The paediatric airway has always been a challenge to both the novice and the experienced airway manager. In this review, we have addressed the challenges of a paediatric airway, especially for the occasional paediatric anaesthesiologist. Children are not small adults and present unique anatomical, physiological and emotional challenges. It is imperative to be aware of these differences and adequately prepare to manage the normal or difficult airway appropriately. In this review, we have analysed recent publications in indexed journals detailing airway challenges in paediatrics and their management. Recent advances and recommendations include the usage of microcuffed tubes, various sizes of supraglottic airways and multiple paediatric-airway friendly videoscopes. Awareness of the differences and how to manage them efficiently is the key to delivery of a safe anaesthetic in small children.

This article concludes a four-article series intended to ignite the minds of readers and empower them to create new knowledge in the context of 'emergency difficult airway access.' The first three articles described the process of knowledge creation in a clinical context where the anaesthesiologist is faced with a difficult airway in a medically underserved area. The utility of an educational app, the 'Research Genie (RG),' available on Google Play Store and App Store, to define and design a research study (knowledge creation) was explained. This article concludes the series with educating the reader in creating innovations based on the new knowledge. The steps of creating the product, process, position, and paradigm innovations are explained simply and comprehensively. Innovation jargon has been demystified for medical professionals to grasp the basis of intellectual property (IP). Various categories of IP, namely patents, copyrights, trademarks, industrial designs, geographical indications, layout design of integrated circuits and plant variety protection have been described in an easily understandable format. The biodesign process of Stanford University has been adapted to elucidate the technique of designing medical devices. Identify-Invent-Implement is the framework followed in the Stanford model. The method to frame a needs statement in the strategic focus area of difficult airway access is explained for the reader to begin the process of innovation. Biodesign concepts such as decision tree analysis, business models, stakeholder analysis, financial planning, regulatory and reimbursement basics have been described. The reader is introduced to medical device rules (2017) that govern biomedical innovations in India. The 'RG' bids adieu to the readers with an invitation to create swaraj (freedom) for everyone in the world from economic, social and administrative constraints so that healthcare is affordable and accessible for all.

Videolaryngoscopes (VLSs) are a promising addition to the difficult airway management armamentarium. These devices utilise video-camera technology to visualise airway structures on a monitor and facilitate endotracheal intubation. They offer an improved view of the glottis without the need for alignment of the oro-pharyngo-laryngeal axes. Today, in the era of the COVID-19 pandemic, there is a need for a shift towards a more cautious and circumspect approach towards airway management. Among the aerosol-generating procedures, endotracheal intubation is especially hazardous. Various protocols and guidelines recommend VLSs as the device of choice for intubating COVID-19 patients. It is thus becoming important that airway managers become adept at using various types of VLSs and troubleshoot problems along the way. We have a plethora of these devices with different configurations and shapes. Through this article, we hope to discuss a few practical troubleshooting tips while using different types of VLSs.

Background: The Macintosh (MAC) laryngoscope has been the gold standard for teaching intubation till date. This manikin-based study was conducted to determine whether McGrath^™ videolaryngoscope (VL) (McG) is comparable to MAC laryngoscope as an educational tool for novice airway managers. Material and Methods: A randomised cross-over manikin-based trial was conducted in a group of 44 final-year medical students. After training for intubation with both laryngoscopes, the students were randomised to Group MAC or Group McG to decide which laryngoscope would be used first. The total time for intubation, number of attempts for successful intubation, ease of visualisation and ease of intubation were assessed. Results: The median time for intubation was 40 s (interquartile range [IQR] 16.5–93.5) for the MAC group and 35 s (IQR 17.5–54.5 s) for McG group (P = 0.22). First attempt success was significantly more in the McG group. Ease of visualisation and ease of intubation were significantly better in the McG group (P ≤ 0.05). Conclusion: The McGrath™ VL appears to be superior to MAC laryngoscope as an educational tool for training novice airway managers in endotracheal intubation.

Background: Laryngoscopy and tracheal intubation are noxious stimuli associated with transient haemodynamic changes which can be deleterious, especially in patients with cardiovascular or intracranial disease. Different pharmacological techniques are used to suppress this response. We designed this study to evaluate whether nebulised lignocaine can attenuate haemodynamic responses to intubation. Patients and Methods: Forty patients were enrolled for the study and randomly allocated into one of two groups, Group L_N (nebulised lignocaine) and Group L_I (intravenous [IV] lignocaine). Group L_N and Group L_I received nebulisation respectively with 5 mL of 2% lignocaine or 5 mL of normal saline 15 min before shifting the patient to the operation theatre. General anaesthesia with endotracheal intubation was provided as per institutional protocol. Participants in Group L_N received 5 mL saline intravenously while Group L_I received 5 mL of 2% lignocaine IV 90 s after muscle relaxant and were intubated 90 s later. Patients were monitored for the first 10 minutes postintubation without any additional drug or any surgical stimulus. Results: In our study, we found a statistically significant suppression of haemodynamic responses following intubation in the nebulised lignocaine group in comparison with the IV lignocaine group. Conclusion: Significant attenuation of haemodynamic responses to intubation was observed with nebulised lignocaine group as compared to IV lignocaine group. We believe that nebulisation of lignocaine is a simple, cost-effective and safe procedure to attenuate haemodynamic responses to intubation. This novel technique could replace the use of other pharmacological interventions for the same purpose, thereby avoiding polypharmacy.

Background: Supraglottic airway devices (SADs) are used to keep the upper airway open and to provide unobstructed ventilation. The recent addition to SADs is the laryngeal tube (LT). It can be inserted blindly past the oropharynx into the hypopharynx to provide a patent airway and mechanical ventilation during emergency conditions and cardiopulmonary resuscitation. Aim: To evaluate the success rate and usefulness of LT insertion for airway maintenance and intermittent positive pressure ventilation on manikins by paramedical personnel. Methods: The technique of LT insertion was explained to 200 paramedical personnel, all of whom attempted its insertion three times; the maximum time allowed for 3 attempts was 3 min. The success rate in terms of ease of insertion, adequacy of ventilation and the audible leak was assessed. The average time taken for insertion and success rate in the first, second and third attempts was assessed. Confirmation was done by ventilation with a self-inflating bag and adequate lung inflation. Results: Average time taken for insertion of LT was 14.66 ± 4.96 s. With progressive attempts, the success rate improved to 86.5%, adequacy of ventilation to 96.5% and only a minimal leak was appreciated in all. Conclusion: The LT could be a reliable device for airway management in emergencies by paramedical personnel as all participants successfully placed it within three attempts with a very good success rate.

Background and Aims: Unanticipated difficult laryngoscopy (DL) can cause life-threatening complications in the operation theatre, intensive care unit and emergency department. Various screening tests have been developed to predict DL. While modified Mallampati test (MMT) is the most commonly used one, it has poor sensitivity. Upper lip bite test (ULBT) and thyromental height test (TMHT) have been shown to be more reliable in predicting DL. The aim of this study was to compare the three tests and evaluate whether a combination of ULBT and TMHT would show better accuracy in predicting DL. Patients and Methods: A total of 109 adult patients undergoing elective surgery under general anaesthesia with endotracheal intubation were assessed using the MMT, ULBT and TMHT before surgery. The required sample size for the study was calculated using the Fisher Z test. The three tests, and a combination of ULBT with TMHT, were compared for their sensitivity, specificity, positive predictive value, negative predictive value and accuracy in predicting DL. Results: The accuracy of MMT, ULBT, TMHT and ULBT + TMHT in predicting DL was found to be 81.65%, 86.23%, 97.24% and 95.41%, respectively. MMT exhibited the lowest sensitivity and had the highest number of false negatives. TMHT exhibited the best accuracy and sensitivity, with the lowest number of false negatives. A combination of ULBT and TMHT did not improve the PPV in the sample tested. Conclusion: TMHT was found to be the best test for predicting DL, and its combination with ULBT did not improve the accuracy.

Rubinstein-Taybi syndrome is a rare genetic disease with multisystem involvement and significant anaesthetic implications. We describe the perioperative anaesthetic management of a 2-year-old child posted for bilateral orchidopexy and left-sided herniotomy.

Tracheal resection is a rare and complex surgery. The critical phases of the surgery are during induction in the presence of a critical airway, intraoperatively during airway transection and postoperatively for the maintenance of the reconstructed airway with planned early extubation to prevent wound dehiscence. An oedematous airway and fixed flexion of the neck are added risks in the postoperative period. We report a case of a 16-year-old boy with tracheal stenosis in the proximal trachea for elective resection and reconstruction. He received intravenous induction with bougie-guided intubation. Intraoperatively, oxygenation was maintained through the transected trachea. As he had an inadequate recovery from anaesthesia at the end of the surgery, he was extubated after few hours of mechanical ventilation and had an unremarkable recovery. A comprehensive planned airway management with anticipation of preoperative airway maintenance and good communication with surgeons are key to the safe management of this complex surgery.

Nasal packs are used in a variety of nasal surgeries. Anaesthesiologists should be aware of the numbers used and their appropriate placements. Accidental tracheobronchial aspiration of a nasal gauze can be catastrophic, resulting in increased patient morbidity and mortality. Rapid diagnosis and quick management should be initiated by maintaining a high index of suspicion and resorting to immediate bronchoscopic removal of the aspirated material.

Vallecular cysts are rare entities in adults and are often asymptomatic. Although rarely life-threatening, they pose an airway challenge when discovered incidentally. There is no technique that has been described in literature that is absolutely conclusive regarding the airway management in cases of vallecular cysts. We report a case of an asymptomatic vallecular cyst encountered in an adult male scheduled for laparoscopic cholecystectomy under general anaesthesia using ProSeal laryngeal mask airway (LMA). Despite selecting the proper size of ProSeal LMA and its correct placement, the patient could not be ventilated. Hence, endotracheal intubation was performed to maintain a patent airway. Direct laryngoscopy revealed a cyst measuring 2 cm × 2 cm at the base of the tongue completely obscuring the glottis. Fibreoptic bronchoscope-guided intubation was planned. The operating table was tilted to the left and direct laryngoscopy repeated after applying rightward external laryngeal manipulation. Cormack-Lehane Grade 3a was obtained allowing the passage of a bougie over which a 7.0 mm ID endotracheal tube was railroaded. The rest of the perioperative period was uneventful, and the patient was extubated without any problem.

Inability to ventilate or oxygenate can be catastrophic. Critical tracheal stenosis may present as a life-threatening airway emergency. We report a 25-year-male who presented to the Emergency Department in respiratory arrest. After endotracheal intubation, there was no tidal volume delivery despite generating high peak airway pressures. Unfortunately, even an emergency surgical airway did not succeed in providing adequate ventilation. Postmortem examination revealed near-total occlusion of the distal tracheal lumen. When a patient has refractory ventilatory failure due to possible airway obstruction, the acute care provider should consider distal tracheal stenosis as one among the differential diagnosis. Conventional approach to airway management, including surgical airway, may not be of help in the presence of distal tracheal stenosis. A skilled emergency physician should possess the ability to think out-of-the-box and be aware of novel techniques to achieve oxygenation and ventilation in a 'failed airway' of this nature. Though appropriate, fibreoptic intubation, extracorporeal membrane oxygenation or emergency thoracotomy may not be readily available or practically feasible options to manage a failed airway due to distal tracheal stenosis.