Background and Aims: Difficult intubation remains a leading cause of anesthetic morbidity and mortality.^[1],[2] Many novel devices such as videolaryngoscopes and Ambu aScope have been introduced.^[3] In the present study, we aim to evaluate Ambu aScope-3^® with standard fiberoptic bronchoscope. Methods: Following Institutional Ethical Committee clearance and consent from parents, sixty ASA physical status I and II children of either gender, 4-12 years, body mass index (BMI) ≤ 30 kg/m², mouth opening < 1 finger, elective temporomandibular joint ankylosis surgery under general anesthesia were randomly assigned into two groups, Group AS (n=30) and Group FB (n=30) to be intubated with Ambu aScope-3^® and standard fiberoptic bronchoscope respectively. Intubations were evaluated regarding the first attempt success rate as the primary objective, while intubation time, optimization maneuvers, glottic view and hemodynamic response as secondary objectives. Sample size α=0.05, β=0.20, pFB= 1.00, pAS=0.70, 10% drop-out/failure, 60 patients were recruited and data was analysed using t-test, and chi-test. Results: Incidence of 1st attempt successful intubation was similar in both the groups (90% in AS, 100% in FB; p=1.00). Time for intubation was 118±25 s in AS, and 90±21 s in FB; p=0.01. The optimization maneuvers required were more in Ambu aScope-3^®. There was a significant increase in the heart rate and BP one minute after intubation in group AS (p = 0.014, p= 0.031). Two failures in group AS were crossed over to FB and analyzed on intention-to-treat analysis. Conclusion: We conclude that both the devices were equally good in the 1st pass success rate. However fiberoptic bronchoscope was better concerning intubation time and hemodynamic stability.

Background and Aims: With the ever-widening spectrum of videolaryngoscopes at our disposal and their availability becoming a necessity in this Covid era, the primary matter of concern is how easy it is to master their use. The objective was to compare learning curves of conventional Macintosh laryngoscope and videolaryngoscopes (VL), C-Mac, and McGrath in terms of time to visualization of vocal cords and time to successful tracheal intubation. Methods: In this study, 38 anesthesiology residents with no prior experience in airway management were randomly allocated to three groups; viz group CL (Conventional laryngoscopy, n=13), group CM (C-Mac VL, n=12), group MG (McGrath VL, n=13). After two months of observation training of laryngoscopy and intubation, each performed a total of 10 tracheal intubations in adults (weight 50-70 kg) with the device as designated by the group to which they were assigned. The time to optimum view of vocal cords (insertion of laryngoscope blade to the visualization of vocal cords) and time to tracheal intubation (insertion of laryngoscope blade to confirmation of tracheal intubation with consistent square wave on the capnograph) was noted. Results: Intergroup differences in time to optimum view of the cords or time to intubation (Mean CL=11.43 seconds, MG=9.5 seconds, CM=9.49 seconds; p=0.08) were found statistically insignificant. However, with conventional laryngoscopy and McGrath VL, there were 6 and 2 failed attempts at intubations, respectively (p=0.001). Conclusion: The learning curves of videolaryngoscopy seem similar to conventional laryngoscopy and intubation. We suggest multicentric trials with a larger sample size to establish the same.

Background and Aims: Although Airtraq videolaryngoscope (VL) has been extensively studied and evaluated in adults, limited literature is available in children. This prospective, single-blinded observational study was conducted to determine its efficacy as an intubating aid in pediatric patients. Methods Airtraq VL-guided intubation was conducted in 50 ASA physical status I and II patients of either gender aged 2-10 years posted for elective surgeries under general anesthesia. Efficacy was determined in terms of the number of intubation attempts, ease of intubation, intubation time, hemodynamic responses, the incidence of hypoxemia and airway trauma. Results were statistically analyzed and presented in number, percentage, mean and standard deviation appropriately. Hemodynamic parameters (pulse rate, systolic blood pressure, diastolic blood pressure and mean arterial blood pressure) were analyzed using paired t-test, the p-value of <0.05 was considered statistically significant. Results: Successful intubation was performed in the first attempt in 48 (96%) cases and the second attempt in 2 (4%) patients. Intubation time ranged between 10-18 seconds with a mean ± SD of 12.42 ± 2.34 seconds. Easy was graded in 47 (94%) intubations and 3 (6%) as 'difficult'. There were no significant hemodynamic changes, no incidence of hypoxia, 2 (4%) patients had lip trauma during intubation. Conclusion: We conclude that Airtraq VL can be a useful intubating aid in 2-10 years of Indian pediatric population It provides easy, safe, quick and excellent glottic visualization facilitating successful intubation with minimal manipulation, little hemodynamic changes, and negligible trauma.

Background and Aims: Nasotracheal intubation is the choice of airway management for orofacial malignancy surgeries. This can be achieved using various adjuncts and techniques. The study aimed to compare 2 techniques using Magill's forceps and cuff inflation technique using a C- Mac videolaryngoscope (VL) with D blade. Methods: Trial was approved by the Institutional Ethics Committee and registered under Clinical Trials Registry India. After obtaining informed consent, based on pilot data of 20 patients, considering 5% of the level of significance with a power of 90%, a total of 52 patients were recruited for the study. 26 in each group having ASA I–III, aged 17-70 years with EGRI (el Ganzouri risk index) score 1– ≤ 7 scheduled for orofacial malignancy surgery requiring nasal intubation were randomized into two groups, Group M and Group C. Patients were randomized into Group M (Magill's forceps guided tracheal intubation using VL) and group C (cuff inflation technique guided tracheal intubation using VL). The C-Mac D blade VL was used. The outcome was the success of nasotracheal intubation in orofacial malignancy surgeries in terms of 1) total time taken for successful intubation, 2) ease of intubation, 3) number of attempts, 4) hemodynamic changes and 5) complications such as desaturation, mucosal bleeding or dental trauma during the procedure. Two independent sample t-tests to compare quantitative variables and Chi-square, Fischer exact test for categorical variables between two groups were used. STATA 14.2 software was used for statistical analysis. Results: The mean time taken for successful nasotracheal intubation was lower with Group C (43.04 ± 4.06 seconds) than with Group M (58.19 ± 4.85 seconds), (p < 0.001). Conclusion: Endotracheal tube cuff inflation is a superior technique that requires less duration for successful intubation and has less incidence of complications.

Background and Aims: Pulse oximetry measures heart rate and perfusion of tissue at fingers, toe, ear, nose, cheek, forehead, tongue may vary at different sites. This study evaluates the relation of differences of oxygen saturation (SpO₂) in different fingers of both hands with its blood supply, anatomy and physiology. Methods: Healthy volunteers from 18 to 35 years without any comorbidities were recruited. Patients who were pregnant, menstruating, smoker, ulnar or radial artery defect, hypotensive, hypothermic, anemic, hemoglobinopathy, have nail polish were excluded from the study. Patients were advised nil per oral for 8 hours and were made to sit for 10 mins to relax (confirming no anxiety). With constant watch with blood pressure and heart rate, oxygen saturation using a pulse oximeter (SpO₂) was measured in all fingers at least for 3 mins. Repeated ANOVA test-Bonferroni test used. Results: We observed the oxygen saturation in various fingers as the right middle (98.62%±1.04), right thumb (98.24%±1.08) while least in the left little finger (97.12%± 1.88) and right little finger (97.34%±1.56) (P=0.0037). Conclusion: Index finger having less SpO₂ compare to middle finger may be because it fed on deep palmer arcus created from radial artery while middle receives both ulnar & radial arterial blood supply and least at little may be due to size.

Background and Aims: In the recent past, many novel devices such as AirTraq and C-MAC videolaryngoscope (VL) have been introduced in an attempt to reduce anaesthetic morbidity and mortality associated with difficult intubation. In this study, we aimed to evaluate and compare C-MAC VL and the AirTraq optical laryngoscope with a standard Macintosh blade as intubating devices with the patient's head in neutral position. Methods: Sixty American Society of Anesthesiologist Physical Status I-II patients were randomly assigned to be intubated with C-MAC VL (Group CM; n = 30) or AirTraq (Group AT; n = 30) in the head-neutral position with or without the application of optimization manoeuvres. The primary outcomes of this study were the success rate and the time taken to intubate. Glottic view, ease of tracheal intubation and haemodynamic responses were considered as secondary endpoints. Results: The incidence of successful intubation was similar in both groups (P = 1.00). However, the time for intubation was significantly less with C-MAC VL (Group CM = 14.9 ± 12.89 s, Group AT = 26.3 ± 13.34 s; P = 0.0014). There was no significant difference between the two groups in terms of ease of intubation and glottic view. However, the haemodynamic perturbations were much less with C-MAC VL. Conclusion: We conclude that both the devices were similar in visualising the larynx in a head-neutral position with similar success rates of intubation. However, the C-MAC VL was better with regard to intubation time.

Background and Aims: Many videolaryngoscopes (VL) have been invented to aid intubation in anticipated and unanticipated difficult airways. In this study, we aimed to compare C-MAC VL and King Vision VL in patients with cervical spine immobilization mimicking a scenario of cervical spine injury. Methods: After approval from the Institutional Ethical Committee, 70 ASA physical status I and II patients with age ranging between 20-60 years were randomly divided into two groups and intubated with C-MAC VL (n=35) and King Vision VL (n=35) with the application of manual inline axial stabilisation (MIAS) and jaw thrust by an experienced anesthetist. Statistical analysis was performed using Microsoft Excel SPSS latest version software. Continuous data were compared using Student's t-test, categorical data using Fisher exact test. Results: Intubation with C-MAC VL took 17.40 ± 5.10 s as compared to King Vision VL 24.80 ± 5.20 s (p < 0.0001). Conclusion: Both devices were 100% successful in achieving first attempt intubation in patients with cervical spine immobilization. C-MAC VL was better concerning intubation time.

Background and Aims: Airway management in infants with hydrocephalous is always a challenging task due to the presence of an enlarged head, difficulty in positioning for intubation, and other associated congenital anomalies. Videolaryngoscopes (VLS) are routinely being used in uncomplicated as well as difficult pediatric airways. The present study was designed to assess the efficacy of the Medicam paediatric videolaryngoscope for intubation in infants with hydrocephalous in terms of intubation time, ease of intubation, number of attempts, POGO score, and adverse events. Methods: After gaining approval from the Institutional Ethical Committee and informed written consent from the parents, this prospective observational pilot study was conducted over one year with total recruitment of 22 infants with hydrocephalous undergoing elective general anesthesia for shunt placement. Medicam videolaryngoscope intubation was achieved by an experienced and skilled anesthesiologist and parameters were noted. Continuous data were presented as mean ± standard deviation while categorical data were presented as absolute values. A Student's t-test to compare continuous parametric data while Fisher's exact test to compare categorical non-parametrical data was used. Results: The time to best glottic view (TTBV) was 8.84±1.40 s and the time to intubation (TTI) was noted to be 29.72±3.27 s. Grade 1 ease of intubation as noted in 15 patients. Eighteen out of 22 patients were intubated on the first attempt. POGO score was 1 in 17 out of 22 patients. Conclusion: Medicam pediatric videolaryngoscope seems to be an effective and safe device for routine TI in infants with hydrocephalous.

Background and Aims: All India Difficult Airway Association (AIDAA) has come up with difficult airway (DA) guidelines to suit the Indian context. We conducted an online survey with the primary aim to know the awareness about AIDAA guidelines and adherence to them in clinical practice. Secondary aims were to explore any variations in practice. Methods: An online web-based questionnaire survey was sent to all practicing anesthesiologists who attended the airway workshop at the conference (ISAMIDKON-Kerala 2020). The validated and piloted questionnaire consisted of 23 questions to evaluate the awareness about and adherence to AIDAA guidelines in clinical practice. Results: The response rate was 68%. The majority of our respondents (81%) were aware of AIDAA guidelines. Apnoeic nasal oxygen insufflation was practiced always by only 19.59%. Although the majority (79.7%) use capnography to confirm intubation always, still 7.35% use it never or sometimes only. When 58.78% report and discuss any DA incidents, only 52.7% issued an alert card to the patient. Half of the respondents ensured 95% oxygen saturation (SpO₂) to do repeat laryngoscopy and 64% go for supraglottic devices after 3^rd attempt of laryngoscopy. Fifty percentages had the training to do cricothyrotomy, but only 41% had ready access to cricothyrotomy set in the workplace. When the variation in practice pattern was analyzed, the use of capnography was more prevalent in private institutions. Clinical practice revealed a significant safety gap with some recommendations like debriefing of DA event, alert card, nasal oxygenation, etc. Conclusion: Awareness about AIDAA guidelines is high among our practicing anesthesiologists, but adherence to recommendations varies and there is room for improvement especially in debriefing DA events and issuing the alert card, use of capnography, and nasal oxygenation.

Background and Aims: Anaesthetizing a pregnant lady is still a challenge to the anesthesiologist. Pulmonary aspiration of gastric contents in pregnant women remains one of the most feared complications of obstetric anesthesia though the patients are made to fast. Bedside ultrasound is the first and the only noninvasive technique useful to estimate gastric volume. The objective of this study was to estimate the gastric volume in term fasted pregnant women based on the gastric antral cross-sectional (CSA) area using ultrasound. Methods: After approval by the Institutional Ethics Committee, we conducted an observational, cross-sectional study. All the enrolled pregnant women were explained regarding the USG scan and written informed consent was taken. It was conducted in 132 pregnant women posted for elective cesarean delivery. A preoperative gastric ultrasound was done in supine and right lateral decubitus (RLD) position using portable sonography. Gastric contents were qualitatively graded. Gastric volume was estimated by measuring the antral cross-sectional area and using a mathematical model. The data was processed using MS Excel and analyzed using the IBM (SPSS) software version 22. Categorical measurements or data that were not normally distributed were analyzed by independent sample t-test and paired t-test. Results: The mean CSA in RLD was 5.75 cm² with an estimated gastric volume of 76.87 ml (SD 8.03). Also, 51.5% of pregnant women fasting for 10 hours had no fluid in the antrum in both supine and RLD positions. We observed that 47% had fluid only in the RLD position. The P-value of < 0.0001 was significant. The 95^th percentile of gastric volume (RLD) wad 90.15 (75.31 -78.44). Majority of pregnant women at term had no fluid content or fluid content only in the RLD position. Conclusion: The majority of the pregnant women had an empty stomach, but one. Fasting duration of more than 8-10 hours showed no solid gastric content in the antrum. The qualitative 3-point grading system can be used to assess the preoperative risk of gastric aspiration.

Background and Aims: Airway assessment using Mallampati classification in different positions and comparing them with the standard technique. And to evaluate the relationship between Mallampati class assessed by these techniques with that of Cormack Lehane's classification using direct laryngoscopy. Methods: In this study, 250 patients aged 20-50 years were studied during the years 2014 to 2017 after obtaining Ethical Committee Clearance and informed consent. The Mallampati test was conducted on patients in four positions - standard position with and without neck extension, with tongue depressed using a tongue depressor and in the supine position. A blinded observer then performed laryngoscopy and intubation. Difficult intubation was assessed according to the Cormack Lehane grading scale. Statistical analysis used: Diagnostic statistical measures for each of the four situations — sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. Results: In this study, 7 patients (2.8%) had difficult laryngoscopy and intubation. There was no difference in the sensitivity of the Mallampati test in the sitting positions and supine position however the sensitivity was decreased when the tongue was depressed but this had the highest specificity and positive predictive value. The negative predictive value was above 95% in all the positions. The accuracy was the highest with Mallampati done with tongue depressed. Conclusion: Based on our results, the sitting position with neck in neutral and extended position had the best correlation in the prediction of difficult laryngoscopy and intubation. Identification of easy intubations was in the sitting position with tongue depressed which also had the highest accuracy as compared to the other positions.

Background and Aims: Endotracheal tube (ETT) is incorrectly placed in more than 50% of neonates which causes many complications. Among various guidelines to determine ETT insertion depth, the American Academy of Pediatrics (AAP) proposes a “weight+6 cm” formula and the 7^th edition of NRP endorses “NTL (nasal-tragus length)+1 cm” formula. We aim to compare weight and nasal-tragus length-based formulae as a guide to ETT insertion depth in neonates undergoing surgery using a fiberoptic bronchoscope. Methods: Sixty full-term neonates were taken as sample size, with 30 included under the “weight+6 cm” formula and the remaining 30 under the “NTL +1 cm “ formula. ETT was inserted and fixed according to precalculated values. Flexible FOB was used to confirm the distance from carina to ETT tip. Midtracheal position is considered to be 20-25 mm above the carina. Repositioning was done if the distance from the carina to the ETT tip is less than 5 mm i.e., if ETT is deep. Chi-squared tests and Mann-Whitney tests were used for analysis. Results: Mean distance measured from carina to ETT tip in NTL group was 9.40 mm with an SD of 6.59 and in the weight group was 3.53 mm with SD of 2.09 respectively. So we have got a closer value for optimal ETT placement in the NTL group. p-value was less than 0.05. ETT of 8 out of 30 neonates were repositioned in the NTL group, whereas 25 out of the 30 in the weight group. So the incidence of repositioning was more in the weight group. Conclusion: Based on the results from the studied sample, we propose NTL based formula seems to be more accurate than the weight-based formula to determine ETT insertion depth in full-term Indian neonates.

Background and Aims: Videolaryngoscopes (VLs) are used as a primary option or rescue device for intubation in various difficult airway guidelines. Recently, pediatric videolaryngoscopy has been introduced. In this study, we compared MPVL with MCL in terms of intubation time as the primary objective. Secondary objectives included the number of attempts, ease of intubation, glottic view using Cormack Lehane grading, adjustment maneuvers, hemodynamic changes, and oxygen saturation and trauma during laryngoscopy and intubation. Methods: Sixty ASA physical status 1 and 2 children (both sexes), age (2-10 years) undergoing elective surgery were randomly divided into two groups for intubation using either of the two devices. We excluded children having anticipated difficult airway, congenital anomalies, heart disease, reactive airway disease and metabolic disease from the study. Parameters mentioned above were recorded. Results: Intubation time was longer in MPVL (20.2±4.4 s) compared to MCL (15.8±3.4 s) group. For MPVL, the ease of intubation in grades 1 and 2 was 25 and 5, respectively. In MCL, the ease of intubation for grades 1 and 2 was 17 and 13, respectively. CL grading for grades 1 and 2 was 26 and 4 respectively in MPVL, while it is 18 and 12 respectively for MCL. Ease of intubation and CL grading were statistically significant. Hemodynamic changes and the number of intubation attempts between the devices were not significant. Conclusion: MPVL showed to be an effective and safe device for intubation in children. Compared to MCL, intubation time was prolonged. However, improved glottic visualization and ease of intubation were noted with MPVL.

Background and Aims: Nasotracheal intubation (NTI) is commonly used in surgeries where better oral exposure is required such as surgeries for oropharyngeal cancers, maxillofacial surgeries and dental surgeries. This technique is frequently associated with nasopharyngeal trauma. A gum elastic bougie is a flexible airway introducer used as an aid in orotracheal intubation. There is a paucity of literature about the efficacy of bougie-guided videolaryngoscopy-assisted nasotracheal intubation in reducing nasopharyngeal trauma. This study aimed to compare the efficacy of videolaryngoscopy-assisted bougie-guided and non-bougie guided nasotracheal intubation by assessing post-intubation nasopharyngeal trauma. Methods: After Institutional Ethical Committee clearance and patient consent, 90 adult patients of American Society of Anesthesiologists (ASA) physical status I-II from 18-70 years of age undergoing elective surgery where nasotracheal intubation was indicated were randomized into 2 groups, bougie group (Group B) where reusable 15 Fr gum elastic bougie was used to facilitate nasotracheal intubation and non-bougie (Group NB) where no bougie was used. Videolaryngoscope was used in both groups. The primary objective was to study the incidence and severity of nasopharyngeal bleeding at 1 minute and 5 minutes of intubation, the time taken for intubation, the need for Magill forceps and external laryngeal manipulation. The results were analysed using the Chi-square test and Mann Whitney test. Results: The demographic profile was comparable in the two study groups. In our study, the incidence of nasopharyngeal bleeding at 1 minute of intubation was 24.4% in group B where bougie was used as an aid versus 82.2% in group NB where no bougie was used for NTI (P < 0.001). At 5 minutes of intubation, none of the patients in group B had bleeding as compared to 33.3% of patients in group NB (P < 0.001). One patient (2.2%) required Magill forceps for intubation in group B as compared to 36 patients (80%) in group NB (P < 0.001). Time taken for intubation was significantly less in group B as compared to group NB (P < 0.001). Conclusion: The use of videolaryngoscopy-assisted bougie-guided NTI significantly decreased the incidence and severity of nasopharyngeal trauma after intubation. It reduced the intubation time and the requirement for Magill forceps for insertion of endotracheal tube.

Background and Aims: Endoscopic procedures are usually performed under monitored anesthesia care. Hypoxia is common due to the sedative effects of drugs and sharing of the airway between endoscopists and anesthesiologists. We compared two different methods of oxygen delivery during flexible endoscopic procedures under monitored anesthesia care for the occurrence of hypoxia. They were oxygen delivery via nasal prongs and oxygen delivery through T-piece via nasopharyngeal airway. The primary objective was to compare hypoxia (that is oxygen saturation, SpO₂ < 90% for at least 15 seconds) and the secondary objective was to compare sedation level and adverse events. Methods: Ethical approval was taken from the Human Research and Ethical Committee before undertaking the study. The study had 66 patients (33 in each group) aged 18-80 years. They were randomly allocated into two groups after written informed consent for randomized control trial. Each patient's SpO₂ every 5 minutes till the end. Statistical analyses were independent t-test, Chi-square test. Result: There is no statistically significant difference in the mean SpO₂ (p > 0.05), but the incidence of hypoxia was less in nasal prongs (6.1%, 2 patients out of 33 patients) as compared to the patients of T-piece via nasopharyngeal airway (27.3%, 9 patients out of 33 patients) (p < 0.05). Conclusion: During flexible endoscopy under monitored anesthesia care, oxygen delivery via nasal prongs offered an advantage over oxygen delivery through T-piece via nasopharyngeal airway as there was less incidence of hypoxia.

Background and Aims: Supraglottic airway devices (SADs) are an established part of the routine and emergency paediatric airway management. To compare the clinical efficacy of Ambu AuraGain (AAG) as a ventilatory device with that of Laryngeal mask airway ProSeal (LMA-P), in paediatric patients undergoing elective surgery under general anaesthesia with controlled ventilation. Methods: One hundred ASA physical status I and II patients who were scheduled to undergo elective surgeries allotted randomly in 2 groups. Institutional Ethical Committee approval obtained and in each case, the child's parent's/guardian's consent was taken. In Group (A) AAG was inserted and in Group (P) LMA-P was inserted in paediatric patients. The oropharyngeal seal pressure (OSP), number of attempts taken for successful insertion, time taken for achieving effective airway, ease of insertion of the device and gastric catheter, anatomical alignment of the device to glottic opening by fiberoptic scoring and intraoperative/postoperative adverse events were compared. Quantitative variables-Independent t-test/Mann-Whitney Test, Qualitative variables- Chi-Square test/Fisher's Exact test. Results: AAG provides higher OSP when measured at 5 minutes (p < 0.0001) and at 30 minutes (p = 0.0001), as compared to LMA-P. The time for achieving effective airway was significantly less with AAG than that with LMA-P (18.2 ± 1.51 seconds and 19.2 ± 1.46 seconds respectively) (p=0.0005). Conclusion: Our study concluded that the AAG, a single-use SAS, is better than LMA-P, a multiple-use SAD, as it provides higher OSP and takes a significantly shorter time for achieving effective ventilation.

Background: We conducted a simulation-based study to compare the intubation characteristics with the use of intubation box (IB) and plastic sheet (PS) using both direct Macintosh laryngoscope and videolaryngoscope (VL). Methods: After obtaining Institutional Ethical Committee clearance (INT/IEC/2020/SP2-966), sixteen residents performed six intubations, three using a Macintosh laryngoscope and 3 with VL using intubation box, plastic sheet and the third without any protective gear respectively. Time taken to intubation was recorded as the primary outcome. First-time success rate, overall success rate, laryngoscopic view, ease of intubation, and any breach in personnel protective equipment (PPE) were the secondary outcomes. Results: The mean time to intubation with Macintosh laryngoscope without ancillary gear, with PS and with IB was [11(3.2) Vs 18.9(6.7) Vs 15.94(6.7), p=0.0001] seconds respectively, while with VL was [15.1(7.5) Vs 25.2 (13.5) Vs 23.3(11.4), p=0.010] seconds respectively. There was a statistically significant difference in the ease of intubation between Macintosh laryngoscope and VL without any ancillary adjunct (p=0.018), with PS (p < 0.001) and IB (p=0.001). The overall success rate was 100% in all scenarios. Conclusion: Use of protective gear prolonged the intubation time with both Macintosh laryngoscope and VL. However, increased difficulty in maneuvering the tube was faced with VL. This warrants aggressive simulation-based training with both the VL and protective gears before using them in clinical practice.

Background and Aims: Difficult laryngoscopy and difficult tracheal intubation occur in 1.5% to 13% of patients undergoing general anesthesia and have always been a concern for anesthesiologists. Several bedside tests such as modified Mallampati test, sternomental distance, thyromental distance, interincisor distance and upper lip bite test are used to predict difficult intubation. To compare upper lip bite test with the measurement of thyromental distance for the prediction of difficult intubation. Methods: After obtaining Institutional Ethical Committee approval and patient consent, this prospective, observational, single-blind study was done on 30 patients who required inhaled general anesthesia with endotracheal intubation for elective surgery. Patients were evaluated for TMD measurement and ULBT. In the ULBT three classes: class I, a patient can raise the lower incisors above the vermilion line; class II, upper lip below the vermilion line; and class III, unable to bite the upper lip. After induction of anesthesia, the patient's grade of laryngeal view by the Cormack Lehane classification was documented. A TMD equal to or less than 6 cm and a class III ULBT were predicted as difficult intubation which was correlated with Cormack Lehane class III or IV which was considered as difficult intubation. The percentage for qualitative data and non-parametric tests like Chi-square, Wilcoxon Rank test, Friedman test were used to find significance level between variables, and p value < 0.05 was considered as the significance level. Results: Of 30 patients involved in the study, two had difficult intubation. Sensitivity, specificity, positive and negative predictive values 100%, 94.4%, 66.6%, 100%, for ULBT, and 50%, 77%, 20%, 93% for TMD. Sensitivity, specificity, and positive predictive value were found to be significantly higher for the ULBT than for TMD (p < 0.05). Conclusion: ULBT is a useful bedside test for the evaluation of patient airway before the general anesthesia with greater sensitivity, specificity, positive predictive value than TMD.

Background and Aims: An immobilized cervical spine is a complex challenge for the anesthesiologist in performing endotracheal intubation. Airtraq allows glottic visualization in a neutral position whereas LMA-Fastrach was designed as a conduit for tracheal intubation; both do not require head and neck manipulation during their application. The present study was conducted to compare intubation through LMA-Fastrach versus Airtraq in a simulated scenario of cervical spine immobility. Methods: Following approval from the Board of Studies and Ethical Committee, the study was done in 70 consenting patients with cervical spine immobilization with a hard cervical collar scheduled for elective surgery under general anesthesia. Patients were randomly allocated and intubated using either LMA-Fastrach (Group I) or Airtraq (Group T) [n=35]. Success at the first attempt, the time required for intubation, ease of insertion, hemodynamic changes and any complications were evaluated. Statistical analysis was done with SPSS Version 17 for Windows (SPSS, Chicago, IL). P-value < 0.05 was considered significant. Results: The mean intubation time was shorter with Airtraq (51.20±20.45 s) as compared to LMA-Fastrach (96.39±14.16 s) (p value < 0.0003). Ease of intubation was also better in the Airtraq group. The heart rate showed a difference in 3 min post-intubation, 99.13±9.64 and 90.13±8.27 beats/min in group I and T respectively (p<0.0125). Mean blood pressure showed an increase at immediate post-intubation (104.26±13.25 mm Hg) and 3 min (100.93±11.95 mm Hg) with LMA-Fastrach (p-value of 0.034 and 0.004 respectively). Conclusion: Airtraq is better than LMA-Fastrach due to shorter intubation time, more ease of intubation and lesser hemodynamic changes.

Background and Aims: Both intubation and extubation are associated with hemodynamic pressor response. We aimed to evaluate if ropivacaine 0.75% nebulization would prevent hemodynamic and cough responses to intubation and extubation. Methods: After obtaining Ethical Committee approval and informed consent, 94 patients were randomly allocated to two groups. Group R and Group N received nebulization with 10 mL 0.75% ropivacaine and 10 mL normal saline respectively. The primary outcome was to measure the intubation and extubation surge. The grade of post-extubation cough, postoperative sore throat and extubation time were our secondary objectives. Mean and standard deviation for numerical variables and percentages for categorical variables were used. Paired t-test, Chi-square test, or Fisher's exact test were used as appropriate. Results: The mean values of heart rate and mean arterial pressure (from intubation to extubation at all time points) were lower in the ropivacaine compared to the normal saline group (P < 0.05). The mean grade of post-extubation cough was 2.40 ± 0.61 vs. 0.66 ± 0.56 in group N and R respectively (p < 0.0001). The mean score of a postoperative sore throat (2.3 ± 0.51 vs. 0.5 ± 0.58, p < 0.0001) after extubation was lower in Group R. The mean extubation time (12.2 ± 3.3 vs. 6.7 ± 2.2, p < 0.0001) was higher in the ropivacaine group. Conclusion: Topical anesthesia with 0.75% ropivacaine nebulization before intubation can significantly reduce the hemodynamic surge. It also reduces the grade of post-extubation cough and postoperative sore throat. The extubation time was more in the R group due to better tube tolerability.

Background and Aims: Laryngeal Mask Airway Supreme (LMAS) and Laryngeal Tube Suction II (LTS II) are second-generation supraglottic airway devices (SAD) used during anesthetic procedures like management of the difficult airway. This study aimed to compare the efficacy of both the devices in terms of their relative ease of insertion and hemodynamic responses.^[1] Methods: A double-blind randomized control trial was conducted with two study groups. After ethical approval, sixty ASA physical status I-II patients were randomly assigned to undergo LMAS (Group A, n=30) or LTS II (Group B, n=30) insertion to secure airway while undergoing surgery under general anesthesia. The outcomes measured were ease of insertion (grade and rapidity) and hemodynamic responses [blood pressure including systolic, diastolic and mean, heart rate and oxygen saturation] before and after device insertion. Data were analyzed by unpaired t-test for parametric data and Fisher exact test for non-parametric data using SPSS-22.0, taking p < 0.05 as significant. Results: The ease of insertion was significantly better with regards to viewing grade and rapidity in the LMAS group as compared to the LTS II group (p = 0.03, p = 0.002, respectively). No significant changes in blood pressure and SpO₂ were seen. However, a significant increase in heart rate was observed immediately (p = 0.041) and 1 minute (p = 0.047) after LTS II insertion.^[2] Conclusion: Both LMAS and LTS II can be used to manage the airway under anesthesia. However, LMA proved to be the better device in terms of ease of insertion and hemodynamic changes.

Background: Rapid sequence induction (RSI) using cricoid pressure (CP) has been surrounded with controversies owing to the potential risks associated with the technique including difficulty in intubation and deterioration of laryngeal view. Currently, there has been no data on the effect of CP on the laryngoscopy force. We hypothesized CP would increase the laryngoscopy force. Methods: Seventy ASA I /II patients between 16 to 65 years of either gender undergoing non-obstetric emergency surgery were randomized to undergo RSI with and without CP after obtaining consent. Institutional Ethical Committee approval was obtained beforehand. General anaesthesia was induced with predetermined doses of propofol, fentanyl and succinylcholine. Peak force of laryngoscopy was recorded as the primary outcome. Laryngoscopic view and time are taken to intubate were noted as secondary outcomes. Results: There was a significant increase in the peak forces of laryngoscopy with the use of CP with a difference of 15.5 (13.8 to 17.2) N. The mean peak forces with and without CP were 40.758±4.2 and 25.2±2.6 N respectively, p<0.001. The intubation success rate was 100% without CP compared to 85.7% with CP, P=0.025. The proportion of patients with CL1/2A/2B with and without CP were 5/23/7 and 17/15/3 respectively, p=0.005. CP resulted in a significant increase in the time taken for intubation with a mean difference of 24.4 (2.2 to 19.9) seconds. Conclusion: Our findings show a significant increase in the peak forces during laryngoscopy with the application of CP along with the deterioration of intubation parameters. This highlights the need for caution while using this manoeuvre in susceptible individuals.

Background and Aims: Ultrasound-guided nerve blocks have increased success rates and lower complication rate. This study compared ultrasound and landmark-guided block of the superior laryngeal nerve (SLNB) during upper airway anaesthesia to aid awake fibreoptic intubation. Methods: This prospective, observational study was done after obtaining Institutional Ethical Committee approval and informed consent. All patients received intravenous 1 mg midazolam and 50 μg of fentanyl for mild sedation before tracheal intubation. Nasal passages were anaesthetised using lignocaine-coated nasopharyngeal airways, nebulization of 3 mL of 2% lignocaine. Two mL of 2% lignocaine was given through the cricothyroid membrane. Group L (n=13) received landmark-guided SLNB, at the lateral end of the thyrohyoid membrane (2 mL of 1.5% lignocaine). In Group U (ultrasound-guided) (n=11) patients, the thyrohyoid membrane was visualized using a linear ultrasound probe (8–13 Hz) and injection was placed just superficial to the membrane using the 'out of plane' method. Results: Quality of airway anaesthesia was comparable between groups (desirable – score 0 and 1, undesirable – scores 2, 3 and 4). 61.53% (8/13) in Group L and 63.63% (7/11) in Group U had desirable scores P=0.916). Mean (±SD) time for intubation was 234.43±112.14 s in Group L and 192.7±94.48 s in Group U (P=0.349). The median (IQR) patient perception of discomfort (NRS) in Group L was 5 (4–8) and Group U, 3 (2–6) (P=0.271). Conclusion: Quality of anaesthesia, time to intubation and patient discomfort are similar to landmark-based and ultrasound-guided SLNB during upper airway anaesthesia to aid awake fibreoptic intubation.

Background and Aims: Identification of a difficult airway preoperatively is essential to reduce mortality and morbidity for which various indices are available. This study aims to compare the ratio of height to thyromental distance (RHTMD), upper lip bite test (ULBT), and Mallampati grading (MPG) as predictors of difficult laryngoscopy in apparently normal-looking patients. Methods: After obtaining approval from the Institutional Ethics Committee, 200 adult patients of either sex, ASA physical status I-III, scheduled for elective surgery under general anesthesia were prospectively enrolled in a comparative analytical study. With their consent, airway assessment using RHTMD, ULBT, and MPG was performed preoperatively and compared to Cormack and Lehane's glottic view on direct laryngoscopy. Sensitivity, specificity, positive and negative predictive value, and accuracy were calculated for each test individually and in combination. Results: The incidence of difficult laryngoscopy (CL grade III, IV) was 5% in the study. Both ULBT and RHTMD were comparable and superior to MPG. The sensitivity, specificity, positive and negative predictive value and accuracy of ULBT was 50%, 99.47%, 83.33%, 97.42% and 97% respectively and the same for RHTMD was 50%, 98.95%, 71.43%, 97.41% and 96.5% respectively. Combination of the 3 tests gave 100% sensitivity, 96.84% specificity, 62.5% PPV, 100% NPV and 97% accuracy. Conclusion: Rather than using a single predictor, combining RHTMD, ULBT chances of correctly anticipating the risk of difficult laryngoscopy may help in the proper selection of equipment, technique, and participation of personnel experienced in difficult airway management.

Background: Syndromic patients with severe micrognathia present a difficult airway. Conventional laryngoscopy and tracheal intubation are difficult in these patients. Fiberoptic devices remain the gold standard for airway management in these difficult airways. As these devices may not be always available, whether these cases can be managed with supraglottic airway devices (SAD) remains an enigma. Cases: Four syndromic patients between 4-7 months of age with severe micrognathia for glossopexy were included. Following failed attempts to secure airway conventionally or with fiberoptic devices, they were managed uneventfully with i-Gel throughout the procedure. Conclusion: SADs, including i-Gel, are not the definitive technique of airway management. It can still be effectively used in the management of syndromic patients with a difficult airway, where the conventional mode of securing the airway is not possible.

Background: Needle insertion done for brachytherapy in a breast cancer patient is very painful and requires a significant amount of analgesics. An intercostal nerve block is the injection of local anesthetics in the area where intercostals nerves are located which temporarily interrupts the flow of signals associated with relief in neuropathic/somatic pain, easy to perform and useful as the primary intervention and adjuncts for pain in the chest wall and upper abdomen. Cases Description: Four breast cancer patients of age between 41-45 with body mass index (BMI) of 23-25 kg/m2 without any comorbidities posted for radiation brachytherapy were selected. After adequate investigations, pre-procedure checkup, and maintaining adequate fasting, 2 of the 4 patients were explained about intercostals block for pain relief and consents for publication and block were taken. Intercostal blocks were given at 2^nd to 6^th intercostals spaces with the total amount of 14 ml of an equal mixture of Inj. Bupivacaine 0.5% and Inj.lignocine 2% were given. Two groups of 2 pt were made, A: received Intercostal block, B: didn't receive a block. Both groups were given premedication and oxygen. Intra and postprocedure requirement of analgesia with visual analog scale (VAS) score was noted. Conclusion: Intercostal blocks can be an excellent additive anesthetic technique for carcinoma breast patients undergoing needle insertion for brachytherapy. It also decreases the requirement of sedative drugs and analgesics during the procedure as well as analgesics after the procedure.

Background: Fiberoptic endotracheal intubation is a usually performed technique of airway management in patients with cervical spine injury. Herein, we describe a novel rescue technique of fiberoptic tracheal intubation using Air Q in cervical spine fracture. Case Description: Six cases of atlantoaxial dislocation and 3 cases of odontoid fracture were intubated with Air Q -ILA (as a rescue in 4 and planned in 5 cases) which was used as a conduit to guide the twin assembly (fiberscope inside the tracheal tube). Air Q sizes 2.5 and 3.5 were used. The minimum time to successfully placing the endotracheal tube was 20 seconds and the maximum time was 35 seconds. In two cases of odontoid fracture, it took 2 attempts to successfully securing the endotracheal tube. Written informed consent was taken before anaesthesia. Conclusion: Air Q-ILA-guided tracheal intubation is highly successful in patients with limited cervical spine mobility. Elevation ramp in airway outlet approximates airway anatomy, provides easy insertion. A keyhole-shaped airway outlet elevates the epiglottis to provide unobstructed access to the laryngeal inlet and decreases the chances of failed intubation in patients of the fixed cervical spine.

Background: King Vision^TM videolaryngoscope guides tracheal intubation along with a better glottic view. Cuff inflation in the nasotracheal tube (NTT) makes the tube midline and good alignment with glottic opening. The combination of these two techniques allows intubation without the need for airway instrumentation, thereby minimizing airway trauma and cuff perforation. Case Description: After obtaining written informed consent, 10 patients posted for oromaxillofacial surgeries were included. General anesthesia was induced, NTT was passed up to the oropharynx; with King Vision^TM, the cuff was inflated with 15 mL of air. NTT was advanced to vocal cords, cuff deflated; then advanced into the trachea, and then cuff was reinflated. All patients were successfully intubated without the need for additional aids. Conclusion: Nasotracheal intubation with King Vision^TM videolaryngoscope using the cuff inflation technique is a good alternative to conventional methods.

Background: Paediatric maxillary masses pose a great challenge to the anesthesiologist in terms of management of the anticipated difficult airway. Awake fiberoptic intubation is not an option for children due to lack of cooperation. Cases Description: The anesthetic management of children undergoing maxillary surgeries was documented. A stepwise approach based on recommended principles of airway management was followed: (1) Preoperative evaluation of CT scan to assess patency of nostril and posterior-inferior extent of mass. (2) Preoperative airway obstruction symptoms especially when asleep in supine position. (3) Anticipation of difficult mask ventilation and keeping necessary equipment ready. (4) Awake intravenous access. (5) Inhalational induction maintaining depth and spontaneous respiration followed by a check direct laryngoscopy or videolaryngoscopy to rule out intraoral extension and obstruction. Conclusion: Paediatric patients undergoing maxillary surgeries require a different approach as compared to adults and appropriate assessment and planning are important for successful airway management.

Background: Successful and sustainable training and learning of the management of difficult and normal airways is essential for all active anaesthesiologists. Description: The authors started airway training with the concept of E-learning, hands-on practical training, and small group teaching with good delegate-to-faculty ratio. It also included good interaction and active participation from delegates, discussion of practical points and inclusion of training in human factors. The importance of a multidisciplinary team has been highlighted and emphasized in various training courses as simulation gained popularity. Three years ago, we had an idea of having a combined session with other surgical specialties involved with us in airway management. In the “Can't intubate, Can't oxygenate” scenario we should think of getting help from our surgical colleagues and then we must empower ourselves for this experience. Conclusion: We have incorporated lectures, live workshops, simulation sessions, lively debates, case discussions and competition for case presentation. We have always kept the course adaptive and responsive to the delegate feedback.

Background: Only a thorough understanding of alternative airway strategies can save the day despite readiness for anticipated difficulty. Case Description: An adult male with Treacher Collins syndrome and difficult airway, posted for malar augmentation, was undergoing awake fibreoptic intubation. Every attempt to pass smaller-sized tubes was met with resistance bilaterally and cuffs were damaged which was linked to computed tomographic (CT) scan findings of the right-sided nasal spur with gross septal deviation to the left. Finally, submental intubation was performed to provide bimaxillary occlusion. Conclusion: Change of strategy to submental intubation helped to carry out the intended procedure as per schedule.

Background: Most important contributing factor in development of tracheal stenosis (TS) is prolonged duration of endotracheal intubation (EI). In our case, tracheal stenosis (TS) developed after a single EI for a short duration < 6 hours for a non-airway surgery in the past which is not reported in literature. Case Description: A 40-year-old obese (body mass index 39.21 kg/m²) lady was posted for total abdominal hysterectomy under general anesthesia (GA) with lumbar epidural analgesia (L1-L2) accepted under ASA physical status II. She had undergone surgery for disc prolapse at L4-L5, 17 years back under GA with uneventful perioperative period. After induction and confirmation of ventilation by bag and mask, a neuromuscular blocking agent was given and the first attempt to pass 7.0 mm ETT was made, but the attempt failed to pass the ETT beyond vocal cords. Second attempt was tried over a bougie but failed to railroad ETT beyond vocal cords. Third attempt of intubation done by a senior anaesthesiologist with size 6.0 mm ETT also failed. Ventilation with different sizes of mask was attempted, but adequate seal and tidal volume could not be achieved. Diagnostic bronchoscopy done on table revealed subglottic tracheal narrowing. Patient was woken up without any complication in the postoperative period and surgery postponed. Otolaryngologist review done for tracheal narrowing by flexible fibreoptic laryngoscope revealed subglottic stenosis. Patient consent taken; due efforts made to conceal identity. Conclusion: A patient with uneventful previous intubation does not guarantee an easy airway on subsequent occasions. Even a single, short duration of intubation can cause postoperative tracheal stenosis.

Background: Cystic hygroma is a transilluminating, painless, soft benign tumor composed of various sizes of cystic lumps. Mc site - 70-80% in the neck, (left posterior cervical triangle). We report a 2 month-old child, 3.5 kg presented with a progressively increasing mass on left side of neck with a history of difficulty in breathing and feeding for a week. Case Description: On examination, 8 x 5 cm swelling was noted on the left side of the neck. The oxygen saturation (SpO₂) on room air was 88% with a respiratory rate of 65/min, inspiratory stridor was present, chest indrawing with decreased air entry on the left side, and bilateral basal crepitation was present. CT neck showed anterior and rightward displacement of the larynx with compression of the trachea. Cystic hygroma was planned for excision under general anesthesia with the consent of parents along with anticipated difficult intubation and complications, also a difficult airway cart was kept ready. Preoperative optimization was done. In the operating room, preoxygenation was done followed by inhalational induction sevoflurane and 100% oxygen used. Oral intubation was done on 2^nd attempt with 3 mm uncuffed endotracheal tube. Non-depolarizing muscle relaxant atracurium used. The intraoperative period was uneventful. A trial of extubation was done after reversal and observed for 48 h. Conclusion: Successful results are with proper preoperative evaluation, intraoperative and postoperative complication management.

Background: Fiberoptic intubation is considered the gold standard for difficult airways. Does control of airway with fibreoptic bronchoscope end in itself? We report the case emphasizing this concern. Case Description: A 45-year-old female was posted for microlaryngeal surgery, excision and biopsy after written informed consent was taken for awake fiberoptic intubation as CECT neck and VLS revealed large polypoidal mass obstructing the glottis. The patient was prepared for difficult airway and adequate airway block was administered but the view was obscured because of the sizable mass resulting in extremely difficult fiberoptic intubation. Airway was secured with a 6.5 mm ID flexometallic tube after multiple attempts. Post-procedure tracheostomy was carried out. Conclusion: Procedures with repeated attempts to intubate can worsen the airway obstruction affecting edema, hemorrhage, and pain, where the role of the endotracheal tube is relatively short and tracheostomy is the ultimate savior.

Background: Achondroplasia presents bony distortion in the face, neck and spine causing a difficult airway. Case Description: Ten-month female child with achondroplasia, concomitant atlantoaxial dislocation and hydrocephalus secondary to foramen magnum stenosis, posted for ventriculoperitoneal (VP) shunting. Anaesthesia and surgery were uneventful. At the end of the surgery, no breathing attempts, high blood sugar with a sudden drop in blood pressure. Bradycardia that occurred responded only to adrenaline. Child was extubated after 48 hours but had sluggish movements of limbs. Reintubated within 5 hours and weaned over 6 days. Coning and spinal cord oedema were diagnosed. Conclusion: Identification of atlantoaxial joint dislocation in achondroplasia is a must for successful airway management.

Background: Airway management of a patient with unstable cervical spine undergoing surgical intervention represents a great challenge to an anesthesiologist, particularly during laryngoscopy and intubation. Laryngoscopy inherently involves movements at the occipito-atlantoaxial complex that may aggravate pre-existing cord injury. Case Description: A 17-year-female underwent posterior fusion for atlantoaxial (C1-C2) dislocation, after awake fiberoptic intubation. At the end of surgery, patient was extubated after fulfilling extubation criteria. On arrival to the post-anesthesia care unit, the patient became unresponsive and apneic with a palpable pulse. Resuscitative measures were initiated immediately and LMA Classic #3 was inserted as a rescue airway device. Endotracheal tube 6 mm was introduced through the LMA for achieving a definitive airway and overnight ventilation. Meanwhile, a bougie was used for the removal of LMA in a controlled manner ensuring the stability of the cervical spine. Conclusion: Prompt thinking and quick clinical decisions concerning the airway proved to be lifesaving for the patient especially during the emergency when expertise and advanced airway adjuncts were limited. The preferred technique especially during emergencies should be the one with the highest likelihood of first-pass success and least biomechanical influence on a potentially unstable cervical spine.

Background: Children with Pierre Robin sequence (PRS) exhibit varying degrees of airway obstruction and feeding difficulty, sometimes warranting surgical intervention. Case Description: A 6-day old child undergoing glossopexy for PRS revealed micrognathia, hurried breathing and subcostal retraction. After failed conventional laryngoscopy and nasal intubation, received size #1 i-gel. Use of antisialogogue, Rose's position draining blood and secretions away, limited bleeding reduced opportunity for aspiration. Conclusion: Traditionally, in the compromised airway, supraglottic devices (SGD) are not considered as a standard management technique. SGD can be a valuable airway management technique among children coming for glossopexy. Unlike most airway procedures which tend to compromise airway post-procedure, glossopexy improves the airway.

Background: Epignathus is a rare oropharyngeal tumor with high mortality. Its incidence ranges from 1:35,000 to 1:200,000 live births with a female predominance. Direct laryngoscopy may fail to visualize the larynx in neonates with airway anomalies. The Airtraq is a disposable optical laryngoscope used in difficult airway management in the pediatric population. CaseDescription: A 7 day, 3 kg, full-term neonate with intraoral swelling, measuring 3 cm x 2 cm, central in location, arising from the hard palate. The airway management was successfully done using Airtraq. Conclusion: By successfully intubating the neonate with epignathus using Airtraq, we emphasize the potential for securing the airway in pediatric patients with intraoral tumors.

Background: Pierre Robin syndrome (PRS) presents with airway obstruction and feeding difficulties along with difficult ventilation and intubation. Case Description: A 3 year 7-month-old male, known case of PRS, ASA physical status 1 posted for cleft palate repair. COPUR score was 12 with noisy breathing and saturation 90% on room air. Anesthesia plan was general anesthesia with endotracheal tube (ETT), preserving spontaneous ventilation. Care of anticipated difficult intubation taken. A surgeon for emergency surgical tracheostomy was present. C-MAC D-blade paediatric with uncuffed ETT (4.0 mm) was used to intubate the patient. Tongue stitch was taken. Extubation was uneventful. Conclusion: Thorough airway assessment, preparation for difficult ventilation and intubation, postoperative vigilance are required for successful and safe airway management.

Background: Extubation in repeat surgery of head and neck cancers, particularly post-radiation, is a herculean task and poses a dilemma to the anesthesiologist. Case Description: A 72-year male, previous wide local excision of the left buccal mucosa and radiation two years back, reposted the same procedure with modified radical neck dissection with flap reconstruction due to recurrence. The dilemma was “to or not to” extubate. The AIDAA 2016 Extubation guidelines helped in successful extubation. Conclusion: The decision to extubate is a dilemma in difficult airways, particularly in airway surgeries. AIDAA guidelines provide a plausible and well worked out plan for the successful extubation.

Background: Treacher Collins syndrome is a rare autosomal dominant disorder, with an incidence of 1 in 40,000. Mandibular, maxillary and zygomatic hypoplasia and retrognathia lead to a difficult airway. In this case report, we describe successful airway management of a child with severe mandibulofacial dysplasia. Case Description: A 12-year-old girl with Treacher-Collins syndrome was posted for distractor osteogenesis. On airway evaluation, the mouth opening was 2 fingers and Mallampati class IV. The patient was planned for awake nasotracheal retrograde intubation. After administering local anesthetic nebulization and airway blocks with sedation, the retrograde intubation was attempted but was not successful. This was followed by anesthetizing the patient and performing a fiberoptic guided nasal intubation, which also failed. The patient was then oxygenated well, a muscle relaxant was administered, and was successfully intubated using a fiberoptic device with a 5.5 mm flexometallic tube. The rest of the anesthetic management was uneventful. Conclusion: In a syndromic patient with an anticipated difficult airway, the conventional practice is to not paralyze the patient but to maintain spontaneous breathing, but in these cases, if mask ventilation is ensured, paralyzing the patient may be a better option to facilitate successful intubation.

Background: Cannot intubate Cannot ventilate (CICO) scenario is a nightmare for every anesthetist and emergency physician. The management of the unanticipated difficult airway in the emergency department (ED) remains a challenge even for experienced hands, especially due to an unpredictable and uncontrolled environment, unannounced patient arrival, poor airway preparation time, and lack of advanced airway resources. Case Description: We report a CICO scenario in a 35-year-old female who presented to the ED with severe respiratory distress and its management. The case was managed with a good plan and making the availability of airway equipment and following the team approach. Conclusion: CICO scenario is challenging in the ED, but appropriate planning, selection of airway devices and techniques, clear communication of the plan, and calm execution of learned methods can be lifesaving.

Background: We report a case of successful management of a neonate with tracheoesophageal fistula (TEF), complicated in the postoperative period. Case: A 3-day old baby, diagnosed with TEF and congenital heart disease (CHD) was posted for surgical correction. The baby had pooling of secretions, respiratory distress, with oxygen saturation (SpO₂) of 88%. The baby was referred back on day five with grunting and desaturation. Right lung collapse was noted, and fiberoptic bronchoscopy and suctioning were performed under the bag and mask ventilation. A thick mucus plug was sucked out from the right main bronchus. Conclusion: TEF requires timely intervention with diligence to protect the repaired fistula site from assisting prompt recovery.

Background: The reported incidences of difficult intubation, cannot intubate situation, cannot ventilate cannot intubate situation is 5.85%, 0.35%, 0.02%.^[1] In this case, we highlight the importance of plan B anaesthesia management, rescue supraglottic airway device. Case Description: Middle-aged ASA physical status 1 patient with anterior neck contracture was posted for contracture release. Had severe neck movement restriction, interincisor distance 2 cm, Mallampati class IV. The airway plan was blind nasal intubation with minimal sedation with ketamine but was unsuccessful. I-gel as rescue device inserted to perform contracture release. Rest of the course uneventful. Conclusion: Difficult airway management becomes easier with adequate planning and when due precautions are taken.

Background: The available methods to secure difficult airway in severe post-burn contracture (PBC) over the front of the neck are fiberoptic intubation, intubating LMA (ILMA), blind nasal intubation, retrograde intubation and tracheostomy. Fiberoptic is not available in many centers. LMA requires stylet for insertion which may be traumatic. We describe a case of post-burn contracture (PBC) of the neck where the upside-down technique of AMBU LMA (ALMA) insertion was used for airway management. Case Description: A patient with severe PBC of the neck with fixed flexion deformity and mouth opening of < 2 cm was taken in OT for split-thickness grafting surgery. Fiberoptic guided intubation failed because of equipment malfunction. The shaft of ALMA got stuck on to the chest while its insertion [Figure 1]. Thereafter, ALMA was inserted successfully with the upside-down technique [Figure 2]. Conclusion: ALMA can safely negotiate the sharp oropharyngeal curve in the PBC of the neck with the upside-down technique without the need for stylet and can be used in all age groups.{Figure 1}{Figure 2}

Background: Tracheostomy under sedation in a child with an impossible airway is challenging. Titrating intravenous sedation is an art. A lesser dose may lead to inadequate anesthesia and a laryngospasm with a painful stimulus whereas a larger dose may lead to apnoea with a complete ventilation failure scenario. Case Description: We report a case of a 10-year-old child with a huge intraoral mass for tumor debulking. After preoxygenation, the child was sedated with titrated doses of ketamine to allow a surgical tracheostomy under local anesthesia. Conclusion: Titrated doses of ketamine can be a wonder drug for tracheostomy in the impossible pediatric airway. It is like “walking a tight rope” where balancing between too little and too much is an art.

Background: Management of tracheal lesions remains challenging. We report the case of a 60-year-old male with adenoid cystic carcinoma of trachea for resection and reconstruction. Case Description: After induction and neuromuscular relaxation, endotracheal intubation done under videolaryngoscopic guidance with a 7.0 mm ID flexometallic tube, placed just above the tumor. Under fiberoptic bronchoscopy, a guidance tube was advanced past the tumor, but above the carina. After surgical exploration, the left bronchus was intubated by the surgeon and left single-lung ventilation was started. After tracheal resection, both lung ventilation resumed using an endotracheal tube. The patient was extubated on the table. Conclusion: Airway management for tracheal surgeries should be individualized and a fiberoptic bronchoscopy is an invaluable tool in such surgeries.

Background: Difficult failed airway management account for 2.3%-16.6% of anesthetic deaths. Airway management is tailored to the degree of airway compromise, patient's hemodynamic, oxygenation status. Orofacial, anterior neck burns are challenging - nasal fibrosis; restricted mouth opening; reduced submandibular space, atlanto-occipital joint extension. Post-burn contractures (PBC) patients can be operated on by regional or general anesthetic technique depending on scar area, comorbidity, resources available. Fiberoptic bronchoscopy (FOB) is the gold standard for difficult intubation with advantages of being steerable, continuous visualization of structures and reducing intubation trauma. Case Description: A 45-year-old ASA physical status 1, known case of seizure disorder with a history of burns with contractures over oral commissures, lower eyelids, neck. Examination revealed fibrosed scar over periorbital, circumoral, anterior neck regions with nasal stenosis. Mouth opening was 1 finger and Mallampati, thyromental distance could not be assessed. TMJ joint couldn't insinuate 1 finger. Neck extension restricted to 30° and flexion 15°. Cricothyroid membrane, tracheal rings not palpable, and the patient was unable to prognath. Airway management planning for this patient was awake oral FOB-guided intubation. Airway preparation was done with 2 mL of 4% lignocaine nebulization, 10% lignocaine spray-on posterior pharyngeal wall, and transtracheal block with 1 mL 4% lignocaine. Preoxygenation with 100% oxygen for 5 minutes. FOB-guided tracheal intubation with 7 mm ID cuffed endotracheal tube (ETT), threaded over bronchoscope through the oral cavity with Guedel's airway. Spray as you go technique done with 1 mL of 2% lignocaine as scope reached vocal cord and down trachea. Carina was visualized and scope stabilized with the left hand, ETT negotiated over scope into trachea, bronchoscope slightly withdrawn so that tip of ETT is seen. The bronchoscope was withdrawn after securing the ETT. Conclusion: Successful anesthetic management when the airway is inaccessible and distorted by PBC'S and fibrosis mandates planned approach for securing the airway, use of FOB-aided with suitable oral intubating airway customized to needs of individual patients.

Background: Sublingual hematoma is an uncommon complication of trauma and it poses a challenge for anesthesiologists to airway management. Case Description: We report an unusual case of a sublingual hematoma in a 70-year-old male who had slip and fall and sustained a bilateral mandibular fracture. On examination, his tongue was shifted posterior-superiorly because of the hematoma and he had noisy breathing. The patient was planned for surgical intervention after securing the airway with a surgical tracheostomy, but fiberoptic intubation came to the patient's rescue. Conclusion: Airway management in this case can be a very challenging situation and fiberoptic intubation is a boon for these types of threatened airways, avoiding tracheostomy for securing a definitive airway.

Background: Many of the composite resections for rising head and neck cancers incorporate reconstructive flap techniques. Case Description: We report successful anesthetic management of a patient presenting for revision of PMMC flap following flap failure and fistula. After adequate topicalization of the airway, nasotracheal intubation was attempted using a fiberoptic bronchoscope (FOB). The FOB was unable to bend the tip of the endotracheal tube (ETT) forward into the glottis due to distorted cicatrized anatomy involving the base of the tongue, with manipulation by a skilled operator. Hence, we attempted the C-MAC D blade to provide the anterior curvature required, we passed RAE ETT, into glottis with manipulation. On confirming the position of ETT, the tube was secured and surgery commenced. Conclusion: Airway management in distorted anatomy is tricky and keeping options open leads to successful airway management.

Background: The novel technique of conversion of oral to nasotracheal intubation (flap revision post buccal mucosa cancer - unanticipated difficult nasotracheal intubation). Case Description: We describe our technique of unanticipated difficult nasotracheal intubation. In our patient, who had orotracheal intubation and following surgical intervention required nasotracheal tube placement. Two nasotracheal intubation attempts with conventional and videolaryngoscopes failed. So we inserted the oral bougie-guided orotracheal tube. The tracheal end of the 2nd tube was introduced nasally and extracted through the mouth. Bougie was inserted into the oral tube and oral (1st) tube removed with bougie in the trachea. The nasal (2nd) tube was threaded over the bougie and the bougie extracted through the nostril. Subsequently, the tube advanced into the trachea under videolaryngoscopy. Conclusion: The hybrid technique can be safely followed, avoiding desaturation, where advanced airway gadgets are unavailable when difficult nasotracheal intubation is encountered.

Background: Down syndrome has multisystem effects with potentially difficult airway because of cervical spine slackness. Written informed consent was obtained from the parent for publication of this study. Case Description: We reported a case of a 9-year-old child who underwent stabilization of atlantoaxial joint and foramen magnum decompression in past. Currently presented with spastic quadriplegia posted for adductor release and osteotomy. Preoperative assessment revealed an anticipated difficult airway with absent neck movements. Trachea was intubated successfully for the procedure with a fibreoptic bronchoscope under sedation maintaining spontaneous ventilation. Conclusion: Predicting difficult airway along with knowledge of various equipment has increased the probability of successful airway management.

Background: Awake fibreoptic intubation remains the preferred technique for the management of the difficult airway. Here we present successful awake intubation using videolaryngoscope after anesthetizing the upper airway in a patient with juvenile nasopharyngeal angiofibroma (JNA). Case Description: A young male presented with nasal stuffiness and mass protruding below the free edge of the soft palate. The procedure was explained and patient consent obtained. Desensitisation of the upper airway was done by performing superior and recurrent laryngeal nerve block with bupivacaine which effectively blocked gag and cough reflex. The trachea was intubated successfully using a videolaryngoscope with no hemodynamic changes. Conclusion: Awake videolaryngoscope offers a reasonable alternative to fibreoptic bronchoscope intubation in appropriately identified patients with difficult airways.

Background: Heat and moisture exchanger and filters (HMEF) can alter capnography waveform particularly in paediatric patients undergoing surgery under general anaesthesia and cause the capnogram to disappear. Case Description: A 4-day-old neonate weighing 3 kg undergoing surgery under general anaesthesia showed sudden disappearance in capnogram within a few seconds after installation of an HMEF. The ventilator parameters were within normal limits. The hemodynamic parameters were also stable. Removal of HMEF resulted in the appearance of a normal capnogram. Subsequent surgery was uneventful. Conclusion: HMEF adds to significant dead space volume in neonates owing to filter weight or moisture condensation resulting in erroneous waveform capnogaphy.

Background: Intubating bougie is frequently used as an endotracheal tube introducer in anticipated difficult intubation. However, there is scanty literature available that discuss bougie induced airway trauma-related complications. Case: A 47-year-old obese, non-smoker male admitted to a critical care unit with a thin acute subdural haemorrhage following a road traffic accident. On admission, the Glasgow coma scale (GCS) was 14/15, pupils were normal size and reacting and were managed conservatively. Following GCS deterioration, tracheal intubation was done with a 7.5 mm ID endotracheal tube railroaded over the bougie using hold-up sign. 15 minutes later decreased oxygen saturation and increase airway pressure with decreased air entry on the left side of the chest. Fibreoptic assessment showed rent in the posterior wall of the trachea in the left main bronchus. Conclusion: Pneumothorax following intubation using endotracheal bougie could be due to direct airway injury secondary to posteriorly directed coude tip of the bougie along with a greater depth of insertion secondary to the use of hold-up sign.

Background: Dislocation of the temporomandibular joint (TMJ) is one of the uncommon complications during general anaesthesia (GA) for a lower segment caesarean section surgery. Case: We present a 27-year-old female, weighing 60 kg, G4P2L2SA1 posted for elective lower segment caesarean section (LSCS) surgery with obstetric hysterectomy (OH) because of placenta previa with accreta. After an uneventful induction and surgery, she presented with the inability to close her mouth spontaneously but could close only with some pain on voluntary attempts. A clinical diagnosis of temporomandibular dislocation was made based on - an open mouth unable to close, misaligned dental occlusion, and an empty temporal glenoid bilaterally. Hence, an immediate reference was made to the ENT department who performed the Nelaton maneouvre. Conclusion: Any sign of pain during the closure of the mouth with spontaneous mouth opening post-extubation in a pregnant female should raise the suspicion of TMJ dislocation and should be immediately addressed and treated by closed reduction using the Nelaton manoeuvre.

Background: Advanced oesophageal cancer causes airway obstruction as it invades nearby structures such as the trachea and bronchus. Most patients present late with impending airway obstruction, to begin with as tracheomalacia remains undiagnosed. Case: Our patient was a known case of advanced esophageal cancer and had stridor and underwent an emergency tracheostomy for the same. He was scheduled for upper GI endoscopy and he manifested with airway collapse with strider during the procedure. Here we report a case where an awake, tracheostomised patient with advanced esophageal carcinoma had airway collapse during upper GI endoscopy. Conclusion: Hence a definitive airway such as a tracheostomy doesn't warrant a completely secured airway as distal airway collapse is still a possible complication. Even in the awake patient, the upper GI scope could mechanically cause external compression of the diseased trachea.

Background: Preoperative nap study records oxygen saturation (SpO₂) trend, episodes of noisy breathing, respiratory and heart rates. Case: 13-day-old baby (2.7 kg) with Pierre Robin sequence (PRS) (SpO₂ 97%) scheduled for glossopexy. Nap study (over 84.5 min) recorded SpO₂ 93% (mean) and 83% (minimum) with 74 episodes of noisy breathing and desaturation (<90%) for 8.5 min. Child intubated with pediatric fiberoptic bronchoscope (2^nd attempt after tongue stitch). Postoperative desaturation managed with jaw thrust, lateral position, oxygen and tongue traction. Conclusion: Nap study during awake and asleep states in PRS guides tolerated levels of perioperative desaturation, adding to safe airway management.

Background: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), a technique of apnoeic oxygenation, provides additional time to attempt alternative airway securing options in the difficult airway. Case Description: A 52-year-old obese lady diagnosed with multinodular goiter with the retrosternal extension on a CT scan neck was scheduled for total thyroidectomy. Keeping a difficult airway cart on standby, the airway was secured by direct laryngoscopy and bougie with 6.5 mm cuffed flexometallic endotracheal tube in ramp position with THRIVE as a preoxygenation technique without any desaturation after the neuromuscular blockade. Conclusion: THRIVE helped in using a conventional technique with an increased margin of safety in securing a difficult airway without adverse outcomes.