The use of drugs for airway control has its beginnings in medical anaesthesia. Since then, the 'airway effects' of pharmacological agents have sometimes been a matter of concern, while at other times a boon for the clinician. While several effects of agents on airway function are 'off-target effects', an understanding of these effects could aid in better choice of the drug to be administered to the patient. At the same time, it will aid the drug development scientist in selecting and optimising drug candidates. This review details the developments in the pharmacology of drugs that influence airway function.

The aim of this article is to ignite the minds of readers and empower them to create new knowledge in relation to 'emergency difficult airway access'. It starts with a structured description of a challenging healthcare situation in emergency airway access in a resource-limited setting. Questions in nine domains relevant to healthcare are addressed. The reader is encouraged to create their own questions using the Population/Intervention/Comparison/Outcome format. The concepts of hypothesis framing, variables and conceptual framework are explained based on the research questions. Framing objectives from a research question is explained in the given context. The relevance of each category of question and its implications for practice, policy and advocacy are explained in detail. The writing is contextual and enquiry based. This is the first of a series of four articles. The articles to follow will deal with designing the study, data analysis and applying/expanding knowledge. The aim of the series is to empower readers to create product/process/paradigm/positioning innovations in emergency difficult airway access for better care of humanity.

Background: Airway management in children is different from that of adults and needs special consideration. Laryngoscopy in children with the Miller straight blade can be performed via midline (MID) or paraglossal (PGL) approach. This study aimed to find out whether there was any advantage of one approach over the other in small children. Patients and Methods: After obtaining parental consent and approval from the Institutional Ethical Committee, this randomised, controlled, cross-over study was conducted in 110 children aged 2–24 months belonging to the American Society of Anesthesiologists Physical Status I or II. Children scheduled for elective surgeries under general anaesthesia were allocated randomly into one of the following two groups: A (PGL/MID) or B (MID/PGL) with 55 patients in each group. Following induction of anaesthesia and neuromuscular blockade, laryngoscopy was performed in a cross-over manner with either the PGL or MID approach first. The tip of the blade was placed at the vallecula. Intubation was performed following the second laryngoscopy. Glottic views with and without optimal external laryngeal manipulation (OELM) and ease of intubation were observed. Data were analysed, and P < 0.05 was considered statistically significant. Results: Both the approaches provided the same view in 81/110 children. In the remainder, a better view was obtained with the MID and PGL approaches in 14/110 and 15/110 children respectively. Laryngoscopy was easy in 93/110 children with both the approaches. OELM was required to improve the laryngoscopic view in 37/110 and 40/110 children with the MID and PGL approaches respectively. Conclusion: Using the Miller blade, both the MID and PGL approaches provided comparable laryngoscopic views and intubating conditions for young children in the age group between 2 and 24 months. When a restricted view is obtained, a change of approach may provide a better view.

Background and Aim: Because of its simplicity of insertion, supraglottic airway (SGA) plays an important role in airway management. This study was planned to compare success rate within two attempts at correct placement of Cobra perilaryngeal airway (C-PLA) with laryngeal mask airway Supreme (S-LMA) by novice anaesthesiologists. Secondary objectives included the comparison of time to insertion, ease of insertion and incidence of complications with the device. Methods: The trial was approved by the Institutional Review Board and registered with the Clinical Trials Registry-India (CTRI/2014/08/004913). Fourteen eligible and consenting novice anaesthesiologists were included. Each trainee had to insert each SGA for 5 successful times on the Laerdal airway trainer. After obtaining informed consent, 112 adult patients undergoing elective surgery were randomised to the anaesthesiologists and the SGA device. Induction of general anaesthesia was standardised. Only 2 attempts at insertion of SGA were allowed. Ease of insertion by novices was recorded using a numerical rating scale (NRS) 1 to 10 (10 = easiest). Data were entered into IBM SPSS software version 21.0 (IBM, NY, USA). Categorical data were compared using Chi-square test, while scores were analysed using Mann-Whitney test. Results: There was no difference in success rate between S-LMA (91%) and C-PLA (89%) (P = 0.75). Median time (interquartile range) of insertion for S-LMA was 30 (25–34) seconds and C-PLA was 29 (25–32) seconds (P = 0.53). The incidence of complications was similar for both devices. Novices rated insertion of C-PLA NRS score of 8 (7–9) significantly easier than S-LMA NRS score 7 (5–9) (P = 0.0005). Conclusion: Although the success rate of insertion and time to insertion of C-PLA is similar to S-LMA, novices found C-PLA easier to insert.

Airway management in a child with post-burn contracture (PBC) involving the face, anterior neck and chest is challenging for the anaesthesiologist. Although fibreoptic endoscopy-guided intubation is considered the gold standard for difficult paediatric airway, this may not always be useful. We report the successful management of a distorted airway in a 3-year-old girl scheduled for cosmetic correction of PBC under general anaesthesia. The initial attempt of fibreoptic endoscopy to secure the airway was unsuccessful. The child was subsequently managed by the release of contractures and videolaryngoscopy-guided intubation.

Difficult airway in the paediatric population poses a serious obstacle for tracheal intubation leading to grave consequences. Direct laryngoscopy may often not yield an ideal view for intubation, and the aid of supraglottic airway device, videolaryngoscope (VLS) and/or fibreoptic devices may be sought. We discuss the benefit of using C-MAC^® VLS-guided technique for difficult intubation in a child. We also suggest that videolaryngoscopy be considered a standard approach in paediatric intubations where such facilities are available.

We report the case of a 25-day-old neonate posted for glossopexy. The child born at 35 weeks of gestation was diagnosed to have Pierre Robin sequence. The neonate was underweight (2.2 kg), had difficulty in feeding and had respiratory distress needing respiratory assistance and prone position to maintain saturation. Anticipating difficulty in intubation with respect to physiology, age and mismatch of equipment size, we planned retrograde intubation through a laryngeal mask airway with a 2.5 mm ID tube using a needle cricotracheotomy and a flexible-tipped paediatric urological guidewire. Based on our experience, we propose that neonatal difficult airway can be managed using the retrograde intubation technique.

Difficult laryngoscopy and intubation are life-threatening situations that are commonly seen in obese, short-necked patients. Amongst the various tools that can facilitate successful intubation in such patients, awake fibreoptic intubation is possibly the most popular and safe method. Rarely, the airway abnormality may be so severe that the operating otorhinolaryngologist may face difficulties in performing surgery once the airway has been secured, as happened in our patient.