intubation). 􀀬easurements􀀧 The primary outcome was the intubation success rate after two attempts. The secondary outcomes were time to intubation, successful ventilation rate, time to achieve ventilation, and gastric access success rate. 􀀬ain results􀀧 The overall intubation success rate was significantly higher in the Fastrach™ group than in the iLTS-D ™ group (91.8% vs 70.0%, p ! 0.00􀁁). No difference was found in the ventilation success rate (9􀁂% for iLTS-D ™ and 100% for LMA Fastrach™ 􀁃p ! 0.829􀁄). The time to achieve ventilation and intubation were similar between the groups. No ma􀁅or airway complications were noted. Conclusions􀀧 Although both supraglottic devices provided the same effective ventilation rate, the LMA Fastrach™ was superior to the iLTS-D™ as a conduit for intubation in 99 adult patients without a known difficult intubation. These preliminary results need to be confirmed in studies that include a larger population. Trial registration􀀧 Clinicaltrials.gov, 21.09.201􀁁, Identification Number NCT02922􀁆9􀁆. 

3/21/22

Patient and surgery factors associated with the incidence of

failed and difficult intubation

R. Schnittker,1 S.D. Marshall2 and J. Berecki-Gisolf3

Anaesthesia 2020, 75, 756–766

Summary

Estimates of the rate and risk-factors for difficult airway rarely include a denominator for the number of

anaesthetics. Approaches such as self-reporting and crowd-sourcing of airway incidents may help identify

specific lessons from clinical episodes, but the lack of denominator data, biased reporting and under-reporting

does not allow a comprehensive population-based assessment. We used an established state-wide dataset to

determine the incidence of failed and difficult intubations between 2015 and 2017 in the state of Victoria in

Australia, along with associated patient and surgical risk-factors. A total of 861,533 general anaesthesia

episodes were analysed. Of these, 4092 patients with difficult or failed intubation were identified; incidence

rates of 0.52% (2015–2016) and 0.43% (2016–2017), respectively. Difficult/failed intubations were most

common in patients aged 45–75 and decreased for older age groups, with risk being lower for patients

aged >85 than patients aged 35–44. The risk for failed/difficult intubation increased significantly for: patients

undergoing emergency surgery (OR 1.80); obese patients (OR 2.48); increased ASA physical status; and

increased Charlson Comorbidity Index. Across all age groups, procedures on the nervous system (OR 1.92) and

endocrine system (OR 2.03) had the highest risk of failed/difficult intubation. The relative reduced risk for failed/

difficult intubations in the elderly population is a novel finding that contrasts with previous research and may

suggest a ‘compression of morbidity’ effect as a moderator. Administrative databases have the potential to

improve understanding of peri-operative risk of rare events at a population level.

Updated 3/11/22

Review Article:Apnoeic oxygenation in paediatric anaesthesia: a narrative review

C. Lyons and M. Callaghan 

Anaesthesia 2021, 76, 118–127

Summary

Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs.

This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the

last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow,

nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric

population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and

nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised.

We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and

complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric

patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number

of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in

paediatric difficult airway management is unclear as this has not been the targeted focus of any published

research to date.

Updated 2/27/22

Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis

Reale SC, Bauer ME, Klumpner TT, et al. Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis. Anesthesiology. 2022.

Updated 2/16/22

Updated 2/10/22

EDITORIAL New evidence to inform decisions and guidelines in difficult airway management

Alistair F. McNarry1,* and Takashi Asai2

1Department of Anaesthesia, NHS Lothian, Edinburgh, UK and 2Department of Anesthesiology, Dokkyo Medical

University Saitama Medical Centre, Koshigaya, Japan

British Journal of Anaesthesia, 

doi: 10.1016/j.bja.2021.03.003

Advance Access Publication 

Update 2/1/22

Endotracheal Tube Cuff Leaks: Causes, Consequences, and Management

Mohammad El-Orbany, MD* and M. Ramez Salem, MD†

The consequences of endotracheal tube (ETT) cuff leak may range from a bubbling noise to a

life-threatening ventilatory failure. Although the definitive solution is ETT replacement, this is

often neither needed nor safe to perform. Frequently, the leak is not caused by a structural

defect in the ETT. Cuff underinflation, cephalad migration of the ETT (partial tracheal extubation),

misplaced orogastric or nasogastric tubes, wide discrepancy between ETT and tracheal

diameters, or increased peak airway pressure can cause leaks around intact cuffs. Correction

of these problems will stop the leak without ETT replacement. Alternatively, ETT cuff, pilot balloon,

and inflation system damage due to inadvertent trauma or manufacturing defects may

be responsible. Conservative management ideas (management without ETT replacement) were

previously published to solve the problem. However, when a large structural defect is identified

or conservative measures fail, ETT replacement becomes necessary. This can be performed

with direct laryngoscopy if laryngeal visualization is adequate. A difficult exchange with possible

airway loss should be anticipated, and prepared for, when there are signs and/or history

of difficult intubation. A risk/benefit analysis of each individual situation is warranted before

decisions are made on how best to proceed. Alternative back-up ventilation plans should be

preformulated and the necessary equipment ready before the exchange. In this review, various

management concerns and plans are discussed, and a simple algorithm to manage leaky ETT

cuff situations is presented. (Anesth Analg 2013;117:428–34)

Update 1/13/22

(this is a high level review of facemark ventilation.- WHR)

Facemask ventilation

W.P.L. Bradley1,2 and C. Lyons3,4

BJA Education, 22(1): 5e11 (2022)

! Facemask ventilation is a core airway management

skill that functions as both a primary

technique and a rescue technique of oxygenation.

! The prevalence of difficult mask ventilation is

approximately 1% and of impossible mask ventilation

is approximately 0.05%.

! A two-handed grip and optimisation of the patient’s

and anaesthetist’s positioning can

improve facemask ventilation.

! Facemask ventilation can be improved by using

neuromuscular blocking drugs.

! Complications of facemask ventilation are rare.

Update 1/4/21

Font-of-neck airway rescue with impalpable anatomy during a simulated cannot intubate caFrFnnot oxygenate scenario: scalpelefingerecannula versus scalpelefingerebougie in a sheep model

Andrew Heard et al 

Background: Front-of-neck airway rescue in a cannot intubate cannot oxygenate (CICO) scenario with impalpable

anatomy is particularly challenging. Several techniques have been described based on a midline vertical neck incision

with subsequent finger dissection, followed by either a cannula or scalpel puncture of the now palpated airway. We

explored whether the speed of rescue oxygenation differs between these techniques.

Methods: In a high-fidelity simulation of a CICO scenario in anaesthetised Merino sheep with impalpable front-of-neck

anatomy, 35 consecutive eligible participants undergoing airway training performed scalpelefingerecannula and scalpelefingerebougie

in a random order. The primary outcome was time from airway palpation to first oxygen delivery.

Data, were analysed with Cox proportional hazards.

Results: Scalpelefingerecannulawas associated with shorter time to first oxygen delivery on univariate (hazard ratio [HR].

11.37; 95% confidence interval [CI], 5.14e25.13; P<0.001) andmultivariate (HR.8.87; 95% CI, 4.31e18.18; P<0.001) analyses. In

themultivariablemodel, consultant grade was also associated with quicker first oxygen delivery compared with registrar

grade (HR.3.28; 95% CI, 1.36e7.95; P.0.008).With scalpelefingerecannula, successful oxygen delivery within 3min of CICO

declaration and  2 attempts wasmore frequent; 97% vs 63%, P<0.001. In analyses of successful cases only, scalpelefingerecannula

resulted in earlier improvement in arterial oxygen saturations (e25 s; 95% CI, e35 to e15; P<0.001), but a

longer time to first capnography reading (.89 s; 95% CI, 69 to 110; P<0.001). Nomajor complications occurred in either arm.

Conclusions: The scalpelefingerecannula technique was associated with superior oxygen delivery performance during a

simulated CICO scenario in sheep with impalpable front-of-neck anatomy.

British Journal of Anaesthesia, 2020  doi: 10.1016/j.bja.2020.04.067  

Updated 12/27/21

Front of neck access to the airway: A narrative review

X. Onrubiaa, G. Frovab, M. Sorbelloc, ∗

The concept of Front of Neck Access (FONA) covers a large amount of techniques, principles, problems and

debates. The aim of this review is to discuss the issue of FONA with special regard to the sole cricothyrotomy,

including all technical issues starting from landmark identification to different approaches, either surgical or

percutaneous.

Other open questions remain, such as choice of inner diameter, presence of a cuff, potential advantages of

Seldinger based techniques, including bougie assisted ones, timing and decision making. Despite being a simple

maneuver, cricothyrotomy remains a very complex concept, which should be a core skill of any physician

approaching the airway and as simple as it is, it can make the difference between life and death.

https://doi.org/10.1016/j.tacc.2018.06.001

2210-8440/ ˝ 2018.

Updated 12/15/21

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway^*

Updated 11/29/21

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

H. A. Iliff,K. El-Boghdadly, I. Ahmad, et al 

Anaesthesia 2021

Summary

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; posthaematoma

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.

Updated 11/14/21

A Predictor of Difficult Airway: The Tasli Classification in  Transnasal Flexible Laryngoscopy

*Hamdi Tasli, *Nesibe Esra Karaman, †Dilber Isler, and *Bugra Subasi, *yK€utahya, Turkey

Journal of Voice, July 2021

Abstract: Introduction. Dif!cult airway is de!ned as dif!culty or failure in one or more steps in upper airway

management. Evaluation of the upper airway with physical examination methods and endoscopic devices is crucial

in predicting dif!cult airway. The aim of this study was to evaluate bedside tests, Cormack Lehane (CL) and

Tasli Classi!cation (TC) scores of the patients and it was aimed to reveal the role of TC which will be performed

preoperatively as a predictor of dif!cult tracheal intubation (DTI).

Methods. The study included a total of 98 patients who underwent surgical treatment under general anesthesia.

Demographic data, including age, gender, and body mass index (BMI), and bedside tests consisting Modi!ed

Mallampati Classi!cation (MMC), thyromental (TD) and sternomental (SD) distances, neck circumference

(NC), interincisor distance (IID), CL and TC were recorded.

Results. Evaluation was made of 64 (65.3%) male and 34 (34.7%) female patients ranging in age from 18 to

84 years (mean age: 50.35 § 0.47 years). The successfully intubated patients (SIP) group comprised 68 (69.4%)

patients, and the dif!cult intubation patients (DIP) group, 30 (30.6%). According to CL, the numbers of SIP and

DIP constituting grade 1 was 29 (42.6%) and one (3.3%); grade 2a was 29 (42.6%) and one (3.3%); grade 2b was

eight (11.8%) and three (10%); grade 3a was one (1.5%) and six (20%); grade 3b was one (1.5%) and 14 (46.7%)

respectively. Grade 4 was only detected in the DIP group in 5 (16.7%) patients. According to TC, the numbers of

SIP and DIP constituting grade 1 was 20 (29.4%) and 1 (3.3%); grade 2a was 37 (54.4%) and seven (23.3%); grade

2b was 10 (14.7%) and 18 (60%); grade 3 was one (1.5%) and two (6.7%) respectively. Grade 4 was only detected

in the DIP group in two (6.7%) patients.

Conclusion. The TC, CL, NC and BMI scores were higher in the DIP group and higher TC scores (grade 2b, 3,

and 4) can be a predictor of dif!cult airway. However, it may be more bene!cial to use TC as a complementary

diagnostic tool with bedside tests such as NC, SM, TM and MMC, rather than used alone.

Key words: Diff{cult Airway—The Cormack-Lehane Classi!cation—Transnasal Flexible Laryngoscopy—Bedside

Tests—The Tasli Classi!cation.

Updated 11/13/21

Error traps in pediatric difficult airway management

Updated 10-31-21

A comparison of patient and provider perceptions of awake tracheal intubations

Colin Archer, MD . John Veall, MD, FRCPC . Laura V. Duggan, MD, FRCPC .

Andrew Downey, MBBS, Hons, FANZCA . Peter Rose, MD, FRCPC

Can J Anesth/J Can Anesth, Oct 2021

Updated 10-29-21

 An international survey about rapid sequence intubation of

10,003 anaesthetists and 16 airway experts

M. Zdravkovic,1,2 J. Berger-Estilita,3 M. Sorbello,4 C. A. Hagberg5

Anaesthesia. 2020;75(3):313-322.

Summary

Pulmonary aspiration of gastric content is a significant cause of anaesthesia-related morbidity and mortality.

High-quality prospective randomised evidence to support prevention strategies, such as rapid sequence

intubation, is difficult to generate due to well-described practical, ethical and methodological barriers. We

aimed to generate an understanding of worldwide practice through surveying clinically practicing anaesthetists

and airway experts. Our survey was designed to assess the influence of: departmental standards; patient

factors; socio-economic factors; training; and supervision.Wesurveyed 10,003 anaesthetists who responded to

an invitation to participate on LinkedIn. We then surveyed 16 international airway experts on the same content.

When asked about a hypothetical patient with intestinal obstruction, respondents expressed preferences for

[OR (95%CI)]: the head-up or -down position 4.26 (3.98–4.55), p < 0.001; nasogastric tube insertion 29.5 (26.9–

32.3), p < 0.001; and the use of cricoid force 2.80 (2.62–3.00), p < 0.001, as compared with a hypothetical

patient without intestinal obstruction also requiring rapid sequence intubation. Respondents from lower

income countries were more likely to prefer [OR (95%CI]: the supine position 2.33 (2.00–2.63), p < 0.001;

nasogastric tube insertion 1.29 (1.09–1.51), p = 0.002; and cricoid force application 2.54 (2.09–3.09), p < 0.001

as compared with respondents from higher income countries for a hypothetical patient with intestinal

obstruction. This survey, which we believe is the largest of its kind, demonstrates that preferences for

positioning, nasogastric tube use and cricoid force application during rapid sequence intubation vary

substantially. Achieving agreed consensus may yield better training in the principles of rapid sequence

intubation.

Updated 10-23-21

EDITORIAL New evidence to inform decisions and guidelines in difficult airway management

Alistair F. McNarry, Takashi Asai

Updated 9-18-21

Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis

Ryan Howle, MBChB, FRCA . Desire Onwochei, MBBS, FRCA . Siew-Ling Harrison, MBBS, FRCA . Neel Desai, MBChB, FRCA

Abstract

Purpose The incidence of difficult and failed intubation is higher in obstetrical patients than in the general population because of anatomic and physiologic changes in pregnancy. Videolaryngoscopy improves the success rate of intubation and reduces complications when compared with direct laryngoscopy in adults; however, it is not known whether this extends to obstetrical surgery. The aim of this study was to examine the efficacy, efficiency, and safety of videolaryngoscopy compared with direct laryngoscopy in obstetrics.

Source Central, CINAHL, Embase, MEDLINE and Web of Science databases were searched from inception to 27 May 2020 with no restrictions. Inclusion criteria included randomized-controlled trials (RCTs), observational studies, case series, and case reports that reported the application of videolaryngoscopy to intubate the trachea in pregnant patients having general anesthesia.

Department of Anaesthesia, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Principal findings Overall, four RCTs with 428 participants, nine observational studies, and 35 case reports/series with 100 participants were included. On meta-analysis of three trials, the co-primary outcomes of first-attempt success rate (risk ratio, 1.02; 95% confidence intervals [CI], 0.98 to 1.06; P = 0.29; I2 = 0%) and time to tracheal intubation (mean difference, 1.20 sec; 95% CI, - 6.63 to 9.04; P = 0.76; I2 = 95%) demonstrated no difference between videolaryngoscopy and direct laryngoscopy in parturients without difficult airways. Observational studies and case reports underline the role of videolaryngoscopy as a primary choice when difficulty with tracheal intubation is expected or as a rescue modality in difficult or failed intubations.

Conclusions Evidence for the utility of videolaryngoscopy continues to evolve but supports its increased adoption in obstetrics where videolaryngoscopes should be immediately available for use as a first-line device.

Can J Anesth/J Can Anesth https://doi.org/10.1007/s12630-020-01908-w 

Updated 9-3-21

Updated 8-20-21

Evaluation of super-obesity and super-super-obesity as risk factors for difficult intubation in patients undergoing bariatric surgery

Mohamed Mahmoud, M.D., et al 

Background: Super-obesity is a serious disorder which requires bariatric surgery. The association of

super-obesity and difficult intubation was not adequately established.

Objectives: To determine if super-obesity and super-super-obesity are associated with difficult intubation or not.

Setting: University Hospital.

Methods: A cohort of obese patients scheduled for bariatric surgery was prospectively recruited.

Super-obesity and super-super-obesity were defined as body mass index !50 kg/m2 and 60 kg/m2,

respectively. Intubation difficulty was assessed by 2 methods: (1) intubation difficulty scale; (2) number

of intubation attempts. Risk factors for difficult intubation were recorded. Univariate and multivariate

analysis for risk factors for difficult intubation and difficult mask ventilation were performed.

Results: A total of 658 patients were enrolled in the study including 205 (31%) super-obese and 52

(8%) super-super-obese patients. Ninety-nine (15%) patients required more than 1 intubation

attempt, while 215 (33%) patients had intubation difficulty scale !5. Ninety-four (14.4%) patients

had mask ventilation of moderate difficulty, while only 2 (.3%) patients needed 2-person ventilation.

The independent risk factors for difficult intubation using the two stated definitions were STOP-Bang

and Mallampati score values. The independent risk factors for mask ventilation of moderate difficulty

were STOP-Bang score, Mallampati score, and limited neck extension.

Conclusion: Within obese patients, neither super-obesity nor super-super-obesity was associated

with difficult intubation or difficult mask ventilation. High STOP-Bang and Mallampati score are

the independent factors for difficult intubation. (Surg Obes Relat Dis 2021;-:1–7.)

Updated 7-23-21

Comparison between ultrasound-guided and digital palpation techniques for identification of the cricothyroid membrane: a meta- analysis

Kuo-Chuan Hung1, I-Wen Chen1, Chien-Ming Lin1 and Cheuk-Kwan Sun2,3,* 1Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan, 2Department of Emergency Medicine, E-Da

Hospital, Kaohsiung, Taiwan and 3College of Medicine, I-Shou University, Kaohsiung, Taiwan

Updated 7-15-21

Emergency department evaluation of patients with angiotensinconverting enzyme inhibitor associated angioedema

Philip A. Mudd, MD, PhDa, et al 

American Journal of Emergency Medicine 38 (2020) 2596–2601

Introduction: Angiotensin converting enzyme inhibitor (ACEi) associated angioedema is frequently encountered

in the emergency department. Airwaymanagement is the primary treatment, but published evidence supporting

the decision to intubate patients with this condition is extremely limited.

Method: We performed a retrospective study of all cases of ACEi associated angioedema encountered in a large,

urban, tertiary referral emergency department. We classi!ed demographics, duration of symptoms before presentation,

physical exam !ndings and nasopharyngoscopy !ndings in patients that did and did not require intubation.

Results: We identi!ed a total of 190 separate encounters from 183 unique patients who presented during the 3-

year period of the study. Eighteen (9.5%) of these patients required intubation. Patients requiring intubationwere

more likely to presentwithin 6 h of the onset of angioedema symptoms. Anterior tongue swelling, vocal changes,

drooling, and dyspnea were signi!cantly more common in patients requiring intubation. Isolated lip swelling

was present in 54% of all patients and was the only !nding signi!cantly more common in the group that did

not require intubation.

Conclusions: Rapid progression of symptoms within the !rst 6 h of angioedema onset, anterior tongue swelling,

vocal changes, drooling and dyspnea are associated with intubation for ACEi associated angioedema. Isolated lip

swelling is signi!cantly more common in patients that do not require intubation. Our data provide risk strati!cation

guidance for providers treating patients with suspected ACEi associated angioedema in the emergency

department.

 Updated 7-2-21

Evaluation of super-obesity and super-super-obesity as risk factors for difficult intubation in patients undergoing bariatric surgery

Mohamed Mahmoud, M.D., Ahmed M. Hasanin, M.D., D.E.S.A.*, Maha Mostafa, M.D.,

Fatema Alhamade, M.Sc., Bassant Abdelhamid, M.D., Mona Elsherbeeny, M.D.

Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt

Received 20 October 2020; accepted 31 March 2021

Abstract Background: Super-obesity is a serious disorder which requires bariatric surgery. The association of

super-obesity and difficult intubation was not adequately established.

Objectives: To determine if super-obesity and super-super-obesity are associated with difficult intubation

or not.

Setting: University Hospital.

Methods: A cohort of obese patients scheduled for bariatric surgery was prospectively recruited.

Super-obesity and super-super-obesity were defined as body mass index !50 kg/m2 and 60 kg/m2,

respectively. Intubation difficulty was assessed by 2 methods: (1) intubation difficulty scale; (2) number

of intubation attempts. Risk factors for difficult intubation were recorded. Univariate and multivariate

analysis for risk factors for difficult intubation and difficult mask ventilation were performed.

Results: A total of 658 patients were enrolled in the study including 205 (31%) super-obese and 52

(8%) super-super-obese patients. Ninety-nine (15%) patients required more than 1 intubation

attempt, while 215 (33%) patients had intubation difficulty scale !5. Ninety-four (14.4%) patients

had mask ventilation of moderate difficulty, while only 2 (.3%) patients needed 2-person ventilation.

The independent risk factors for difficult intubation using the two stated definitions were STOP-Bang

and Mallampati score values. The independent risk factors for mask ventilation of moderate difficulty

were STOP-Bang score, Mallampati score, and limited neck extension.

Conclusion: Within obese patients, neither super-obesity nor super-super-obesity was associated

with difficult intubation or difficult mask ventilation. High STOP-Bang and Mallampati score are

the independent factors for difficult intubation. (Surg Obes Relat Dis 2021;-:1–7.) ! 2021 American

Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Abstract

Updated 6/16/21

 Manual in-line stabilisation during tracheal intubation:

effective protection or harmful dogma?

M. D. Wiles

Consultant, Department of Anaesthesia, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

Anaesthesia 2021, 76, 850–853

This month’s ‘Contemporary Classic’ focuses on a landmark

paper from the 1990s. The study by Nolan and Wilson

examined tracheal intubation in patients with a suspected

cervical spine injury [1], a topic which still remains a clinical

concern for anaesthetists today. Cervical spine injury occurs

in 3%–4% of trauma patients, with around 25% of these

patients having a cervical spinal cord injury [2]. Cervical cord

injury is more common in patients who have a reduced

Glasgow Coma Scale (GCS), and around 25% will have

injuries to other body systems [2]. As a result, these patients

are likely to require airway intervention, either to protect/

secure their airway or to facilitate treatment or investigation

of their injuries. Clinicians are often worried about the

possibility that tracheal intubation may either worsen an

existing neurological deficit or cause a new spinal cord

injury. This is despite there being little published evidence

showing an association between tracheal intubation and

either primary or secondary cervical cord damage [3, 4].

Updated 6/9/21

Airway Management in Surgical Patients WithObstructive Sleep Apnea

Edwin Seet, MBBS, MMed, FAMS,* Mahesh Nagappa, MD,† and David T. Wong, MD, FRCPC‡

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, and the

difficult airway is perhaps the anesthesiologists’ quintessential concern. OSA and the difficult

airway share certain similar anatomical, morphological, and physiological features. Individual

studies and systematic reviews of retrospective, case-control, and large database studies have

shown a likely association between patients with OSA and the difficult airway; OSA patients

have a 3- to 4-fold higher risk of difficult intubation, difficult mask ventilation, or a combination

of both. The presence of OSA should initiate proactive perioperative management in anticipation

of a difficult airway. Prudent intraoperative management comprises the use of regional

anesthesia where possible and considering an awake intubation technique where there is the

presence of notable difficult airway predictors and risk of rapid desaturation following induction

of general anesthesia. Familiarity with difficult airway algorithms, cautious extubation, and

appropriate postoperative monitoring of patients with OSA are necessary to mitigate perioperative

risks. (Anesth Analg 2021;132:1321–7)

Updated 5-25-21

Carbon dioxide monitoring in children – a narrative review of physiology, value and pitfalls in clinical practice

Susan Humphreys, Andreas Schibler, Britta S von Ungern-Sternberg

Introduction

Continuous capnography has been recognised as an essential monitoring device in all

anaesthetised patients, despite which airway device is in use, regardless of their location, as a

measure to improve patient safety 1. Capnography is the non-invasive measurement of a sample

of the exhaled carbon dioxide (CO2) which has multiple clinical uses including as a method to

confirm placement of a tracheal tube and/or to assess ventilation, perfusion and metabolism.

Notably, capnography is used during routine paediatric anaesthesia to assess ventilation and as a

surrogate measure for arterial carbon dioxide pressure (PaCO2). The inaccuracies associated with

these surrogate measures need to be considered to inform improved ventilation management of

infants and children. This review highlights some major principles to understand the CO2

elimination, the physiology of paediatric capnography, the clinical application and the limitations

of capnography during anaesthesia for neonates, infants and small children.

Paediatr Anaesth, 2021,  epub before print

Updated 5-20-21

 Evaluation of super-obesity and super-super-obesity as risk factors for difficult intubation in patients undergoing bariatric surgery

Mohamed Mahmoud, M.D., Ahmed M. Hasanin, M.D., D.E.S.A.*, Maha Mostafa, M.D.,

Fatema Alhamade, M.Sc., Bassant Abdelhamid, M.D., Mona Elsherbeeny, M.D.

Background: Super-obesity is a serious disorder which requires bariatric surgery. The association of

super-obesity and difficult intubation was not adequately established.

Objectives: To determine if super-obesity and super-super-obesity are associated with difficult intubation

or not.

Setting: University Hospital.

Methods: A cohort of obese patients scheduled for bariatric surgery was prospectively recruited.

Super-obesity and super-super-obesity were defined as body mass index !50 kg/m2 and 60 kg/m2,

respectively. Intubation difficulty was assessed by 2 methods: (1) intubation difficulty scale; (2) number

of intubation attempts. Risk factors for difficult intubation were recorded. Univariate and multivariate

analysis for risk factors for difficult intubation and difficult mask ventilation were performed.

Results: A total of 658 patients were enrolled in the study including 205 (31%) super-obese and 52

(8%) super-super-obese patients. Ninety-nine (15%) patients required more than 1 intubation

attempt, while 215 (33%) patients had intubation difficulty scale !5. Ninety-four (14.4%) patients

had mask ventilation of moderate difficulty, while only 2 (.3%) patients needed 2-person ventilation.

The independent risk factors for difficult intubation using the two stated definitions were STOP-Bang

and Mallampati score values. The independent risk factors for mask ventilation of moderate difficulty

were STOP-Bang score, Mallampati score, and limited neck extension.

Conclusion: Within obese patients, neither super-obesity nor super-super-obesity was associated

with difficult intubation or difficult mask ventilation. High STOP-Bang and Mallampati score are

the independent factors for difficult intubation. (Surg Obes Relat Dis 2021;-:1–7.) ! 2021 American

Society for Bariatric Surgery. 

Updated 4-29-21

• PMID: 33904779
• DOI: 10.2217/cer-2021-0068

Updated 4-21-21

Ultrasound identification of the cricothyroid membrane: the newstandard in preparing for front-of-neck airway access

Michael S. Kristensen1,* and Wendy H. Teoh2

Conclusions

The meta-analysis by Hung and colleagues4 unequivocally documents the superiority of ultrasound for guiding identification and marking of the cricothyroid membrane, and the

limitations of palpation methods, especially in the obese and in those with pathology of the neck. The clinical consequences should be that, in cases where pre-induction visual inspection 

or palpation methods do not with certainty identify the cricothyroid membrane and the midline of the airway, the cricothyroid membrane should be identified with ultrasonography

and marked with the patient in extended-neck position. Subsequently, the patient can be placed in the desired position for airway management and induction. In case that the initial

airway management fails and front-of-neck airway access is needed, the patient can be returned to the extended-neck position, and the marking of the centre of the cricothyroid

membrane will again be correct.

Updated 4-13-21

Updated 4-7-21

Quantification of the effect of body mass index on cricothyroid membrane depth: a cross-sectional analysis of clinical CT images

Ghaffar, S.  et al 

Abstract

OBJECTIVES: The recommended front of neck access procedure in can't intubate, can't oxygenate scenarios relies on palpation of the cricothyroid membrane (CTM), or dissection of the neck down to the larynx if CTM is impalpable. CTM palpation is particularly challenging in obese patients, most likely due to an increased distance between the skin and the CTM (CTM depth). The aims of this study were to measure the CTM depth in a representative clinical sample, and to quantify the relationship between body mass index (BMI) and CTM depth. METHODS: This is a retrospective analysis of 355 clinical CT scans performed at a teaching hospital over an 8-month period. CTM depth was measured by two radiologists, and mean CTM depth calculated. Age, gender, height and weight were recorded, and BMI calculated. Linear relationships between patient characteristics and CTM depth were assessed in order to derive a predictive equation for calculating CTM depth. The variables included for this model were those with a strong association with CTM depth, that is, a p value of 0.10 or less. RESULTS: Mean CTM depth was 8.12 mm (IQR 6.36-11.70). There was no association between CTM depth and sex (beta -0.33, 95% CI -1.33 to 0.68, p=0.53), height (cm) (beta 0.01, 95% CI -0.05 to 0.06, p=0.79) or age (years) (beta -0.01, 95% CI 0.10 to 0.15, p=0.62). Increasing weight (kg) (beta 0.12, 95% CI 0.10 to 0.15, p<0.001) and BMI (kg/m(3)) (beta 0.52, 95% CI 0.44 to 0.60, p<0.001) were strongly associated with CTM depth. Predicted CTM depth increased from 6.4 mm (95% CI 4.9 to 8.1) at a BMI of 20 kg/m(2) to 16.8 (95% CI 13.7 to 20.1) at BMI 40 kg/m(2). CONCLUSION: CTM depth was strongly associated with BMI in a retrospective analysis of patients having clinical CT scans.

Emerg Med J  Feb 2021

Updated 3-26-21

Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management

Rebecca L. Kornas, MD,* Clark G. Owyang, MD,† John C. Sakles, MD,‡ Lorraine J. Foley, MD, MBA

Multiple international airway societies have created guidelines for the management of the difficult

airway. In critically ill patients, there are physiologic derangements beyond inadequate

airway protection or hypoxemia. These risk factors contribute to the “physiologically difficult

airway” and are associated with complications including cardiac arrest and death. Importantly,

they are largely absent from international guidelines. Thus, we created management recommendations

for the physiologically difficult airway to provide practical guidance for intubation

in the critically ill. Through multiple rounds of in-person and telephone conferences, a multidisciplinary

working group of 12 airway specialists (Society for Airway Management’s Special

Projects Committee) over a time period of 3 years (2016–2019) reviewed airway physiology

topics in a modified Delphi fashion. Consensus agreement with the following recommendations

among working group members was generally high with 80% of statements showing agreement

within a 10% range on a sliding scale from 0% to 100%. We limited the scope of this analysis to

reflect the resources and systems of care available to out-of-operating room adult airway providers.

These recommendations reflect the practical application of physiologic principles to airway

management available during the analysis time period. (Anesth Analg 2021;132:395–405)

Added 3/5/21

Barry N. Singleton1,*, Fiachra K. Morris2, Barbaros Yet3, Donal J. Buggy4 and Zane B. Perkins5

 Effectiveness of intubation devices in patients with cervical spine immobilisation: a systematic review and network meta-analysis

 Background: Cervical spine immobilisation increases the difficulty of tracheal intubation. Many intubation devices have

been evaluated in this setting, but their relative performance remains uncertain.

Methods: MEDLINE, EMBASE, and the Cochrane Library were searched to identify randomised trials comparing two or

more intubation devices in adults with cervical spine immobilisation. After critical appraisal, a random-effects network

meta-analysis was used to pool and compare device performance. The primary outcome was the probability of firstattempt

intubation success (first-pass success). For relative performance, the Macintosh direct laryngoscopy blade was

chosen as the reference device.

Conclusions: For intubation performed with cervical immobilisation, seven devices had a better probability of first-pass

success compared with the Macintosh. However, more studies using MILS (rather than a cervical collar or other alternative)

are needed, which more accurately represent clinical practice.

British Journal of Anaesthesia, xxx (xxx): xxx (xxxx)

doi: 10.1016/j.bja.2020.12.041

Advance Access Publication Date:

Added 1/30/21

Comparison between ultrasound-guided and digital palpation techniques for identification of the cricothyroid membrane: a meta-analysis.

Hung KC, Chen IW, Lin CM, Sun CK.    Br J Anaesth. 2021;126(1):e9-e11.

Surgical cricothyrotomy is a potentially life-saving procedure in the ‘cannot intubate/cannot oxygenate’ scenario. As this procedure is not performed frequently, the conventional use of digital palpation to identify the cricothyroid membrane carries the risk of misidentification and failed cricothyrotomy. The recent introduction of ultrasound-guided identification of the cricothyroid membrane could be a potential solution. A few published RCTs have shown the effectiveness of this ultrasound approach for improving the success rate of cricothyroid membrane identification compared with the conventional palpation technique. However, most of these trials were small scale and conducted in different settings (e.g. emergency room or anaesthesia care unit), and a number of studies failed to show significant differences in the accuracy of cricothyroid membrane identification between the two techniques. Furthermore, there are concerns that the use of ultrasound technique may prolong the procedure time, which can be life threatening in an emergency situation. We conducted this meta-analysis to analyse whether the ultrasound-guided approach is superior to the palpation technique

Added 1/20/21

Airway management in the critically ill

Sheila Nainan Myatra

Despite advances in the management of critically ill patients, tracheal intubation in these patients remains a

high-risk procedure associated with increased morbidity and mortality. Recent interventions to enhance patient

safety and improve first pass success in tracheal intubation emphasize reducing repeated attempts at tracheal

intubation, oxygen desaturation and cardiovascular collapse during airway management by optimizing

patient physiology to mitigate risks and avoid complications. These include various strategies to improve periintubation

oxygenation like use of noninvasive ventilation, high flow nasal cannula oxygen and gentle mask

ventilation between induction of anesthesia and laryngoscopy; use of a videolaryngoscope and a bougie;

careful selection of drugs including neuromuscular blocking agent; improved strategies to avoid

haemodynamic collapse; rescue oxygenation strategies and human factor considerations.

Summary

Recognizing the challenges and using the appropriate interventions to improve first pass tracheal intubation

success, while maintaining patient safety are essential during tracheal intubation in critically ill patients. This

review will provide recommendations based on the current evidence, various guidelines and expert opinion in

the field. Further research will help us better understand the best strategies to improve patient outcomes.

Current Opinion in Critical Care

2020, published ahead of print

Added 10/15/21

An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts

Added 9/3/20

 Use of the intubating laryngeal mask airway in the emergency

department: A ten-year retrospective review

Brian E. Driver, Marc Martel , Tarissa Lai , Tracy A.Markob, Robert F. Reardon 

 American Journal of Emergency Medicine 38 (2020) 1367–1372

Background: Extraglottic devices, such as the intubating laryngeal mask airway (ILMA), facilitate ventilation and oxygenation and are useful for emergency airway management, especially as rescue devices. In the operating room setting the ILMA has been highly successful. However, its performance in the ED has not been described. We sought to describe the indications for and success of the ILMA when used in the ED. Methods: We performed retrospective, observational study of patients who had an LMA® Fastrach™ (hereafter termed ILMA) placed in a single ED between 2007 and 2017. Patients were identified by keyword search of ED notes in the electronic medical record. Trained abstractors reviewed charts and videos to determine patient characteristics,  indication for ILMA placement, success of oxygenation and ventilation, intubation methods and success, and complications related to the device. Results: During the study period 218 patients had an ILMA placed in the ED. The ILMA was used as a primary device in 118 patients (54%), and as a rescue device in 100 patients (46%). The median number of ILMA uses per faculty physician during the study period was 3. The ILMA oxygenated and ventilated successfully in 212 instances (98%), including 96 times (96%) when used as a rescue airway. Failure of oxygenation was due to tracheal injury (2), abnormal laryngeal inlet anatomy (2), or poor operator technique (1). Intubation through the ILMA was successful in 159 of 192 patients (83%), including a success rate of 81% (112 of 139 patients) with blind intubation. Conclusion: The ILMAwas highly successful in oxygenation, with reasonable intubation success, even when used infrequently by emergency physicians. The ILMA should be considered a valuable primary and rescue intubation device in the ED.

Added 11/18/19

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.

Added 11/10/19

 The midline approach for endotracheal intubation using GlideScope video laryngoscopy could provide better glottis exposure in adults: a randomized controlled trial.

 Added 10/24/19

High-Flow Nasal Oxygen Improves Safe Apnea Time in Morbidly Obese Patients Undergoing General Anesthesia: A Randomized Controlled Trial.

Added 10/16/19

A Narrative Review of Oxygenation During Pediatric Intubation and Airway Procedures.

Added 9/26/19

Supraglottic airway devices in difficult airway management: a retrospective cohort study of 658,104 general anaesthetics registered in the Danish Anaesthesia Database.

Added 9/19/19

Added 9/3/19

 Added 8/15/19

Added 8/2/19

Airway changes following labor and delivery in preeclamptic parturients: a prospective case control study.

Added 7/17/19

Supraglottic airway devices in difficult airway management: a retrospective cohort study of 658,104 general anaesthetics registered in the Danish Anaesthesia Database. Anaesthesia. 2019 Feb;74(2):151-157. doi: 10.1111/anae.14443. Epub 2018 Oct 4.

Added 6/27/19

Endotracheal Intubation with the King Laryngeal Tube™ In Situ Using Video Laryngoscopy and a Bougie: A Retrospective Case Series and Cadaveric Crossover Study. 

J Emerg Med. 2017 Apr;52(4):403-408

Added 6/13/19

Pre-operative voice evaluation as a hypothetical predictor of difficult laryngoscopy. 

Anaesthesia. 2019 Jun 11. 

Added 6/3/19

The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients.

Added 5/24/19

The inaccuracy of using landmark techniques for cricothyroid membrane identification: a comparison of three techniques.

 Added 5/16/19

The inaccuracy of using landmark techniques for cricothyroid membrane identification: a comparison of three techniques.

Added 5/3/19

Added 4/3/19

Added 3/28/19

Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel–finger–tube’ method

Added 2/20/19

Current practice for awake fiberoptic intubation- some unanswered questions

Editorial  T Murphy and B Howes

Anesthesia 2017, 72, 678-9

Mask ventilation.

Added 12/28/18

Note from Will Rosenblatt, MD  The following article from EMS services lends evidence to what we have believed for many years, and was in-part confirmed in 2004 from the landmark paper from Tom Mort, that there is a point of diminishing returns when it comes to repeated attempts at airway management. Validation is a wonderful thing - both validation of our opinions and of prior research. I encourage you to read the full article. 

Defining the plateau point: When are further attempts futile in out-ofhospital

advanced airway management?☆

Jeffrey L. Jarvisa,b,⁎, Dustin Bartonc, Henry Wangd

A B S T R A C T

Background: We sought to characterize the number of attempts required to achieve advanced airway management (AAM) success.

Methods: Using 4 years of data from a national EMS electronic health record system, we examined the following subsets of attempted AAM: 1) cardiac arrest intubation (CA-ETI), 2) non-arrest medical intubation (MED-ETI), 3) non-arrest trauma intubation (TRA-ETI), 4) rapid-sequence intubation (RSI), 5) sedation-assisted ETI (SAI), and 6) supraglottic airway (SGA). We determined the first pass and overall success rates, as well as the point of additional attempt futility (“plateau point”).

Results: Among 57,209 patients there were 64,291 AAM. CA-ETI performance was: first-pass success (FPS) 71.4% (95% CI: 70.9–71.9%), 4 attempts to reach 91.5% (91.2–91.9%) success plateau. MED-ETI performance was: FPS 66.0% (95% CI: 65.1–67.0%), 3 attempts to reach 79.2% (78.4–80.0%) success plateau. TRA-ETI performance was: FPS 61.6% (95% CI: 59.3–63.9%), 3 attempts to reach 75.8% (73.7–77.8%) success plateau. RSI performance was: FPS 76.1% (95% CI: 75.1–77.1%), 5 attempts to reach 95.8% (95.3–96.2%) success plateau. SAI performance was: FPS 66.9% (95% CI: 65.1–68.6%), 3 attempts to 85.3% (83.9–86.6%) success plateau. SGA performance was: FPS 88.7% (95% CI: 88.0–89.3%), 5 attempts to reach 92.8% (92.3–93.4%) success plateau.

Conclusion: Multiple attempts are often needed to accomplish successful AAM. The number of attempts needed to accomplish AAM varies with AAM technique. These results may guide AAM practices

Added 11/24/18 

Obstructing pathology of the upper airway in a post-NAP4 world: time to wake up to its optimal management 

Law JA, Morris IR, Malpas G  Canadian Journal of Anesthesia/Journal canadien d'anesthésie

November 2017, Volume 64, Issue 11, pp 1087–1097

Added 11/13/18

Added 10/5/18

Predictive risk factors of failed laryngeal mask airway insertion at first attempt.

Added 9/28/18 

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Added September 24, 2018

 Crit Care. 2018 Sep 23;22(1):236. doi: 10.1186/s13054-018-2150-6.

Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures.

Added September 7, 2018

Gastric emptying is not prolonged in obese patients.

 Added Aug 29, 2018

Obesity and GERD.

Added Aug 1, 2018

Videolaryngoscope versus Macintosh laryngoscope for tracheal intubation in adults with obesity: A systematic review and meta-analysis.

Hoshijima H, Denawa Y, Tominaga A, Nakamura C, Shiga T, Nagasaka H. J Clin Anesth. 2018 Feb;44:69-75.Author information

Abstract

The following list includes citations that have been incorporated into the AOD lectures.

Added July 16, 2018

Work of breathing for cuffed and uncuffed pediatric endotracheal tubes in an in vitro lung model setting.

Thomas J, Weiss M, Cannizzaro, Both CP, Schmidt AR, Paediatr Anaesth. 2018 Jul 13. 

Abstract 

BACKGROUND: 

Added July 10, 2018

Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children.

Kojima T1, Harwayne-Gidansky I2, Shenoi AN3, Owen EB4, Napolitano N5, Rehder KJ6, Adu-Darko MA7, Nett ST8, Spear D9, Meyer K10, Giuliano JS Jr11, Tarquinio KM12, Sanders RC Jr13, Lee JH14, Simon DW15, Vanderford PA16, Lee AY17, Brown CA 3rd18, Skippen PW19, Breuer RK20, Toedt-Pingel I21, Parsons SJ22, Gradidge EA23, Glater LB24, Culver K2, Nadkarni VM25, Nishisaki A25; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI).

Pediatr Crit Care Med. 2018 Jun;19(6):528-537

Added July 6

Roth D1, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H.

Cochrane Database Syst Rev. 2018 May 15

Added June 6, 2018

Cochrane Database Syst Rev. 2018 Jun 4;6

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates.

Lingappan K, Arnold JL, Fernandes CJ, Pammi M.

 Added 5/31/18

Importance  The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear.

Added 5/15/18

Rahmani F, Parsian Z, Shahsavarinia K, Pouraghaei M, Negargar S, Mehdizadeh Esfanjani R, Soleimanpour H.

Anesth Pain Med. 2017 Nov 12;7(6):e58350. 

Added 5/1/18

Nasal highflow eliminates CO2 from lower airways.

Bräunlich J, Goldner F, Wirtz H. Respir Physiol Neurobiol. 2017 Aug;242:86-88. 

INTRODUCTION: 

 Added 3/1/18

The Utility of the C-MAC as a Direct Laryngoscope for Intubation in the Emergency Department.

Sakles JC, Mosier JM, Patanwala AE, Arcaris B, Dicken JM. J Emerg Med. 2016 Oct;51(4):349-357

 Abstract

Capnography versus standard monitoring for emergency department procedural sedation and analgesia.

Wall BF, Magee K, Campbell SG, Zed PJ.Cochrane Database Syst Rev. 2017 Mar 23;3:CD010698. dAuthor information

Added 2/5/18

 Comparison Between Direct and Video-assisted Laryngoscopy for Intubations in a Pediatric Emergency Department.

Added 1/11/18

Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.

Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.

Added 1/5/18

Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.

Yeatts DJ1, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.

J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.

Added 12/13/17

Morbidity and mortality in children undergoing bronchoscopy for foreign body removal.

Roberts CA, Carr MM. Laryngoscope. 2017 Aug 17. 

Abstract

Added 12/4/17

The Impact of a Soiled Airway on Intubation Success in the Emergency Department When Using the GlideScope or the Direct Laryngoscope.

Sakles JC, Corn GJ, Hollinger P, Arcaris B, Patanwala AE, Mosier JM1. Acad Emerg Med. 2017 May;24(5):628-636. doi: 10.1111/acem.13160. Epub 2017 Mar 17.

Predictors of complicated airway foreign body extraction.

Sjogren PP, Mills TJ, Pollak AD, Muntz HR, Meier JD1, Grimmer JF.

Laryngoscope. 2017 Aug 16. doi: 10.1002/lary.26814. [Epub ahead of print] 

Added 11/15/17

The Impact of a Soiled Airway on Intubation Success in the Emergency Department When Using the GlideScope or the Direct Laryngoscope.

Sakles JC1, Corn GJ, Hollinger P, Arcaris B, Patanwala AE, Mosier JM1. Acad Emerg Med. 2017 May;24(5):628-636.  

Added 11/5/17 

Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit.

Joshi R, Hypes CD, Greenberg J, Snyder L, Malo J, Bloom JW, Chopra H, Sakles JC, Mosier JM.

Ann Am Thorac Soc. 2017 Mar;14(3):368-375. doi: 10.1513/AnnalsATS.201606-472OC.

Added 10/14/17

Management of Patients with Predicted Difficult Airways in an Academic Emergency Department.

Sakles JC, Douglas MJK, Hypes CD, Patanwala AE, Mosier JM. J Emerg Med. 2017 Aug;53(2):163-171

Abstract

Added 9/30/17

Comparison Between Direct and Video-assisted Laryngoscopy for Intubations in a PediatricEmergency Department.

Eisenberg MA, Green-Hopkins I, Werner H, Nagler J. Acad Emerg Med. 2016 Aug;23(8):870-7.

Abstract

Added 9/21/17

Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department.

Added 8/23/27

Management of Patients with Predicted Difficult Airways in an Academic Emergency Department.

Sakles JC, Douglas MJK, Hypes CD, Patanwala AE, Mosier JM

J Emerg Med. 2017 Aug;53(2):163-171. doi: 10.1016/j.jemermed.2017.04.003. Epub 2017 Jun 9.

Added 8/4/17

Surgical Management of Supraglottic Stenosis Using Intubationless Optiflow.

Tam K, Jeffery C, Sung CK.

Ann Otol Rhinol Laryngol. 2017 Aug 1

Abstract

Added 7/21/17

The use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) in 17 cases of subglottic stenosis.

To K, Harding F, Scott M, Milligan P, Nixon IJ, Adamson R, McNarry AF

Clin Otolaryngol. 2017 Jun 21

 Added 5/16/17

Safety and Efficacy of Dexmedetomidine as a Sedative Agent for Performing Awake Intubation: A Meta-analysis.

Zhou LJ1, Fang XZ, Gao J, Zhangm Y, Tao LJ Am J Ther. 2016 Nov/Dec;23(6):e1788-e1800. 

Added 5/9/17

Incidence and risk factors for early postoperative reintubations

Tillquist MN, Gabriel RA, Dutton RP, Urman RD. J Clin Anesth. 2016 Jun;31:80-9

Added 5/3/17

Preoxygenation: Physiologic Basis, Benefits, and Potential Risks.

Nimmagadda U1, Salem MR, Crystal GJ.

Anesth Analg. 2017 Feb;124(2):507-517.

Added 4/26/17

Angioedema in the emergency department: a practical guide to differential diagnosis and management.

Bernstein JA, Cremonesi P, Hoffmann TK, Hollingsworth J, Int J Emerg Med. 2017 Dec;10(1):15

Added 4/18/17

Perioperative Complications in Obstructive Sleep Apnea Patients Undergoing Surgery: A Review of the Legal Literature.

Fouladpour N1, Jesudoss R, Bolden N, Shaman Z, Auckley D. Anesth Analg. 2016 Jan;122(1):145-51.

Abstract

Added 4/13/17

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation.

Lewis SR1, Butler AR, Parker J, Cook TM, Smith AF. Cochrane Database Syst Rev. 2016 Nov 15;11:CD011136.

 Added 3/22/17

Effect of Boussignac continuous positive airway pressure ventilation on Pao2 and Pao2/Fio2 ratio immediately after extubation in morbidly obese patients undergoing bariatric surgery: a randomized controlled trial.

Added 3/3/17

Preoxygenation: Physiologic Basis, Benefits, and Potential Risks.

Nimmagadda U1, Salem MR, Crystal GJ. Anesth Analg. 2017 Feb;124(2):507-517. 

 Added 2/28/17

Safety and Efficacy of Dexmedetomidine as a Sedative Agent for Performing Awake Intubation: A Meta-analysis.

Am J Ther. 2016 Nov/Dec;23(6):e1788-e1800.

Added 2/16/17

A comparison of videolaryngoscopes for tracheal intubation in predicted difficult airway: a feasibility study.

Vargas M, Pastore A, Aloj F, Laffey JG, Servillo G

Added 1/24/17

Massive Subcutaneous Emphysema and Bilateral Tension Pneumothoraces After Supplemental Oxygen Delivery via an Airway Exchange Catheter: A Case Report.

Hulst AH, Avis HJ, Hollmann MW, Stevens MF. AA Case Rep. 2017 Jan 15;8(2):26-28

Added AOD 12/23/16

Choice of anesthesia for category-1 caesarian section in women with anticipated difficult tracheal intubation: the use of decision analysis

A.J. Krom et al. Anaesthesia 2016 (Pre-publication) 

Abstract

Added AOD 11/21/16

A cadaver study comparing three fibreoptic-assisted techniques for converting a supraglottic airway to a cuffed tracheal tube.

Olesnicky BL, Rehak A, Bestic WB, Brock JT, Patterson L. Anaesthesia. 2016 Nov 11. doi: 10.1111/anae.13733. [Epub ahead of print]

Added AOD 11/8/16

Mask Ventilation during Induction of General Anesthesia: Influences of Obstructive Sleep Apnea.

Sato S1, Hasegawa M, Okuyama M, Okazaki J, Kitamura Y, Sato Y, Ishikawa T, Sato Y, Isono S. Anesthesiology. 2016 Nov 2. [Epub ahead of print]

Abstract

Added AOD 11/2/16

Emergency ventilation with the Ventrain® through an airway exchange catheter in a porcine model of complete upper airway obstruction.

de Wolf MW1, Gottschall R2, Preussler NP2, Paxian M2, Enk D3.

Author information

Direct Versus Video Laryngoscopy for Intubating Adult Patients with Gastrointestinal Bleeding.

Carlson JN1, Crofts J1, Walls RM2, Brown CA 3rd2. West J Emerg Med. 2015 Dec;16(7):1052-6. doi: 10.5811/westjem.2015.8.28045.  

Comment by Dr. Rosenblatt: Ive long said that VL should supplant DL, except maybe in one situation - the blood airway (i.e., GI bleed).  Just about ready to say "I was wrong!"  Lots of success with VL in documented GI bleed here.

ADDED AOD 10/7/16

Effect of Boussignac continuous positive airway pressure ventilation on PaO2 and PaO2/FIO2 ratio immediately after extubation in morbidly obese patients undergoing bariatric surgery:

Guimarães J, et al.

Journal of Clinical Anesthesia (2016) 34, 562–570

Abstract

Study Objective: Pathophysiological changes after laparoscopic Roux-en-Y gastric bypass may increase the risk of pulmonary complications in morbidly obese patients. The purpose of the study was to assess the impact of immediate postextubation use of Boussignac continuous positive airway pressure (CPAP) on arterial oxygenation in morbidly obese patients undergoing laparoscopic Roux-en Y gastric bypass. The hypothesis is that the use of CPAP may improve oxygenation in the postoperative period when compared to Venturi mask. Design: Randomized controlled study.

Journal of Clinical Anesthesia (2016) 34, 562–570

ADDED AOD 9/22/16

Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure.

Driver BE, Plummer D, Heegaard W, Reardon RF.

J Emerg Med. 2016 Sep 17. pii: S0736-4679(16)30454-1

ADDED AOD 9/12/16

ADDED AOD 9/5/16

Transtracheal jet ventilation in the 'can't intubate can't oxygenate' emergency: a systematic review.

Duggan LV1, Ballantyne Scott B2, Law JA3, Morris IR4, Murphy MF5, Greendale DE, Br J Anaesth. 2016 Sep;117 Suppl 1:i28-i38. 

 heading 3 title  5 all else