Background: Descriptions of course of illness during prolonged intensive care is as essential as studying outcomes in extremely low gestational age neonates (ELGANs). Understanding the expected trajectory of respiratory illness aids in the recognition of risk factors followed by appropriate counselling and resource allocation. We studied the patterns of respiratory illness in ELGAN over the first 2 weeks and its association with bronchopulmonary dysplasia (BPD). Methodology: Levels of respiratory care in ELGAN from 2017 to 2021 were analysed. They were classified into four groups (pragmatically at the bedside) based on oxygen requirements as Category 1: persistent low needs (PL) – FIO₂ <0.3 on day 3, and FIO₂ <0.3 at 2 weeks, Category 2: progressive worsening (PW) – FIO₂ <0.3 on day 3, worsening to >0.3 at 2 weeks, Category 3: persistent high needs (PH) – FIO₂ >0.3 on day 3, continuing to need >0.3 at 2 weeks and Category 4: progressive improvement (PI) – FIO₂ >0.3 on day 3, improving to <0.3 at 2 weeks. The proportion of infants in each group who developed BPD was also determined. Results: Seventy-four survivors of 91 live-born ELGAN were included, of whom 29.7% developed BPD. Most infants were in PL category (83.8%). Those in the worse categories (PW and PH) constituted only 4.05%. The association of classification as worse patterns (PW or PH) with BPD was not statistically significant, but the numbers were very small. Conclusions: Major proportion of ELGAN were categorised into reassuring archetypes of respiratory requirements. Drawing conclusions about the association with BPD may need analysis of a larger number of infants.

Background: Obstructive sleep apnoea (OSA) in children is associated with the development of perioperative adverse respiratory events. The aim of our study was to find out the incidence of perioperative adverse respiratory events, to identify the risk predictors and to determine the appropriate anaesthetic agents in children with OSA. Methods: After obtaining approval from the the Institutional Review Board, 189 children with OSA who had undergone adenotonsillectomy between 2004 and 2009 were selected from a retrospective review of case files. Variables recorded included demographic data, coexistent medical illnesses, anaesthetic techniques (including induction agents and muscle relaxants) and perioperative analgesia. The severity of OSA was determined based on polysomnographic criteria. Adverse events including difficult airway, desaturation due to bronchospasm or laryngospasm, postoperative desaturation and unplanned intensive care unit (ICU) admission occurring up to 24 h postoperatively were recorded. Results: The incidence of perioperative respiratory adverse events was 19.6%. Severe OSA (odds ratio [OR] 5.8; 95% confidence interval [CI] 1.8–18.53; P = 0.003) and moderate OSA (OR 3.9; 95% CI 1.1–13.1; P = 0.029) were independent risk factors associated with complications. There was no correlation between the intraoperative anaesthetic techniques or use of perioperative opioid analgesics and the perioperative adverse respiratory events. Conclusions: Preoperative diagnosis of OSA using polysomnography has been shown to identify children who are at increased risk of perioperative adverse respiratory events in children. In our review, 19.6% of children with OSA were at risk. The use of a severity index may better identify children at higher risk.

Large tumours occupying one half of the thoracic cavity are rare and may cause life-threatening complications by compression or invasion of vital structures that results in cardiovascular and/or respiratory insufficiency. In-depth preoperative planning is necessary after assessment of perioperative risk of hemithoracic masses. By providing lung isolation, one-lung ventilation technique provides improved surgical conditions compared to conventional dual-lung ventilation for thoracic surgery. As double-lumen tubes are not available for smaller children, balloon-tipped bronchial blockers remain the technique of choice, especially under the age of 6 years. Huge intrathoracic masses in small children with radiological and clinical findings suggesting airway compression are high risk for airway complications. Fibreoptic bronchoscope-guided intubation should be preferred in view of tracheobronchial compression by the mass and placement of an endobronchial blocker helps in one-lung ventilation in small children. The management of these tumours is challenging and should be performed only in specialised centres.

A 35-year-old male weighing 94 kg developed significant oropharyngeal and perilaryngeal oedema with sepsis in the postoperative period following mandibular advancement surgery. He needed change of an existing nasotracheal tube to the orotracheal route in the intensive care unit (ICU). The procedure had to be abandoned in the ICU for fear of losing the airway in this patient requiring high inspired oxygen concentration of 60% and positive end expiratory pressure of 8.0 cm H₂O. The changeover of tube was safely achieved in the operation theatre by utilising the splinting effect of the existing nasotracheal tube that helped to keep the oedematous epiglottis lifted while an airway exchange catheter (AEC) was placed by its side under videolaryngoscopic guidance. Railroading the new orotracheal tube over the preplaced AEC after withdrawing the nasal tube while receiving oxygen at 4 litres per minute helped to accomplish the safe exchange of the tracheal tube.

Anaesthesia for otorhinolaryngological procedures has always been challenging in view of a shared and often difficult airway. A 55-year-old male, a known case of carcinoma right maxilla, presented to us following right total maxillectomy, bilateral anterior and posterior ethmoidectomy, sphenoidectomy and right supraomohyoid neck dissection. He needed a revision maxillectomy in view of a residual lesion predominantly in the right superior nasal cavity and maxillary sinus. Mouth opening was restricted to 1.5 cm making direct laryngoscopy impossible. The mass in the right nasal cavity had eroded and caused deviation of the nasal septum completely towards the left, making nasal fibrescopy also difficult. We successfully managed the airway using the technique of asleep oral fibreoptic-guided intubation.

Pierre Robin sequence (PRS) with bilateral temporomandibular joint (TMJ) ankylosis is a rare and challenging case for anaesthesiologists. A 6-year-old girl with PRS along with bilateral progressive TMJ ankylosis was scheduled for gap arthroplasty. Her mouth opening was <1 finger. Securing the airway in a syndromic child with mandibular hypoplasia was challenging. We performed an asleep fibreoptic bronchoscope (FOB)-guided nasotracheal intubation while retaining spontaneous breathing. Managing a difficult paediatric airway needs expertise. We believe that with the use of FOB, difficult airways can be successfully and safely managed.