Management of the airway is central to the practice of anaesthesiology and yet surveys reveal that trainees frequently feel poorly trained in this area. Good skills in airway management include not only technical proficiency with an increasingly complex and wide range of equipment but also the clinical judgement and experience to use them appropriately. Lapses in judgement, education and training are leading causes of patient morbidity and mortality. It is now more imperative than ever for anaesthesiology training programmes to carefully review their curricula and evaluate the educational tools being used for effective advanced airway education of the next generation of airway specialists. Residency programmes have also seen the need to incorporate a formalised airway rotation into their curricula. One to 2-year long airway fellowships are now being advocated to provide the trainee a unique opportunity to master the advanced clinical knowledge and techniques necessary to successfully manage the most challenging clinical scenarios in airway management. It is essential for educators and practitioners alike to consider innovative models of training, advancing and retaining of skills. Such advanced skills can ensure the safe airway management and delivery of quality care to patients of all ages and medical complexity. Before preparation of the manuscript, a PubMed and Cochrane search of the scientific literature published in the past 10 years with the terms 'anesthesiology training', 'airway management education' and 'advanced airway management skills' was conducted.

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Endotracheal intubation is a routine procedure performed by anaesthesiologists worldwide. It is as routine as the placement of a peripheral intravenous catheter. Albeit the gold standard for securing the airway, endotracheal intubation comes with it's share of adverse effects, one of the worst being loss of voice or aphonia. A literature search in major medical databases revealed useful information about the aetiopathogenesis, various mechanisms and risk factors leading to vocal symptoms and acoustic variations. Patient risk factors such as age and co-morbid conditions and anaesthetic considerations such as size of endotracheal tube, number of attempts, mean cuff pressure, anaesthetic agents used and nature and duration of surgery all seem to have a role in this intriguing problem. This review also includes cases we have personally come across in our practice. Based on our experience of cases that we have come across, we propose an algorithm to avoid such a problem.

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

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

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Introduction: Currently, coronavirus disease 2019 (COVID-19) infection is a global challenge to the medical community, often resulting in acute respiratory distress syndrome and respiratory failure needing mechanical ventilation. Tracheostomy is needed for prolonged ventilation as the severity of respiratory failure often escalates, needing extended ventilation in an intensive care unit (ICU). Objective: The objective of study was to evaluate clinical details of performing tracheostomy including patient profile, surgical steps, complications and precautions by health-care workers in the ICU of a specially assigned hospital for COVID-19 patients. Patients and Methods: This is a retrospective study of 22 COVID-19 patients who underwent bedside surgical tracheostomy in the ICU. Patient profile such as age, gender, comorbidities, complication of tracheostomy, ventilator withdrawal after tracheostomy and nosocomial infections of health-care workers related to tracheostomy were analysed. Results: In the study period of 6 months, there were 12,850 COVID-19 patients admitted to our COVID-designated hospital, of whom 2452 patients needed ICU care. A total of 610 patients needed ventilatory support, with 22 patients aged between 42 and 75 years (mean age of 64 years) undergoing a tracheostomy (16 males and 6 females). The median duration from the day of the orotracheal intubation to the day of tracheostomy was 13 days. Conclusion: Surgical tracheostomy on COVID-19 patients is a high-risk aerosol-generating procedure for health-care workers. It should be performed with close communication between otorhinolaryngologists, anaesthesiologists and intensivists, along with adequate personal protective equipment for smooth management of the airway.

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This article is the second of a 4-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 aim of this series is to empower readers to create product/process/paradigm/position innovations in emergency difficult airway access for better care of humanity. The reader is familiarised with an educational smart phone-based application - Research Genie. The application has been designed and created by St. John's Medical College Research Society. The reader will be trained in a stepwise manner to use this application. Study design for each domain-specific objective is described. The most appropriate guideline to ensure quality of the study is stated. Explaining study designs using a domain-specific objective imparts ability to choose the most appropriate study design in a particular domain. Nine domains of healthcare have been explored namely description, laboratory range estimation, incidence/prevalence estimation, evaluating therapies, measuring costs in healthcare, critically evaluating new tests, measuring risk, correlating variables and describing experiences, perceptions and beliefs. Principles of sampling strategy have been explained in a simple and lucid manner.

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Statistics is assumed to be a tough nut to crack by novices and young researchers mainly because of the lack of understanding of the fundamentals. This article describes the types of data and the methods for compiling the raw data in an orderly fashion, followed by appropriate handling of the collected data to ensure completeness and quality. Once the data are entered into statistical software, distribution of the data should be assessed to apply appropriate statistical tests. Since the type and nature of distribution of data are the main determinants of the type of statistical test to be applied, researchers should have a thorough understanding of these aspects to help derive meaningful outcome from their research.

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Irrational driving among youth is a matter of serious concern in the present world. India leads the way having one of the highest numbers of road traffic accidents (RTAs) globally. Penetrating injury of the face following RTA can be catastrophic due to the close vicinity of vital structures and major blood vessels. Management of airway is of foremost importance for the successful resuscitation of the trauma patient as per the Advanced Trauma Life Support guidelines. We report a case of successful nasal intubation and subsequent anaesthetic management following sedation with ketamine and dexmedetomidine of a young male with penetrating injury of the floor of mouth and base of tongue by an iron rod. Such a combination of ketamine and dexmedetomidine can be an attractive option for airway management in acute trauma settings.

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Introduction: We conducted a randomised, controlled, prospective, multicentric comparison of channelled blade versus non-channelled blade of the King Vision™ videolaryngoscope for orotracheal intubation. Patients and Methods: A total of 66 patients included in the study were divided into two groups as follows: Group CH for intubation with channelled blade and Group NC for intubation with non-channelled blade. We compared the intubation time, ease of intubation and best laryngeal view obtained. Ease of intubation was categorised into ease of device insertion and ease of passage of endotracheal tube. Various impingements which occurred at the laryngeal inlet were observed and manoeuvres used to accomplish intubation were noted. Results: The grade of laryngeal exposure and time of laryngeal exposure were similar in both types of blade. We found a shorter intubation time of 15.24 ± 10.6 s in Group CH, whereas it was 28.57 ± 14.09 s in Group NC (P < 0.001). Impingement of the endotracheal tube at the glottic inlet was similar in both the groups, but manoeuvring of the device was not needed after laryngeal exposure in the case of the non-channelled blade. Manoeuvres needed to accomplish successful intubation were different in each group. Intubation with channelled blade requires anticlockwise rotation of the endotracheal tube as it is advanced in the slot while slight withdrawal and redirection towards the centre was needed most often with the non-channelled type of blade. Conclusions: We conclude that when used with the channelled blade, the King Vision videolaryngoscope requires shorter intubation time as compared to its use with the non-channelled blade. Anticlockwise rotation of the advancing endotracheal tube within the channel slot overcomes major impingement at the larynx and facilitates intubation with the use of channelled blade while slight withdrawal and redirection towards the centre are needed for successful intubation using the non-channelled blade.

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Obstructive sleep apnoea (OSA) is a term used to describe repetitive episodes of complete or partial upper airway obstruction that occur during sleep. It is a highly prevalent medical disorder and a challenge to treat. The treatment options include continuous positive airway pressure, oral appliances and surgical interventions depending on the severity of the condition. Among these, oral appliances are commonly used as primary therapy for the treatment of OSA because these appliances are designed to either encourage maxillary transverse development or advance the mandible, which will significantly reduce the OSA. This narrative review emphasises the role of various oral appliances in the treatment of OSA and will serve as a guide to clinicians in choosing the proper dental appliance.

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This article is the third of 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'. This article describes sample size calculation, descriptive statistics and inferential statistics in simple and lucid language without using any formulae. The reader should have followed the steps of knowledge creation as described in the first two articles and framed objectives for a given challenging healthcare situation. The study design and variables to operationalise the objective should have been defined. With this information in the background, the article empowers the reader to calculate sample size for a given objective. The pathway to access this information on the 'Research Genie (RG)' app is described for every objective in all the nine relevant domains of healthcare, i.e. description, laboratory range estimation, incidence/prevalence estimation, evaluating therapies, measuring costs in healthcare, critically evaluating new tests, measuring risk, correlating variables and describing experiences, perceptions and beliefs. Mathematical and statistical jargon are deliberately kept at bay. This is followed by describing summary measures and tests of significance for each objective. The pathway to access this on RG is described. On reading and assimilating this article, healthcare personnel can communicate meaningfully with the biostatistician while explaining the data required to calculate the sample size for a given objective. The researcher learns to list the possible summary measures and tests of significance for a particular objective. With an intention to demystify all these complicated concepts, I may have erred on the side of oversimplification. I pray for forgiveness from the biostatisticians and sincerely recommend all these are discussed with the biostatistician and approval sought before putting them in print.

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Regardless of aetiology, acquired tracheo-oesophageal fistula (TEF) is a life-threatening condition due to the risk of pulmonary soiling and sepsis. Distorted airway anatomy below the glottis makes airway management challenging. We present the anaesthetic management for TEF repair in an adult male who developed fistula following organophosphorus poisoning. Maintaining optimum position of the endotracheal tube (ETT) during cross-field ventilation and ETT repositioning is crucial. For better understanding of the anaesthetic management for this relatively rare surgery, we have described airway management sequentially to coincide with different phases of surgical interventions.

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

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Background and Aims: Obstructive sleep apnoea is characterised by repetitive partial or complete obstruction of the upper airway during sleep, leading to the reduction or cessation of airflow despite ongoing respiratory effort. Obesity, dyslipidaemia, hypertension, diabetes mellitus and cardiac arrhythmias are common co-existing comorbidities, placing patients at high risk for anaesthesia should they present for incidental or corrective surgeries. These patients are sensitive to opioids, induction and inhalational anaesthetics. Drug-induced sleep endoscopy (DISE) helps in assessing the exact site of airway obstruction and gives valuable inputs for surgical correction. The procedure includes stage-wise induction of sleep and airway visualisation during pharmacologically-induced sleep. Patients and Methods: Thirty patients, aged between 20 and 60 years, with a history of snoring and night arousals, were selected for DISE after taking informed consent. Intravenous propofol 0.5 mg/kg loading dose, followed by a titrated infusion of up to 50 μg/kg/min, was given throughout the procedure. The lowest value of oxygen saturation (SpO₂), apnoeic episodes, total propofol used and DISE findings were documented. The airway was managed after the procedure till the patients regained full consciousness. Results: Lower SpO₂ readings were observed in patients with complete collapse at the tongue base and in patients with floppy epiglottis. Conclusion: DISE is a dynamic, safe, easy-to-perform procedure that visualises the precise site of airway obstruction and guides in the planning of surgical correction thereafter. DISE findings provide valuable information for titrating doses of anaesthetic agents for incidental surgeries and perioperative management. However, the fine balance between identifying the obstruction and preventing desaturation is often challenging.

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Background: Neither all anticipated difficult airways prove to be difficult intubations nor can all difficult intubations be accurately predicted. We conducted this prospective observational study to evaluate the incidence of anticipated difficult airway and concurrent difficult intubation and look for any correlation between them. Patients and Methods: In this study, 352 patients aged >18 years posted for elective surgery requiring general anaesthesia with the placement of endotracheal tube were recruited after obtaining the Ethical Committee approval and written informed consent. The airway was examined at the time of preanaesthetic check up and assigned the modified Mallampati class and Wilson's score. The modified Mallampati Class III/IV and Wilson's score of >4 were considered a difficult airway. Concurrent intubation was graded according to the Cormack–Lehane classification on laryngoscopy. Other parameters such as the duration of laryngoscopy, time taken for intubation and number of attempts were also noted. The incidence of anticipated and unanticipated difficult airway was calculated separately for each score along with its sensitivity, specificity, positive predictive value and negative predictive value. The significance of this association was analysed using the Chi-square test. Results: The incidence of the anticipated difficult airway by the modified Mallampati classification was 6.8%, whereas that by Wilson's score was 2.5%. The incidence of actual difficult intubation was 13%. Actual difficult airways out of those anticipated by the modified Mallampati classification were only 8, whereas those anticipated by Wilson's score were 27. Correlation between them was calculated using the Chi-square test with P < 0.05 considered as statistically significant. Conclusions: Modified Mallampati classification could fairly predict the true-negative results and Wilson's score even though not routinely used is a better indicator for true-positive values. Thus, Wilson's score should be included in routine preanaesthetic evaluation.

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Background: Respiratory complications after cardiac surgery increase morbidity, mortality and length of hospital stay. Oxygen administered using a high-flow nasal cannula (HFNC) improves oxygenation because of its ease of implementation, tolerance and clinical effectiveness. We sought to compare this technique with conventional oxygen therapy (OT) after extubation following paediatric cardiac surgery. We compared HFNC versus conventional OT in postoperative paediatric cardiac surgical patients. Our primary objective was to evaluate the relative efficiency of improving PaCO₂elimination in the first 48 h following extubation. Patients and Methods: A single-centre, prospective, unblinded, randomised controlled trial was conducted in a 15-bedded post-cardiac intensive care unit on 50 paediatric cardiac surgical patients <2 years of age undergoing elective surgery with Risk Adjustment for Congenital Heart Surgery score ≥2. At the start of weaning off ventilation, patients were randomly assigned to either of the following groups: HFNC or OT. Arterial blood samples were collected before and following extubation at the following time points: 1, 6, 12, 24 and 48 h. While the primary outcome was comparison of arterial PaCO₂post-extubation, the secondary outcomes were PaO₂and PaO₂/FIO₂ ratios and any complications associated with either technique. Continuous data were expressed as mean ± standard deviation and compared using independent samples t-test or the Mann–Whitney U-test. Chi-square test was used for categorical parameters. Results: Demographic and clinical variables were comparable in the two groups. PaO₂and PaO₂/FIO₂ ratios were significantly improved in the HFNC group (P < 0.05) with lesser requirement of FIO₂(P < 0.05) in comparison to conventional OT. No complications were observed during HFNC therapy, nor was there any treatment failure. Conclusion: Compared with conventional OT, the use of HFNC following extubation in paediatric cardiac surgical patients appears to be safe, improves oxygenation and carbon dioxide elimination with lesser inspired oxygen concentration.

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Background: Introduction of the laryngeal mask airway (LMA) has revolutionised the practice of anaesthesia. This study compares the clinical performance of Ambu Aura40 LMA with Classic LMA in anaesthetised spontaneously breathing patients in terms of its ease of use and side effects. Patients and Methods: In this prospective randomised controlled study, 176 patients were allocated to either the Classic LMA or Ambu Aura40 LMA group according to a pregenerated block randomisation number sequence with concealment method. The allocated LMA was placed under general anaesthesia without muscle relaxant. The time and ease of insertion were noted in addition to any adverse events. Results: It was observed that Ambu Aura40 LMA and the Classic LMA were positioned successfully in the first attempt in 94% and 81% of patients respectively. The Ambu Aura40 LMA was placed in <12 s in 52% of patients, whereas only 2% of patients in the Classic LMA group could have the device placed within 12 s. Ninety-four percent of Classic LMA and 48% of Ambu Aura40 LMA were placed between 12 and 16 s, respectively. Statistically, a significant difference was noted with time and ease of insertion in between the groups. Conclusion: Ambu Aura40 LMA is better in terms of ease of insertion, with reduced time for insertion and lesser incidence of postoperative sore throat in comparison with Classic LMA.

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

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The physiologically difficult airway is defined as one in which severe physiologic derangements place patients at increased risk of cardiovascular collapse and death during tracheal intubation and transition to positive pressure ventilation. Patients with a physiologically difficult airway can be divided into those who are critically ill and those who are not. The critically ill patient with a physiologically difficult airway may present with hypoxaemia, hypotension, right ventricular failure, metabolic acidosis and neurologic injury. Noncritically ill patients with a physiologically difficult airway are patients who are obese, paediatric, pregnant or at risk of aspiration during tracheal intubation (after a meal, with gastroesophageal reflux disease, intestinal obstruction, etc). Recognition of this high-risk group of patients is essential to implement measures to avoid complications during tracheal intubation. Unlike the anatomically difficult airway, where placing the endotracheal tube safely within the trachea is the primary goal, in patients with a physiologically difficult airway, prevention of adverse events is equally important during airway management. Strategies to prevent complications associated with physiologically difficult airway include measures to improve the chance of first-pass success, effective peri-intubation oxygenation and measures to avoid hypotension and haemodynamic collapse.

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Supraglottic airway devices (SADs) have revolutionised perioperative airway management. These devices have contributed significantly to airway management, especially in the context of anticipated or unanticipated difficult airway, thereby decreasing airway-related morbidity. The use of these devices is now accepted even for positive pressure ventilation due to better seal and modifications (such as a double cuff or cuff material) preventing gastric insufflation with lesser chances of regurgitation. The quality of seal depends on how accurately the cuff matches the dimensions of the laryngeal inlet. Various methods and techniques are used for confirming the optimal placement of SADs with variable success rate. Evaluation based on conventional clinical tests is most commonly used for assessing the correct placement of SADs. However, clinical tests have been associated with limited outcome as they may not definitely be able to detect improper placement of SAD. Malpositioning may increase the incidence of complications such as altered airway dynamics, gastric insufflation, regurgitation and aspiration of gastric contents. The accuracy of these tests to identify malposition has been questioned by recent studies where fibreoptic evaluation of position of SAD identified many unacceptable placements which had been considered acceptable on the basis of clinical tests. Another limitation of these tests is that they fail to provide anatomic evidence of optimal SAD placement. Thus, other methods are required to confirm SAD position to avoid adverse events related to the airway. This review elaborates on the use of ultrasound to assess the optimal placement of supraglottic airway devices.

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The choice of an appropriate study design is one of the crucial steps in the research process after framing a research question. A single research question may fit into different study designs. Each design has its own merits and drawbacks; diligence in implementing the methodology and data collection reflects good study design. Sample size justification and power analysis are foundations of a study design. They should ideally be settled when framing a research question and creating the study design. An adequate sample size minimises random error or chance occurrence. 'A just large enough' sample supports the researcher to estimate expected cost, time and feasibility. The sample 'size' is a tug-of-war between reality and scientific effectiveness and is highly influenced by study designs. Null hypothesis (H₀) is the assumption that there is no difference in the treatment groups, whereas an assumption that there is a difference is called alternate hypothesis (H_a). Type I error (α) finds difference in the absence of one (false-positive conclusion), whereas Type II error (β) indicates probability of false-negative results. If the calculated P value is smaller than α, the researcher rejects the null hypothesis (H₀) and welcomes the alternative hypothesis (Ha). There are several validated software available for sample size calculation. Sample size tends to be smaller for means than percentages. As the sample size increases, the P value tends to become small. Finally, a statistically significant result might not always be clinically relevant.

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Large data obtained from research are subjected to statistical analysis so that outcomes can be extrapolated to the larger population. Towards this end, such large data have to be consolidated into smaller, simpler expressions of measures, representing the outcomes of the whole sample. These form the descriptive statistics, which will later on help in inferential statistics, involving the different variables within one group and more than one group. Their distribution features are analysed and are described as sums, averages, relationships and differences. These measures are classified as those of central location and those of dispersion. Mean, Median and Mode are the three main measures of central tendency and Range. Percentile, variance, standard deviation, standard error and confidence interval are measures of dispersion. Correlation and regression can be used to describe the relationship between two numerical variables. Correlation is a measure of association and regression is used for prediction. Regression analysis helps to assess 'influential' relationships between the data. Changes among one or more variables might affect other variables.

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The set of observations recorded during research work is termed data. Data can be described as numerical or categorical. While numerical data are further divided into discrete or continuous, categorical data are further divided into nominal or ordinal data. These data may be represented in a textual manner or with the help of illustrations (tables or graphs). The selection of a proper mode of representation of data helps in the optimal understanding of results. The level of importance of each parameter determines the mode of representation. The present article attempts to introduce the various methods of data presentation and throw some light on the benefits and limitations of each mode of data presentation.

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Coronavirus disease 2019 (COVID-19) has reached pandemic proportions, with a large number of patients succumbing to the disease and numerous requiring airway interventions. It is imperative in these challenging times for medical personnel involved in airway management and general care of these patients to know about the complexities involved and what additional precautions need to be taken while securing the airway.

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