Airway management during the perioperative period is a vital component of perioperative care. However, there is a lack of consensus on the selection of medications, timing of administration, and the management of airway complications. This consensus aimed to promote a more rational and standardized application of airway management medications.

Clinical medical and pharmaceutical experts were invited to participate in this study using the modified Delphi method. Participants completed two rounds of online surveys, with the second round based on the responses from the first round.

Participants (n = 42) reached a consensus on 11 clinical issues and formed 11 recommendations for clinical practice, each with a consensus degree of more than 80%. The recommendations covered aspects of preoperative, intraoperative, and postoperative risk factors evaluation, along with crucial points of medication monitoring in preventing and treating perioperative pulmonary complications.

The modified Delphi method resulted in consensus recommendations for the perioperative physician-pharmacist airway co-management. We hope this consensus will prevent pulmonary complications and improve patient outcomes through collaborative discussions between physicians and pharmacists.

Difficult ventilation and intubation in anaesthesia are highly complex and challenging for the anaesthetist. We aim to present a case of successful nasotracheal intubation with surgical incision and video laryngoscope in a patient with anticipated difficult ventilation and intubation due to a limited mouth opening. A patient was an 81-year-old female scheduled for oral surgery for lip cancer. The patient's American Society of Anesthesiologists (ASA) physical classification was class III, and the oral airway was assessed as a Mallampati Class IV. A comprehensive preoperative evaluation of the patient revealed limited mouth opening (distance between incisors 1cm) and multiple decayed and broken teeth. A 2cm surgical incision of the skin was performed by plastic surgery under local anaesthesia and sedation without general anaesthesia. A high-flow nasal cannula (HFNO) was used for preoxygenation and to prevent desaturation during a difficult intubation. The oral cavity was topicalised with 2% lidocaine, and after the topical nasal vasoconstrictor to the nasal cavity, we selected a 7.0mm nasal flexible endotracheal tube (ETT). We inserted it into the right nostril with a video laryngoscope under local anaesthesia and sedation without general anaesthesia, and then, the patient's nasotracheal intubation was successfully performed. A multidisciplinary team approach to airway management should include all participants in planned patient care in the operating room, intensive care unit (ICU), post-anaesthesia care unit, or ward.

The aim of this study was to investigate the incidence, risk factors and airway management of postoperative haematoma following anterior cervical spine surgery (ACSS).

A retrospective nested case-control study.

A tertiary hospital in China.

A total of 13 523 patients within a single-centre longitudinal ACSS cohort were identified from March 2013 to February 2022. Patients with postoperative haematoma after ACSS were enrolled as the haematoma group, and others in the cohort without haematoma were randomly selected as the non-haematoma group by individually matching with the same operator, same gender, same surgery year and similar age (±5 years) at a ratio of 4:1. Subsequently, patients with haematoma were included in a subgroup for analysis.

Postoperative haematoma and difficult intubation prior to haematoma evacuation.

The incidence of postoperative haematoma out of all ACSS was 0.4% (55/13 523). A total of 275 patients were enrolled in the study, including 55 patients in the haematoma group and 220 patients in the non-haematoma group. Anterior cervical corpectomy and fusion (ACCF) (OR 2.459; 95% CI 1.302 to 4.642; p =0.006) and the maximum mean arterial pressure (MAP) during recovery (OR 1.030; 95% CI 1.003 to 1.058; p =0.028) were identified as independent risk factors for haematoma. In the subgroup analysis, 29% of patients with haematoma experienced difficult intubation, and retropharyngeal haematoma (OR 10.435; 95% CI 1.249 to 87.144; p =0.030) was identified as an independent risk factor for difficult intubation. Patients with haematoma had longer hospitalisation duration (p <0.001) and greater costs associated with their stay (p <0.001).

ACCF and elevated maximum MAP during the recovery period were independent risk factors for postoperative haematoma following ACSS. Patients with post-ACSS haematoma are at high risk of a difficult airway, with retropharyngeal haematoma being strongly associated with challenging airway management. Postoperative haematoma was associated with longer hospitalisation duration and greater costs.

China Clinical Trial Registry: ChiCTR2400086263.

Ankylosing spondylitis (AS) is a chronic inflammatory disease that leads to progressive spinal rigidity and severe cervical deformities, making airway management highly challenging for anesthesiologists.

We report a case of a 45-year-old patient with severe AS complicated by a cervical spine fracture and extreme cervicothoracic kyphosis. Due to a significantly limited mouth opening and an unassessable thyromental distance, conventional intubation methods were not feasible. Awake fiberoptic nasotracheal intubation, facilitated by remifentanil infusion and topical anesthesia, was successfully performed while maintaining spontaneous breathing. However, despite effective airway management, the patient later developed a massive pulmonary embolism leading to cardiac arrest.

Airway management in AS patients requires a tailored approach based on anatomical limitations. Fiberoptic intubation remains the gold standard in severe cases, ensuring minimal cervical movement and optimal visualization. Alternative methods, such as videolaryngoscopy and laryngeal mask airway placement, may be useful in selected cases. However, in cases of extreme deformity, tracheostomy remains a last-resort option.

Awake fiberoptic intubation remains the safest approach in severe AS cases with cervical spine involvement, minimizing the risk of spinal cord injury and ensuring airway security.

This article reviews the key elements of anesthesia care for patients presenting for craniofacial surgeries, including preoperative evaluation and preparation, intraoperative management, and pain management strategies.

Flexible optical intubation (FOI) is the preferred technique for managing anticipated difficult airways, particularly in awake patients when anatomical factors complicate conventional laryngoscopy. Mastering the procedure requires skills, but a comprehensive overview of the evidence on training and assessment of FOI skills is lacking. There is no evidence-based consensus on educational strategies and recommendations for skill acquisition and retention, thus highlighting a significant gap in airway management training. Accordingly, we aim to assess the current evidence on training and assessment in FOI for future educational recommendations.

This scoping review adheres to the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) statement and the PRISMA Extension for Scoping Reviews guideline. Eligible studies include qualitative and quantitative research focusing on education, technical training, and assessment of FOI skills in clinical personnel with no obligate comparator. Outcomes should be assessable using Kirkpatrick's four levels of training evaluation. A systematic literature search will be conducted across multiple databases, including Cochrane Library, EMBASE, Cinahl, Scopus, and PubMed. Two independent authors will screen the studies, with discrepancies resolved by a third reviewer. Extracted data will be analyzed descriptively, with a discussion on potential biases in the included literature. The quality of the studies will be assessed using the Medical Education Research Study Quality Instrument (MERSQI).

The results of this scoping review may serve as a foundation for educational recommendations. By synthesizing available evidence, this review aims to guide future research and policy recommendations for FOI skill acquisition and maintenance.

Although mandibular retrognathia has been recognized as one of the predictors of difficult laryngoscopy, its definition remains vague, with no clearly established skeletal evaluation systems. The Sassouni classification system, used to categorize the maxillofacial morphology systematically (nine types), can be easily performed using preoperative radiographic findings. This study aimed to investigate the relationship between difficult laryngoscopy and Sassouni type 5, a group characterized by a small mandible and a large overbite.

This retrospective study comprised patients diagnosed with jaw deformities who underwent orthognathic surgery for malocclusion under general anesthesia at our clinic. The patients were divided into two groups: Sassouni 5 and non-Sassouni 5 (types 1, 2, 3, 4, 6, 7, 8, and 9). Difficult laryngoscopy was evaluated by examining the degree of difficulty in laryngeal exposure, which was defined as grades 3 and 4 based on the Cormack-Lehane (CL) classification. Additionally, we evaluated the relationships between the Sassouni 5 group and three predictors of difficult laryngoscopy (Mallampati classification, Wilson score, and hyomental distance [HMD]).

Of the 187 patients included in this study, 44 belonged to the Sassouni 5 group, and the remaining 143 belonged to the non-Sassouni 5 group. The proportion of patients with CL grade 3 or higher was significantly higher in the Sassouni 5 group (n = 9; 20.5%) than in the non-Sassouni 5 group (n = 6; 4.2%). Furthermore, 10 (22.7%) patients in the Sassouni 5 group had a Mallampati score of 3 or higher, 44 (100%) had a Wilson score of 2 or higher, and 38 (96.7%) had an HMD of less than 3 fingerbreadths. The corresponding numbers in the non-Sassouni 5 group were 8 (5.6%), 48 (33.6%), and 43 (30.1%), respectively. The incidence of difficult laryngoscopy in the Sassouni 5 group was significantly higher than that in the non-Sassouni 5 group (p < 0.001).

These findings indicate that the incidence of difficult laryngoscopy can be predicted using the Sassouni classification, which can be easily analyzed using lateral cephalograms obtained routinely before corrective surgical procedures. The Sassouni 5 group could be used as an important predictive tool in clinical practice.

In hypoxemic children with difficult airway, or for minor elective procedures, the use of a supraglottic airway device may be preferred to endotracheal intubation, whether with a laryngeal mask or laryngeal tube. Second-generation laryngeal masks may offer a better safety profile. Whether they should be preferred to laryngeal tubes is unknown. This study aimed to compare the efficacy and safety of second-generation laryngeal masks and laryngeal tubes in children.

This randomised-controlled trial was conducted in a single university hospital in children <18 years undergoing elective anaesthesia in urology, minor paediatric surgery and gynaecology. Patients were 1 : 1 randomised to the laryngeal mask or laryngeal tube group. Children were allocated a second-generation laryngeal tube or a second-generation laryngeal mask as the primary airway device. The primary endpoint was insertion time. Secondary endpoints included first-attempt success, overall success and complications, which included hypoxia (SpO 2  < 90%), laryngospasm, bronchospasm, aspiration and bleeding.

In total, 135 patients were randomised, with 61 allocated to the laryngeal tube and 74 to the laryngeal mask group, with a median age of 5.4 and 4.9 years, respectively. Median insertion time was significantly longer in the laryngeal tube group (37 vs. 31 s; difference of medians: 6.0 s; 95% confidence interval: 0.0-13.0). The laryngeal tube had a significantly lower first-attempt (41.0%) and overall success rate (45.9%) than the laryngeal mask (90.5% and 97.3%, respectively). Those allocated to the laryngeal tube group had a higher ratio of complications (27.8%) compared to the laryngeal mask group (2.7%).

This randomised-controlled trial reported that in children undergoing elective anaesthesia, the use of a laryngeal tube was associated with a longer insertion time.

Apnoeic oxygenation using high-flow nasal oxygen is becoming a commonly used technique in adult patients undergoing laryngotracheal surgery. Despite widespread adoption, there are no best practice guidelines governing its safe delivery.

To develop a checklist for use during laryngotracheal surgery to guide the safe delivery of apnoeic oxygenation using high-flow nasal oxygen.

Recognised experts in the field of apnoeic oxygenation were invited to participate in a Delphi process to establish essential items for inclusion in the safety checklist. An online Delphi survey platform was used to facilitate this process.

A panel of 36 experts was assembled from 11 countries. They participated voluntarily in an 8-week Delphi process that included one preliminary round, two electronic voting rounds and a final virtual roundtable discussion. A small steering group was responsible for leading the Delphi process, collating the electronic voting responses, analysing the results and compiling the final checklist.

The consensus threshold for inclusion/exclusion of items in the safety checklist was set at at least 80% for the first and second electronic voting rounds. The consensus threshold was set at 70% for the final roundtable discussion.

The final checklist comprises 19 items, sub-divided into pre-procedure, peri-procedure and post-procedure aspects of patient care. The Delphi process was well attended, with an expert attrition rate of only 6%. A number of items reached more than 90% consensus, including the requirement to establish patients' suitability for the technique in advance of surgery and preparedness for the immediate implementation of an agreed individualised rescue oxygenation strategy.

A Delphi process involving international experts has formulated a 19-item checklist for guiding the safe delivery of apnoeic oxygenation using high-flow nasal oxygen in adult patients undergoing laryngotracheal surgery. Further studies are required to assess the effects of this checklist on patient safety and outcomes.

The optimal introducer for tracheal intubation with a hyperangulated blade videolaryngoscope for patients in the ICU remains uncertain. Both stylets and flexible-tip bougies have been used, yet there is limited evidence on which is more efficacious.

We conducted a randomised controlled trial comparing flexible-tip bougie vs. stylet using a hyperangulated blade videolaryngoscope (C-MAC® D-blade). Adults admitted to the ICU who required tracheal intubation were included. Primary outcome was first-attempt tracheal intubation success. Secondary outcomes included the number of tracheal intubation attempts; tracheal intubation difficulty; and incidence of complications.

A total of 140 patients were allocated randomly (40 female (29%); mean (SD) age 68 (13.0) y). First-attempt tracheal intubation success was higher in patients allocated to flexible-tip bougie (69/70, 99%) compared with stylet (58/70 (83%), p = 0.005). The proportion of patients' tracheas intubated in one, two or three attempts was 69/70 (99%), 1/70 (1%) and 0/70 (0%) in the flexible-tip bougie group, compared with 58/70 (83%), 7/70 (10%), and 5/70 (7%) in the stylet group, respectively. More patients in the stylet group required laryngeal manipulation (22/70 (31.4%)) during tracheal intubation compared with the flexible-tip group (7/70 (10%)). Anaesthetists rated 69/70 (99%) of tracheal intubations with the flexible-tip bougie as not difficult or slightly difficult compared with 63/70 (90%) for the stylet group. No significant difference in the incidence of complications was observed between the two techniques.

In the ICU, first-attempt tracheal intubation success with a hyperangulated blade videolaryngoscope was higher using the flexible-tip bougie than the stylet. No differences were observed in operator difficulty or complication rates between the two techniques.

Visual laryngoscope, as the most commonly used tracheal intubation tool in clinical practice, has a high intubation success rate and is quick to learn, but there are risks of over flexion of the neck, tooth loss, etc. The visual stylet helps to make up for these shortcomings. This study aimed to compare the effects of the visual stylet and visual laryngoscope on transoral single lumen tracheal intubation in non-difficult airways. The primary outcome was intubation time, and secondary outcomes included glottic exposure time, first success rates, hemodynamic indices, intubation-related complications. A total of 148 patients were included, with 75 in the visual stylet (VS) group and 73 in the visual laryngoscope (VL) group. The intubation time in the VS group was 35 (11) seconds, significantly shorter than the 41 (9) seconds in the VL group (P < 0.001). Immediately post-intubation, the MAP in the VS group was 80 (20.5) mmHg, lower than 87 (23) mmHg in the VL group (P < 0.01). Intubation-related complications are also lower in VS group compared to VL group. Other outcomes don't have significant difference. Our study has demonstrated that the visual stylet significantly reduces intubation time and provides more stable hemodynamics. For patients with limited mouth opening, shorter thyromental distance, or higher Cormack-Lehane grades, the visual stylet may potentially be a better choice compared to video laryngoscopy for tracheal intubation.Trial registration China Clinical Trial Registry (ChiCTR2100051812) (05/10/2021).

Preoxygenation is a crucial preparatory step for intubation. Several strategies for preoxygenation exist, including facemask oxygen, high-flow nasal cannula (HFNC), and non-invasive positive pressure ventilation (NIPPV). However, the comparative efficacy of these strategies remains largely uncertain. We aimed to compare the efficacy and safety of HFNC, NIPPV, and facemask oxygen for preoxygenation of patients who are critically ill requiring tracheal intubation.

In this systematic review and network meta-analysis, we searched Embase, MEDLINE, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials for randomised clinical trials published from database inception until Oct 31, 2024, with no language restrictions. We included randomised controlled trials that compared HFNC versus NIPPV, HFNC versus facemask oxygen, or NIPPV versus facemask oxygen in adult patients (age ≥18 years) who were critically ill requiring intubation in the intensive care or emergency department setting. We had no additional eligibility criteria for our network meta-analysis. We used Covidence software to screen eligible trials. Two reviewers independently screened trials for titles and abstracts, and then subsequently screened full-text reports. Discrepancies were resolved by discussion or a third party adjudicator. Summary-level data were extracted manually using a structured data collection form. Outcomes of interest were hypoxaemia during intubation, successful intubation on the first attempt, serious adverse events, and all-cause mortality. We performed a frequentist random-effects network meta-analysis. We assessed the risk of bias using the modified Cochrane tool (RoB 2.0) and the certainty of evidence using the GRADE approach. The protocol is registered on the Open Science Framework.

We initially identified 6900 records, of which 48 were assessed via full-text screening, and 15 eligible studies with 3420 patients were included in our systematic review and network meta-analysis. Findings suggested that use of NIPPV for preoxygenation probably reduces the incidence of hypoxaemia during intubation versus HFNC (relative risk 0·73 [95% CI 0·55-0·98]; p=0·032; moderate certainty) and reduces the incidence of hypoxaemia versus facemask oxygen (0·51 [0·39-0·65]; p<0·0001; high certainty). HFNC for preoxygenation reduces the incidence of hypoxaemia during intubation versus facemask oxygen (0·69 [0·54-0·88]; p=0·0064; high certainty). None of the preoxygenation strategies affected the incidence of successful intubation on the first attempt (all low certainty). None of the preoxygenation strategies appeared to affect all-cause mortality (very low-to-moderate certainty). NIPPV probably reduces the risk of serious adverse events versus facemask oxygen (0·30 [0·12-0·77]; p=0·011; moderate certainty) and might reduce the risk of serious adverse events versus HFNC (0·32 [0·11-0·91]; p=0·035; low certainty). HFNC might not reduce the risk of serious adverse events versus facemask oxygen (0·95 [0·60-1·51]; p=0·83; low certainty).

Preoxygenation with NIPPV or HFNC rather than facemask oxygen might prevent hypoxaemia during tracheal intubation of adults who are critically ill. Compared with HFNC, NIPPV probably decreases the incidence of hypoxaemia during intubation. Our findings will inform updated international guidelines on preoxygenation.

None.

Background/Objectives: Difficult intubation is a significant clinical issue in emergency medicine as well as anesthesia practice, occurring more frequently in obese patients. Traditional assessment methods may not be sufficient to predict difficult intubation. This study aims to evaluate the ability of ultrasound-measured skin-to-epiglottis distance (SED) to predict difficult laryngoscopy in obese patients and investigate its applicability in clinical practice. Methods: This prospective observational study was conducted between February 2024 and January 2025 at Gaziantep City Hospital on obese patients undergoing bariatric surgery. Patients aged 18 years and older with an American Society of Anesthesiologists (ASA) classification of I-II-III were included in the study. Demographic data, standard airway assessment parameters (neck circumference, thyromental distance, sternomental distance, etc.), and ultrasound-measured skin-to-epiglottis distance were recorded. All intubation procedures were performed by a single experienced anesthesiologist following standard protocols, and laryngoscope view was assessed according to the Cormack-Lehane classification. Results: Among the 61 patients included in the study, 16.4% were classified as having a difficult airway, and 13.1% experienced difficult intubation. No significant correlation was found between standard airway assessment parameters and difficult intubation. However, ultrasound-measured skin-to-epiglottis distance (SED) was significantly higher in patients with difficult intubation (p = 0.004), making it a strong predictor. Additionally, modified Mallampati (p < 0.001), modified Cormack-Lehane (p = 0.003), and Wilson scores (p = 0.001) were significant in predicting difficult airway, although Wilson score was not significant for difficult intubation (p = 0.099). Conclusions: Our study suggests that ultrasound-measured skin-to-epiglottis distance may be a valuable predictor of difficult intubation in obese patients. Given the limitations of preoperative assessment methods, incorporating ultrasound into airway evaluation as a complementary tool provides significant benefits. Larger-scale studies in the future are necessary to further assess the clinical efficacy of this method.

We aimed to determine the clinical predictors of perioperative anticipated and unanticipated difficult intubation using a matched case-control study. We recruited patients undergoing surgery with endotracheal intubation from 2015 to 2020. Difficult intubation was defined as at least 3 attempts to perform intubation with conventional or video laryngoscopy before surgery. Controls were randomly selected in a ratio of 3:1 matching on year of surgery, site of operation and age within 5 years. Clinical predictors were evaluated. A multivariate conditional logistic regression analysis was performed and presented with adjusted odds ratios (OR) and 95% confidence intervals (CI). We selected 168 cases and 504 controls out of 62,111 intubated patients. The predictors for anticipated difficult intubation were previous history of difficult airway (OR [95% CI]: 6.4 [1.3,32.5]) and abnormal facial appearance/syndrome (OR [95% CI]: 6.1 [1.3,28.0]). The predictors of unanticipated difficult intubation were BMI < 15 kg/m2 (OR [95% CI]: 4.6 [1.5,14.4]), ASA physical status of 3 (OR [95% CI]: 3.6 [1.1,11.3]), airway/neck/oral deformity (OR [95% CI]: 2.1 [1.03,4.3]) and tumors at intraoral, airway or thyroid (OR [95% CI]: 2.4 [1.1,4.9]). Undiagnosed airway/neck/oral deformity and tumors at intraoral, airway or thyroid sites might be encountered with unanticipated difficult intubation, especially in patients who have a normal general appearance.

The assessment and management of critically injured pregnant trauma patients represents a high-risk, low-frequency event. One in every 12 pregnant patients experience physical trauma during their pregnancy, but only 0.1% experience major trauma with an injury severity score (ISS) greater than fifteen. It is crucial that emergency medical services (EMS) clinicians understand the anatomic and pathophysiologic changes that impact morbidity and mortality for pregnant trauma patients so they can effectively provide life-saving interventions and resuscitation for this patient population.

Adequate facemask ventilation during induction of anaesthesia is a key aspect of patient safety. Difficulties can therefore be life-threatening for the patient.

The case presented here illustrates a rare cause of an orbital fistula that led to a serious problem during facemask ventilation and demonstrates why team communication is so important.

Preparatory errors in patient assessment and anaesthetic preparation were identified as sources of error.

To determine whether the use of videolaryngoscopy (VL) is more effective than direct laryngoscopy (DL) for orotracheal intubation in obese patients.

This is a systematic review and meta-analysis.

A comprehensive search was conducted in five databases for studies published up to December 26, 2023, using a PICO strategy. Fifteen studies were identified for quantitative analysis and included in our meta-analysis.

The participants of the included primary studies (obese patients).

Orotracheal intubation with videolaryngoscopy or direct laryngoscopy.

Videolaryngoscopy, direct laryngoscopy, intubation time, first--pass success rate, minor complications.

No significant differences were found in intubation time between VL and DL in obese patients (MD: -4.84; 95% CI: -13.49 to 3.80; I2: 90%). In the subgroup analysis, the Airtaq technique showed a significant difference in intubation time compared to the Macintosh technique (MD: -25.29; 95% CI: -49.17 to -1.38; I2: 95%). However, no significant differences were observed in the first--pass success rate (OR: 1.58; 95% CI: 0.77-3.23; I2: 33%) or in complications such as pain (OR: 1.15; 95% CI: 0.75-1.75; I2: 0%) and voice changes (OR: 0.76; 95% CI: 0.46-1.26; I2: 0%) between the two methods.

There are no significant differences in intubation time, first--pass success rate, or complications between VL and DL in obese critical patients.

The objective of this study was to develop an extubation practice protocol for adult intensive care unit (ICU) patients who underwent endotracheal intubation, providing theoretical guidance for clinical extubation procedures in the ICU.

A research team was established consisting of medical, nursing, anaesthesia, and respiratory therapy professionals; the multidisciplinary team systematically searched domestic and foreign literature, summarised the best evidence, and combined it with clinical practice experience to preliminarily develop an extubation protocol for adult ICU patients who underwent endotracheal intubation. Seventeen experts in critical care medicine, intensive care nursing, clinical anaesthesia, and respiratory therapy were invited to participate in a Delphi expert consultation to screen and modify the draft protocol.

The response rates of the two Delphi expert enquiries were 100% and 94.1%, with expert authority coefficients of 0.94 and 0.93, respectively, and Kendall's concordance coefficients were 0.152 and 0.198, respectively, indicating statistically significant differences (p < 0.001). The final protocol included three level I indicators, 14 level II indicators, and 34 level III indicators, covering extubation evaluation, implementation, and postextubation management.

The extubation protocol for adult tracheal intubation patients in the ICU constructed in this study is scientific, practical, and reliable. This study can provide theoretical guidance for extubation in ICU patients who have undergone endotracheal intubation.

Tracheal intubation (TI) is often needed in the intensive care unit (ICU) but can have disastrous consequences. The MACOCHA score was developed for prediction of difficult intubation (DI) in critically ill.

After Institutional Ethics Committee approval, we conducted this prospective, single-center observational study. Evaluated the ability of MACOCHA score to predict difficult intubation in our ICU. We included 500 adults undergoing TI in our ICU. We collected the demographic data, details of ICU admission, and intubation-related data for calculating MACOCHA score. We used Statistical Package for the Social Sciences (version 21) for analysis. The accuracy of MACOCHA score for predicting DI was determined by area under the receiver operating characteristic (AUROC) curve. The Hosmer-Lemeshow goodness-of-fit statistics was used to determine calibration.

Since complete dataset was available for 449/500 patients, we analyzed their data. Acute renal failure and shock were the most frequent reasons for TI. Ketamine and rocuronium were most commonly used drugs for TI. The incidence of DI was 13.5% (60/449). There were 30 patients whose Mallampati score was either III and IV, while 84 and 45 patients had severe hypoxemia and coma before TI, respectively. The AUROC curve for the MACOCHA score was 0.659 (confidence interval, 0.574-0.743), suggesting a moderate discrimination. The Hosmer-Lemeshow goodness-of-fit test showed moderate calibration (χ2 = 3.142, with p = 0.208). One hundred and seventy-one (26.5%) complications occurred in the entire cohort. Some patients had multiple complications.

The MACOCHA score showed moderate discrimination and calibration in predicting DI in our study.

Kulkarni AP, Bhosale SJ, Kalvit KR, Cherian S, Shrivastava AM, Gorade MR. Evaluation of MACOCHA Score for predicting Difficult Intubation in Critically Ill Cancer Patients: A Prospective Observational Study. Indian J Crit Care Med 2025;29(3):208-214.

Obesity poses significant challenges by altering upper airway anatomy and making mask ventilation and tracheal intubation difficult. In 2023, 46.1% women and 35.9% men > 18 years were classified as obese in Qatar, yet intubation complications in this group have not been extensively studied. The aim of this study was to evaluate the frequency and types of intubation complications in adults with severe obesity undergoing bariatric surgery and to identify incidence of difficult intubation and associated risk factors.

In this retrospective cohort study, 2421 patients (1664 females and 746 males) were analyzed. All patients with severe obesity aged over 18 years with a BMI of 40 kg/m2 or higher, who underwent bariatric surgery from January 2014 to January 2024, were included. Difficult intubation was defined as the need for video laryngoscopy, cricothyrotomy, intubation via a supraglottic airway device, use of a stylet or bougie, more than one intubation attempt, or desaturation during intubation.

None of the patients experienced any complications of interest. Video laryngoscope was used in 85 patients (3.5%), first-attempt intubation success rate was 95.4%, with more than one attempt required in 4.6% of cases. Logistic regression revealed that the odds of complicated intubation were 1.5 times higher in patients with a BMI > 60, 8.9 times higher in those with Cormack-Lehane class IV, and 5.1 times higher in patients with Mallampati score of IV. Comorbidities increased the odds by 1.3 times, with asthmatic patients having 2.1-fold higher odds.

This study highlights the challenges of tracheal intubation in patients with severe obesity undergoing bariatric surgery and the need for tailored strategies to manage these difficulties.

Airway management in maxillofacial surgery is a critical aspect of anesthesia and perioperative care, demanding a broad array of techniques to ensure effective ventilation and oxygenation. The anatomical and physiological complexities of maxillofacial procedures necessitate a deep understanding of airway management strategies. Patients undergoing maxillofacial surgery often face heightened risks of airway compromise due to trauma, congenital abnormalities, or the surgical interventions themselves, requiring clinicians to be proficient in both routine and advanced techniques. This narrative review synthesizes current evidence and clinical practices in airway management for maxillofacial surgery. It examines the anatomical and physiological considerations, preoperative assessment protocols, intraoperative management, and postoperative care strategies. Preoperative assessments are crucial for identifying potential airway management difficulties, utilizing risk assessments, physical examinations, and imaging. Intraoperative strategies include endotracheal intubation while surgical techniques such as tracheostomy, cricothyroidotomy, submental, and retromolar intubation offer alternatives for securing the airway. Postoperative care focuses on meticulous planning and coordination to prevent complications such as airway obstruction and hypoxemia. Extubation is identified as a particularly high-risk phase, necessitating advanced techniques and multidisciplinary collaboration to ensure patient safety. The review underscores the importance of a comprehensive, multidisciplinary approach to airway management in maxillofacial surgery, highlighting the need for ongoing advancements in techniques and technologies to enhance patient outcomes.

 Difficult airway management is essential in anesthesia practice. Particular challenges are posed to patients who require intraoperative one-lung ventilation. Specific guidelines for these scenarios have been lacking. The recent update of German guidelines incorporates recommendations for securing the airway in anticipated difficult airway scenarios in patients requiring one-lung ventilation. However, scientific data on this specific topic is rare.

 A retrospective analysis was conducted on adult patients undergoing thoracic surgery with one-lung ventilation from 2016 to 2021. During these years, the standard of practice has been in line with the now published guidelines. Patients with anticipated difficult airways were identified, and airway management strategies were analyzed.

 Among 3,197 anesthetic procedures, 44 cases involved anticipated difficult airways, primarily due to prior head and neck tumor treatment. Nasal bronchoscopic awake intubation followed by oral reintubation under videolaryngoscopic inspection and the use of bronchial blockers was the standard procedure. No severe complications were recorded, and one-lung ventilation was maintained successfully in all cases.

 The study highlights the challenges of managing difficult airways during thoracic surgery. Recommendations align with recent guidelines, emphasizing the importance of tailored approaches. The use of single-lumen tubes with bronchial blockers appears favorable over double-lumen tubes, offering comparable ventilation quality with reduced risks.

 Despite limitations, the study underscores the safety and efficacy of tailored airway management strategies during one-lung ventilation in patients with anticipated difficult airways. The presented approach offers patient safety and practicability. Further multicenter studies are warranted to validate these findings and refine clinical approaches.

Difficult airway management is a significant challenge in clinical anesthesia, critical care, and emergency medicine. Inadequate management can lead to severe complications including organ damage and death. This study assessed the variability in difficult airway management across China and focused on how patient and operator factors influenced outcomes in operating rooms.

A multicenter observational cross-sectional study.

This study was conducted from November 2022 to November 2023 and included 25 secondary and tertiary hospitals across various regions in China.

In the total of 181,399 general anesthesia patients, 384 (0.21 %) were identified as having difficult airways.

Data were gathered from a specialized questionnaire comprising four sections with 27 questions and analyzed using logistic regression in SPSS to identify key factors that influenced effective management of difficult airways.

This study focused on preoperative assessment, anesthesia selection, intubation attempts, and contingency planning for difficult airway management practices among anesthesiologists.

In anticipated difficult airways, rapid sequence induction was used in 51.7 % of the cases, maintaining spontaneous breathing under general anesthesia in 11.1 %, and awake intubation in 36 %. For unanticipated difficult airways, 95.9 % of the anesthesiologists opted for rapid sequence induction. Limited mouth opening was the most common cause of difficult airways and obesity and ankylosing spondylitis were identified as significant factors. The logistic regression analysis identified the type of difficult airway, anesthesiologist experience, and assessment methods as key factors influencing the first attempt intubation success.

The accuracy of difficult airway assessment and first attempt intubation success is influenced by both patient-related factors and the anesthesiologist's expertise. Regional and institutional variability in decision-making and tool selection underscores the critical need for standardized guidelines and comprehensive training to enhance airway management outcomes across diverse clinical settings in China.

Airway devices may be scarce in limited resource situations, such as prehospital settings or austere environments. Tube tip in pharynx (TTIP) ventilation is a simple, one-handed technique that may prove valuable for ensuring airway control in a life-threatening situation. The technique only requires a standard cuffed endotracheal tube and a self-inflating bag. This case report illustrates a scenario where both bag-valve-mask (BVM) ventilation and intubation failed, and the TTIP technique was utilized successfully several times during the case management. This case report illustrates that TTIP may be a useful technique, especially in limited resource settings. It is easy to learn, takes seconds to perform, and has minimal equipment requirements. The case report is reported according to the CARE guidelines. Informed consent from the patient is obtained.

A thyroid mass is an uncommon cause of a difficult airway when planning for intubation. An enlarged thyroid may lead to difficulties with intubation and airway management, oftentimes causing tracheal compression, deviation, or both. Tracheal compression increases the risk of tracheomalacia, which could lead to possible airway collapse. Moreover, the inability to intubate on the first attempt may increase the risk of airway-related complications to the patients. Here, we present three cases of a thyroid mass with a cystic component causing tracheal deviation or compression causing shortness of breath and difficult intubation which necessitated preoperative intervention. Various techniques such as inhalational anesthetic agents, fiberoptic intubation, and awake direct laryngoscopy-aided intubation have been described in the literature but were not used due to potential complications. Needle aspiration of the thyroid cyst was performed in each case to release pressure on the trachea before intubation. No complications occurred during or following the needle aspiration procedures. Each of the three patients was subsequently intubated with a glide scope and underwent a hemithyroidectomy for definitive management.

To systematically appraise the quality of clinical practice guidelines (CPGs) regarding awake tracheal intubation (ATI) and to compare the consistency of common recommendations.

Systematic review, critical appraisal and narrative synthesis of CPG recommendations for ATI.

A systematic search of the PubMed, EMBASE, Cochrane, Web of Science, and Scopus databases was conducted up to July 1, 2024, to identify up-to-date CPGs. The AGREE II (Appraisal of Guidelines for Research and Evaluation) checklist was used to critically appraise the CPGs. Interrater agreement was determined via intraclass correlation coefficients (ICCs) with a two-way random effects model for each domain and overall rating score. All the suggestions extracted from the included guidelines were sorted and analyzed and summarized via the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Our study resulted in 939 records and ultimately 7 CPGs were appraised. The content of these CPGs covered six themes of ATI: indications, airway local anesthesia, the intubation procedure, checking the tube position, management after ATI failure, and the extubation process. When the AGREE II tool was used to appraise CPGs, only 3 CPGs were rated as "high" quality. With the exception of domain 1, we observed good agreement in all five other domains (ICCs over 0.7). These CPGs provided relatively consistent recommendations and evidence on intubation procedures and checking tube position. In terms of indications and airway local anesthesia, there was controversy. Twenty-nine recommendations regarding ATI were summarized through the GRADE system, among which 16 were considered relatively reliable.

Through the AGREE II tool and the GRADE system, the strengths and weaknesses of each CPG were comprehensively analyzed on the basis of its scientific validity and practicability. Moreover, the limitations of the current CPGs in terms of indications, airway local anesthesia and complex clinical situations are presented, and clinicians are encouraged to apply the guidelines more scientifically and to update and improve the guidelines.

CRD4202458548 (PROSPERO).

Guidelines on airway management in neonates and infants recommend using a stylet when a videolaryngoscope is used, but it is not clear if the use of a stylet facilitates tracheal intubation and which shape of the stylet is suitable in neonates.

As a preliminary simulation study of a randomized controlled cross-over design, 25 anesthesiologists (3 specialists, 11 senior residents, and 11 junior residents) used a McGrath® MAC videolaryngoscope (Covidien, Medtronic, Tokyo, Japan) blade 1 for tracheal intubation (of a 3.5-mm ID Shiley™ tube with a cuff), with one of four differently shaped stylets (C-shaped, J-shaped, hockey stick-shaped and double C-shaped) or without a stylet in a manikin of a neonate, and compared intubation times.

Compared with intubation time without the use of a stylet, intubation time was significantly longer with the use of the J-shaped stylet (P = 0.007; median (95% CI) difference: 2 (1 to 2) s) or with the hockey stick-shaped stylet (P = 0.0002; median (95% CI) difference: 9 (9 to 10) s). In contrast, intubation time was similar between no stylet and the C-shaped stylet (P = 0.90; median (95% CI) difference: 0 (0 to 0) s) or between no stylet and the double C-shaped style (P = 0.60; median (95% CI) difference: 0 (0 to 0) s).

In conclusion, while time to tracheal intubation would be similar with and without the use of a stylet, the shape of the stylet would affect intubation time in neonates.

The objective of this study is to develop a model that incorporates clinical measurements with 3D radiomic signatures extracted from CT images of oral and maxillofacial surgery patients to evaluate mask ventilation. A prospective cohort trial was conducted to enroll patients scheduled for oral and maxillofacial surgery. After obtaining informed consent, clinical measurements and head and neck CT images were collected. The anesthesiologist who managed the airway graded the mask ventilation. Difficult mask ventilation was defined as mask ventilation that required assistance or the use of an oral airway or other adjuvant by the anesthesiologist. For radiomics analysis, 3D airway segmentation was extracted and calculated 3D radiomic signatures and corresponding radiological features. Subsequently, features in the clinical measurements model and radiomic signatures model were determined using the least absolute shrinkage and selection operator (LASSO) classifier. A mixed model was developed that incorporated both radiomic signature features and clinical measurement features. A total of 716 patients were enrolled in the study. The mixed model combined the five 3D radiomic signatures and six clinical measurements, and was found to have the highest predictive accuracy. In the validation group, the mixed group had an area under the curve (AUC) of 0.851, which was higher than the AUC of 0.812 in the clinical measurements model and 0.827 in the radiomic signatures model. This study developed a mixed model that combines 3D radiomic signatures and clinical measurements. Its application in clinical practice can assist in identifying patients at risk of experiencing difficult mask ventilation during oral and maxillofacial surgeries.

For anticipated difficult airways, awake tracheal intubation is strongly recommended by guidelines for its high success rate and safety. The key to successful awake tracheal intubation is effective airway topicalization. Currently available topicalization techniques have corresponding drawbacks and complications. Especially for subglottic topicalization, noninvasive techniques are not effective. Subglottic spray via epidural catheter with a flexible bronchoscope provided an effective and noninvasive technique.

A 73-year-old female patient with a history of giant goiter for 9 years suffered chest tightness and shortness of breath, and a 54-year-old male patient with a neck mass and hoarseness were scheduled for thyroidectomy.

Two cases of anticipated difficult airway due to compression by a giant goiter.

The subglottic area was topicalized via an epidural catheter with a flexible bronchoscope, and awake tracheal intubation was successfully performed.

This technique was effective in eliminating airway reactions and hemodynamic fluctuations during awake intubation and improving the intubation success rate and patient tolerance.

This is the first report of subglottic topicalization via an epidural catheter with a flexible bronchoscope applied in cases of awake intubation in giant goiter. The epidural catheter spray is safe and effective in awake intubation of an anticipated difficult airway, and this noninvasive technique is an alternative option to transtracheal injection.

Airway management is a critical aspect of anesthesiology, essential for ensuring patient safety during various medical interventions, including surgery, emergency care, and critical care settings. Despite advancements, difficult laryngoscopy and tracheal intubation remain significant challenges, particularly in emergency scenarios, posing risks of hypoxia, brain damage, and death. This article examines the efficacy of videolaryngoscopy (VLS) and video laryngeal mask airways (VLMA) in improving airway management outcomes compared to traditional techniques across diverse clinical environments. We conducted a comprehensive review of literature and current practices, analyzing the advantages and limitations of VLS and VLMA. The paper highlights the importance of visualization in airway management and evaluates the effectiveness of these devices in various settings. VLS and VLMA offer several benefits over traditional direct laryngoscopy, including enhanced glottic visualization, higher first-attempt success rates, reduced rates of oxygen desaturation, and fewer adverse events. These devices provide a larger angle of view and allow for real-time monitoring, improving overall patient safety. Additionally, they serve as excellent educational tools for training anesthesiologists and other healthcare providers involved in airway management. In emergency and critical care scenarios, the rapid and accurate placement of airway devices is crucial. VLS and VLMA facilitate quicker and more reliable intubation, reducing the likelihood of complications such as esophageal intubation or airway trauma. These technologies also allow for better teamwork and coordination as the airway view can be shared with the entire medical team. The adoption of VLS and VLMA as standard practice in airway management can significantly enhance visualization and success rates, reducing the risk of complications. These devices should be integrated into routine clinical use to improve patient outcomes. Further research is warranted to optimize their application and explore advancements such as artificial intelligence in airway management.

Videolaryngoscopy (VL) and apneic oxygenation are highly recommended and increasingly used in pediatric anesthesia practice; yet, availability, use in recommended clinical settings (e.g., neonates, airway emergencies, and out-of-operating-room tracheal intubation), and the association of VL availability with how pediatric anesthesiologists define difficult intubation have not been explored.

An electronic survey was distributed to the members of several international pediatric anesthesia societies to examine the availability and practice patterns of VL and to explore the criteria used to define a difficult tracheal intubation in children in the context of VL.

The response rate was 12.9%. VL was reported to be "most likely available" in main pediatric operating rooms and offsite locations 93% and 80.1% of the time, respectively. Fifty-seven percent of participants would select VL first when anticipating a difficult tracheal intubation; nearly 30% of respondents would choose direct laryngoscopy first and VL as a backup in this scenario. One-third of subjects would select VL as their first choice for nonoperating room (non-OR) emergency tracheal intubation and for premature or newborn infants, regardless of anticipated difficulty with intubation. Thirty percent of subjects reported using apneic oxygenation during difficult laryngoscopy. Institutional VL availability was not associated with how providers defined difficult tracheal intubation.

VL is highly available, but the adoption of VL and apneic oxygenation for managing difficult tracheal intubation was lower than expected, given recent recommendations by pediatric anesthesia societies. There was heterogeneity in how difficult intubation was defined, resulting in a possible patient safety risk.

The supraglottic airway device (SGD) was introduced as a breakthrough in airway management. The Fastrach emerged as the first commercially available intubating SGD, drawing extensive investigation. I-gel is a more recent device that has gained popularity, can be used as an intubating SGD, and replaced Fastrach in many institutions. However, there is uncertainty regarding the comparison between these devices in terms of efficacy for intubation and ventilation, and safety in an airway rescue situation.

PubMed, EMBASE, Scopus, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing I-gel and Fastrach SGD in adult patients undergoing intubation. The primary outcome was the first-pass success rate for tracheal intubation. Secondary outcomes were tracheal intubation time, SGD insertion time and success, and complications. We computed risk ratios (RRs) to assess binary end points and weighted mean differences (WMDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome and its subgroup analysis ( P < .05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes ( P < .01 was considered statistically significant).

This study included a total of 14 RCTs encompassing 1340 patients. The results indicated a significant difference in the first-pass success rate favoring Fastrach (RR, 0.81; 95% CI, 0.67-0.98; P = .03; I² = 91%). In the subgroup analysis, when a flexible scope was utilized through I-gel, providers achieved a better tracheal intubation first-pass success rate (RR, 1.05; 95% CI, 1.01-1.11; P = .03; I² = 0%), compared with the Fastrach. Overall intubation success rates (RR, 0.92; 99% CI, 0.82-1.04; P = .08, I² = 92%) and time (WMD - 1.03 seconds; 99% CI, -4.75 to 2.69; P = .48; I² = 84%) showed no significant difference irrespective of the device used. There was no significant difference regarding device insertion time by the providers (WMD -6.48 seconds; 99% CI, -13.23 to 0.27; P = .01; I 2 = 98%). Success rates of the providers' initial SGD insertion and complications such as sore throat (RR, 1.01; 99% CI, 0.65-1.57; P = .95, I² = 33%) and blood presence post-SGD removal (RR, 0.89; 99% CI, 0.42-1.86; P = .68, I² = 0%) showed no significant difference.

Based on our findings, a higher first-pass success rate was observed with the use of Fastrach when compared to I-gel. However, the use of I-gel might result in a better intubation success rate with the flexible scope-guided intubation. There are no significant differences in performance in terms of the success rate for intubation overall, time for device insertion, or time to intubation or complications regardless of the device used.

Assessing the extent of pathology in difficult airways and choosing the optimal airway management strategy in such cases can be a challenge for clinicians. Preoperative endoscopic airway examination (PEAE) is helpful in evaluating a challenging airway and formulating an airway plan in stable patients. A 52-year-old male scheduled for esophagogastroduodenoscopy (EGD) and biopsy presented with dysphagia, aphonia, mucositis, mucosal bleeding, and impaired mouth opening from pain. We were unable to complete the airway exam and were concerned about possible airway edema. PEAE was easily performed in preoperative holding area, airway was significant for erythema with no significant edema, no active bleeding, and mucosa had cobblestone-like appearance. With this information, we were confident to undergo EGD and biopsy with native airway under total intravenous anesthesia (TIVA). The patient was later diagnosed with diffuse large B cell non-Hodgkins lymphoma and paraneoplastic pemphigus.

Artificial intelligence (AI) algorithms, particularly deep learning, are automatic and sophisticated methods that recognize complex patterns in imaging data providing high qualitative assessments. Several machine-learning and deep-learning models using imaging techniques have been recently developed and validated to predict difficult airways. Despite advances in AI modeling. In this review article, we describe the advantages of using AI models. We explore how these methods could impact clinical practice. Finally, we discuss predictive modeling for difficult laryngoscopy using machine-learning and the future approach with intelligent intubation devices.

Beals syndrome, also known as Beals-Hetch syndrome or congenital contractural arachnodactyly, is an autosomal dominantly inherited, rare connective tissue disorder characterized by flexion contractures, arachnodactyly, camptodactyly, severe kyphoscoliosis, and, less frequently, cardiovascular features. We describe the successful management of labor analgesia in a pregnant woman with Beals syndrome. During labor, a combined spinal/epidural technique was performed uneventfully, and intermittent top-ups were administered as needed at lower-than-usual volumes. Eutocic delivery occurred without complications, and both mother and baby were discharged three days later. Given the sparse literature about obstetric patients with Beals syndrome, we summarize the main anesthetic challenges and suggested approaches.

Patients with head and neck cancer often experience airway complications. This case highlights a patient with nasopharyngeal cancer post-radiotherapy (RT), who presented with a difficult airway (DA). An 83-year-old woman, scheduled for a partial left lower lobe pneumonectomy, had received RT for nasopharyngeal cancer one year prior. Physical examination revealed trismus, limited neck movement, Mallampati class IV, and grade III on the upper lip bite test. Bronchoscopy showed mucous membrane irregularities in the nasopharynx, along with an edematous epiglottis and vocal cords. After general anesthesia induction, both mask ventilation and McGrath™ intubation (Covidien Inc., Tokyo, Japan) attempts failed. Lifting the patient's tongue manually allowed visualization of the vocal cords via a fiberoptic bronchoscope, enabling successful intubation. Patients who have undergone head and neck radiotherapy (HNRT) are at increased risk of DAs due to radiation-induced fibrosis (RIF) of pharyngeal soft tissues.

Small case series have described awake supraglottic airway placement in infants with significant airway obstruction and difficult intubations. We conducted this study to determine outcomes when supraglottic airways were placed in awake children enrolled in the international Pediatric Difficult Intubation Registry including success of ventilation, success of tracheal intubation, and complications.

We reviewed the Pediatric Difficult Intubation Registry to identify all cases of awake supraglottic airway placement before planned tracheal intubation from August 2012 to September 2023 with subsequent review of details of awake supraglottic airway placement in the medical record. We present descriptive statistics of patient demographics, ventilation and intubation outcomes, and complications.

A supraglottic airway was placed in an awake child in 95 of 8061 (1.2%) cases in the Pediatric Difficult Intubation Registry. Median age was 37 days (range 0-17.6 years) and median weight was 3.7 kg (1.6-46.7 kg). Sixteen (17%) cases were in patients older than 2 years and 7 (7%) were in adolescents. Adequate ventilation via a supraglottic airway was achieved in 81/95 (85%, 95% confidence interval [CI], 77%-93%) encounters. Inadequate (n = 13) or impossible (n = 1) ventilation occurred in 14/95 (15%). No complications were reported with supraglottic airway placement. For subsequent intubation, there was a 35% (33/95) first-attempt success rate and 99% (94/95) eventual success, with 1 patient awakened after failed attempts at tracheal intubation. Hypoxia occurred during the first intubation attempt in 9/95 (9%) encounters. The incidence of hypoxia was lower in encounters in which ventilation via the supraglottic airway was adequate (4/81, 5%) than in encounters in which ventilation via the supraglottic airway was inadequate or impossible (5/14, 36%).

Although infrequently attempted, awake placement of a supraglottic airway in children with difficult airways achieved adequate ventilation and provided a conduit for oxygenation and ventilation after induction of anesthesia across a spectrum of ages.

Difficult airway management (DAM) is a challenging aspect of anesthetic care. Although nearly all DAM episodes result in successful intubation, complications are common and clinical decision-making may be complex. In adults with anticipated DAM scheduled for nonemergent surgery, we prospectively observed clinical decisions made during DAM such as awake/sedated versus anesthetized, choice of initial and subsequent devices, case cancellation/postponement, conversions between awake and anesthetized approaches, and process complications such as multiple intubation/supraglottic airway (SGA) insertion attempts, difficult bag-mask ventilation (BMV), hypoxemia, and cardiovascular destabilization.

From 2009 to 2014, we prospectively observed 1295 episodes of anticipated DAM in a convenience sample of 1245 adults scheduled for nonemergent surgery. Trained observers recorded airway management decisions and process complications during DAM. We described clinical decisions made during DAM and outcomes including number of attempts, need for BMV, hypoxemia, and cardiovascular destabilization.

No cases were canceled/postponed for airway management failure and all intubations were eventually successful. Of the 1295 episodes of airway management in our study cohort, 166 (13%) were intubated awake. Patients intubated awake had more difficult airway indicators than those intubated anesthetized, their first-pass success rate was 49%, 30% required ≥3 attempts, 4% required a device change, 50% experienced hypoxemia, and 29% experienced cardiovascular destabilization. Among the 1129 patients intubated while anesthetized, first-pass success rate was 64% and 20% required ≥3 attempts, 11% required a device change, hypoxemia occurred in 30%, and cardiovascular destabilization in 20%. One patient (0.08%) was converted from an anesthetized to an awake approach. Patients with a failed anesthetized intubation attempt and difficult BMV between attempts were at high risk for multiple attempts (67%) and hypoxemia (100%).

Airway management was successful in all patients and the incidence of process complications was higher than in routine airway management. Despite a high risk of DAM, 87% of patients were intubated anesthetized and conversions between awake and anesthetized approaches were rare. That patients intubated awake had more difficult airway indicators implies that clinicians reserve awake intubation for particularly difficult airways. The high incidence of multiple attempts, hypoxemia, and cardiovascular destabilization in patients intubated awake suggests that awake airway management remains challenging. We found no clear pattern in device choices after a first failed attempt. Patients with a first failed anesthetized intubation attempt and difficult BMV were at particularly high risk for hypoxemia.