#JanuAIRWAY

2022
The 31 day Twitter educational event compilation
Brought to you by @dastrainees, @Vapourologist and #DASeducation

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Editors

Helen Aoife Iliff

Tom Lawson

Contributors

Tom Lawson
Helen Aoife Iliff
Imran Ahmad
Alistair Baxter
Tim Cook
Adam Donne
Sadie Khwaja
Nuala Lucas
Moon-Moon Majumdar
Brendan McGrath
Barry McGuire
Andrew McKechnie
Alistair McNarry
Sarah Muldoon
Anil Patel
Elizabeth Ross
Natalie Silvey

Illustrations, Graphics and Images

The large majority of graphics and illustrations are by Tom Lawson or Helen Aoife Iliff.
Some have been adjusted from the original Twitter content in an effort to prevent any
potential copyright infringements in this compilation. Original images sources can be
found in the further reading. We thank all image contributors. Some images have been
reproduced in good faith, for educational purposes only. Where possible permissions
have been sought. If any copyright holders have any issues please contact us at
trainee@das.uk.com and the content will be withdrawn.

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Acknowledgements

We thank and acknowledge all those who contributed to the #JanuAIRWAY 2022
content, both for the original twitter event and this compilation.

We thank the Dif cult Airway Society (DAS), Society for Obesity and Bariatric
Anaesthesia (SOBA) and British Association of Otorhinolaryngology (ENT-UK) for their
direct or member support and engagement in this work.

We thank Imran Ahmad, Alistair Baxter, Ravi Bhagrath, Abhijoy Chakladar, Tim Cook,
Adam Donne, Gunjeet Dua, Kariem El-Boghdadly, Craig Johnstone, Sadie Khwaja,
Nuala Lucas, Moon-Moon Majumdar, Brendan McGrath, Barry McGuire, Andrew
McKechnie, Alistair McNarry, Fauzia Mir, Sarah Muldoon, Achuthan Sajayan, Ellen
O’Sullivan, Anil Patel, James Peyton, Elizabeth Ross, Natalie Silvey and Sarah Tian for
their review of the content.

We offer particular thanks to Jeff Gadsden for the inspiration.

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Disclaimers

This is the compilation of tweetorial content from #JanuAIRWAY. Every effort has

been made to ensure the content is factually correct and up to date. It is not
intended to replace other existing educational materials. If you identify any errors
please notify us at trainee@das.uk.com.

This is intended to be a learning resource - it is not a guideline. For all DAS

Guidelines please refer to the peer reviewed publications.

Inclusion of content (equipment, techniques and scoring systems etc.) in

#JanuAIRWAY does not constitute DAS endorsement.

Some images have been reproduced in good faith, for educational purposes only.
Where possible permissions have been sought. If any copyright holders have any
issues please contact us at trainee@das.uk.com and the content will be withdrawn.

DAS Education and Joining DAS

The DAS Education team are passionate about delivering good quality learning
resources. Our Educations Co-leads work closely with our Trainee Reps to put
together material and events we hope our members will bene t from.

Details on how to become a DAS member are available here

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FORWARD
| on behalf of the Difficult Airway Society |

DAS is mostly known for its airway management guidelines, Annual Scienti c
Meetings and airway courses. However, this year we decided to try something new,
something that is beyond the traditional scope of DAS. The brain child of one of our
Education leads with help from the current DAS Trainees DAS took on #JanuAIRWAY
- a month of daily educational tweets covering all matters airway! An immense
amount of work has been involved in putting this educational material together and
we feel it has been a huge success. Many congratulations to the team involved, in
particular Tom Lawson and Helen Iliff, who have given a huge amount of time to the
preparation and delivery of this project! The overwhelmingly positive response,
excellent feedback and huge twitter engagement has encouraged us to put together this compilation. We
hope you enjoy the content and will share this free and valuable educational resource.

- Imran Ahmad, DAS President

All the best ideas are stolen. #JanuAIRWAY was no different. Dr Jeff Gadsden’s
#Blocktober, 31 days of regional anaesthesia content; each day highlighting a
different block, provided the inspiration. A programme of airway-related teaching
materials (with a suitable month pun name) was created covering a broad range of
airway management topics, that could appeal to the widest audience, from the novice
to the experienced. With the help of an amazing team (thanks to our contributors, but
special thanks to the DAS trainee representatives; Natalie Silvey, Moon-Moon
Majumdar and especially, Helen Iliff), over the last year, the project has evolved from
those amateurish beginnings into something far greater than I could’ve hoped for
alone. I hope that #JanuAIRWAY and this compilation will become an evolving airway training resource that
is used by practitioners across the globe for many years to come.

- Tom Lawson, DAS Education Co-lead & Creator of #JanuAIRWAY

Natalie, Moon-moon and I have thoroughly enjoyed working with Tom to bring you
#JanuAIRWAY 2022. We hope those on twitter have enjoyed not just the content, but
also engaging with DAS in a less traditional form. For those not on twitter I hope you
nd the compilation an interesting read and useful educational resource - and
perhaps it may convince you to join us in the twittersphere @dastrainees for
#JanuAIRWAY in 2023!

- Helen Aoife Iliff, Trainee Rep

If anyone has any feedback please feel free to contact us at either trainee@das.uk.com or
ezine@das.uk.com

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CONTENTS
Day and Theme Day and Theme

1st Oxygen Physiology 19th The Obstructed Airway: Nasal / Oral

2nd Airway Assessment 20th The Obstructed Airway:

Larynx / Laryngopharyngeal
3rd De ning the Dif cult Airway
21st The Obstructed Airway:
4th Airway Investigation, Lung Function
Larynx / Extrathoracic Trachea
Tests and Airway Ultrasound
22nd The Obstructed Airway: Intrathoracic
5th Airway Strategy/Planning
23rd Malacias; Bleeding & SVC Obstruction
6th Basic Airway Equipment
24th The Paediatric Airway
7th Airway Laryngoscopy
25th The Obstetric Airway
8th Capnography & Oesophageal
Intubation 26th The Traumatic Airway

9th High Flow Nasal Oxygen (HFNO) 27th The Neurosurgical Airway

10th Cook Airway Exchange Catheter 28th The Bariatric Airway

11th Aintree Intubation Catheter 29th Extubation & Cook Staged Extubation
Set
12th Awake Tracheal Intubation (ATI)
30th Guidelines, Guidelines, Guidelines
13th Jet Ventilation
31st Dif cult Airway Conditions
14th One Lung Ventilation

15th Tracheostomies and Laryngectomies

16th eFONA: Cannula Techniques

17th eFONA: Scalpel Techniques

18th Extra eFONA equipment Further Reading

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“Here’s the rule: no one’s expected to have all the answers. If you are
asked a question, and do not know the answer, just say, “I don’t know,
but I’ll nd out.” And when you do, never fail to pass along the correct
information. You can never tell who the elephant in the room may be –
because elephants just don’t forget.”

- Marty Sklar, Imagineer

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OXYGEN PHYSIOLOGY
| Always. Be. Oxygenating! |

The meaningful delivery of adequate oxygen is the fundamental aim of all airway management.
Think A.B.O. – Always. Be. Oxygenating. Knowledge of the three basic equations for oxygen
physiology is essential:

1. Arterial Oxygen Content

2. Oxygen Delivery

3. Oxygen Consumption

They can steer us towards various physiological parameters that we can manipulate to treat
(failure of tissue oxygenation)/hypoxaemia (a low concentration of oxygen in arterial blood).

The oxygen cascade shows levels and processes involved and differentials for hypoxaemic
hypoxia:

1. Decreased inspired partial pressure of oxygen (e.g. altitude or low FiO2)

2. Alveolar gas mixture - dilution with CO2 (hypoventilation – for example excess opiate)

3. Diffusion (e.g. pulmonary brosis)

4. Shunt, V/Q mismatch (e.g. pneumonia, pulmonary oedema)

5. Increased O2 demand/use (e.g. sepsis, malignant hyperthermia)

Other causes of hypoxia include anaemic hypoxia (e.g. anaemia, carbon monoxide poisoning),
stagnant or ischaemic hypoxia (e.g. cardiogenic shock), and rarely – histotoxic hypoxia (e.g.
cyanide toxicity).

The Oxy-Hb curve shows why the focus in desaturation must be getting oxygen in. When the
SpO2 starts to fall, it’s slow initially but then precipitous. The bene t is, often a little oxygen going
back in, in general means a rapid rise back to safety.

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Pre/apnoeic oxygenation are key weapons, but must be done well. Patience, vital capacity
breaths +/- high ow nasal oxygen are key. They are of particular importance in patients with
obesity, who may have a smaller functional residual capacity and be more dif cult to facemask
ventilate.

Here are some articles that might be of interest:

a. Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange

(THRIVE): a physiological method of increasing apnoea time in patients with dif cult
airways. Anaesthesia. 2015; 70: 323-9

b. McNamara MJ, Hardman JG. Hypoxaemia during open-airway apnoea: a computational

modelling analysis. Anaesthesia. 2005; 60: 741-6

c. Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online)

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AIRWAY ASSESSMENT
| Needs to be global |

NAP4 showed poor airway assessment contributes to poor outcomes. Thorough assessment is
essential. There are a number of bedside tests available to help assess for potential dif cult
airway management.

Airway Assessment should be holistic & comprised of three basic parts:

1. History - including review of previous management (if possible)

2. Examination - visual examination and bedside tests

3. Investigations

NAP4 gives us a structure to focus our examination on anatomical/procedural dif culty:

1. Dif cult bag mask ventilation

2. Dif cult Supraglottic Airway Device (SAD) insertion

3. Dif cult laryngoscopy

4. Dif cult tracheal intubation

5. Dif cult Front of Neck Airway (FONA)

6. Dif cult tracheal extubation

The problem is that individually, none of these are perfect, with widely variable sensitivity &
speci city; possibly improved when combined. But many unanticipated dif cult airways are still
missed - see this 2018 Cochrane review.

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A thought-provoking nding of Norskov et al's Danish Airway Database cohort study was that
dif cult mask ventilation was unanticipated in 94% of cases (808/857). This is why airway
assessment needs to be holistic.

Here are some papers / links that you might nd interesting:

a. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B. Prediction of

dif cult mask ventilation. Anesthesiology. 2000; 92:1229-36

b. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible
mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009; 110: 891-7

c. Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict dif culty at
intubation in the emergency department? Emergency Medicine Journal. 2005; 22: 99-102

d. Detsky ME, Jivraj N, Adhikari NK, et al. Will This Patient Be Dif cult to Intubate? The
Rational Clinical Examination Systematic Review. JAMA. 2019; 321: 493–503

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DEFINING THE DIFFICULT AIRWAY

| It’s complicated |

The term “Dif cult Airway” has de nitions. NAP4 has a procedural framework - useful but not the
whole picture. Hans Huitink and Bouwan’s introduce “complexity factors” in their 2015 editorial on
“The myth of the dif cult airway:airway management revisited”.

Complexity factors make easy things dif cult e.g. operator experience, location, time pressures.
They have to be considered. Huitink also suggests ditching the term ‘dif cult’ in favour of ‘basic
and advanced’.

Our airway assessment aims to determine dif culty of management. We want to use our holistic
assessment (history, examination and investigations) to answer several questions.

As well as consideration of complexity factors we also need situational awareness. We like to

imagine concentrating ‘thinking zones’ emanating from the patient.

1. Patient (anatomy, physiology)

2. Airway manager (experience, fatigue, stress)

3. Team (experience, number)

4. Environment (time, familiarity, safety)

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When we want to integrate our assessment info and situational awareness, the Cyne n framework
(by Dave Snowden) and the Johari window can help our mental model for decision-making in
‘dif cult airways’.

Here are some papers / links that you might nd interesting:

a. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit
Project: Major complications of airway management in the United Kingdom. 2011 (online)

b. Grey AJG, Hoile RW, Ingram GS, Sherry KM. The Report of the National Con dential
Enquiry into Perioperative Deaths 1996/1997. 1998 (online)

c. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic
accuracy of anaesthesiologists' prediction of dif cult airway management in daily clinical
practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia
Database. Anaesthesia. 2015; 70: 272-81

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AIRWAY INVESTIGATIONS, LUNG

FUNCTION TESTS AND AIRWAY
ULTRASOUND
| Physiology and physics in action |

2 broad categories we can use to round out our airway assessment; ow/volume-based lung
function tests & imaging techniques. They vary in their usage and usefulness.

Spirometry (literally ‘measuring breath’) and ow-volume loops give us information on the
mechanics of ventilation. They can be helpful in a more global assessment of respiratory function,
but are less helpful in acute airway management.

Diffusing Capacity / Transfer factor can augment lung function tests and give us info about
alveolar diffusion and alveolar thickness. Again, helpful in global assessment, but less helpful
acutely.

Imaging techniques – these can be incredibly useful in peri-operative management. Two main
types: radiological (CT, MRI and/or USS) and endoscopic techniques.

The key information you want is:

1. Is an airway abnormality present?

2. If so what kind – usually compression / stenosis

a. Lesion location and extent?

b. Maximal airway diameter?

c. Airway displacement?

d. Other structures involved / in the way (e.g. blood vessels)?

Here are some papers / links that you might nd interesting:

a. Crawley SM and Dalton AJ. Predicting the dif cult airway, British Journal of Anaesthesia
Education, 2015; 15: 253–7

b. Ahmad I, Millhoff B, John M, Andi K, Oakley R. Virtual endoscopy--a new assessment tool
in dif cult airway management. Journal of Clinical Anesthesia. 2015; 27: 508-13

c. Zhou Z, Zhao X, Zhang C, Yao W. Preoperative four-dimensional computed tomography

imaging and simulation of a breoptic route for awake intubation in a patient with an
epiglottic mass. British Journal of Anaesthesia. 2020;125: e290-2

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What about Airway Ultrasound? It’s a useful, yet simple, skill to support safe airway management.
Check out Michael Seltz Kristensen's work – undisputed master of airway ultrasound.

Indications?

Scan to locate:

• Cricoid cartilage for cricoid pressure

• Cricothyroid membrane if at risk of cricothyroidotomy

• Tracheal rings for tracheostomy

• Superior laryngeal nerve for regional anaesthesia

(For point-of-care gastric USS check out this summary by

El-Boghdadly, Wojcikiewicz and Perlas - here.)

Here we focus on the transverse views for cricothyroidotomy.

Start by getting the patient in the position, in which you
would perform a tracheostomy – consider a bag of uid
under the shoulders.

Linear probe / transverse orientation. Start with the probe on the neck under the chin. Scan
caudally until you see the thyroid cartilage – triangular or inverted V-appearance between strap
muscles (angle of the thyroid cartilage is more acute in males).

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Scan caudally looking for the air-mucosa interface - a bright hyperechoic white line - represents
the beginning of the tracheal lumen below the cricothyroid membrane– hence a target for
cricothyroidotomy (reverberation artefact is below in tracheal lumen beneath).

You can mark the position of the cricothyroid membrane at this level with a pen on either side of
the probe (left and right, top and bottom).

Continuing caudally the cricoid cartilage comes into view as a hypoechoic inverted U or
horseshoe shape with the Air-Mucosa Interface below.

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The tracheal rings will come into view as hypoechoic ring-like shapes with air-muscosa interface
below and thyroid gland above and to either side – useful to know its location and vascularity
before percutaneous tracheostomy.

Longitudinal/parasagittal views along trachea, air-mucosa interface = long white line, cartilages
appear as hypoechoic ovals – sometimes called a ‘string of pearls’ – they look a bit like coffee
beans! You can use any needle or cannula in a transverse orientation to identify the level.

Here are some papers/links that you might nd interesting:

a. Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identi cation of the cricothyroid
membrane: best evidence, techniques, and clinical impact. British Journal of Anaesthesia.
2016; 117: i39-i48

b. Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark
identi cation for cannula cricothyroidotomy. Anaesthesia. 2010; 65: 889-94

c. Dinsmore J, Heard AM, Green RJ. The use of ultrasound to guide time-critical cannula
tracheotomy when anterior neck airway anatomy is unidenti able. European Journal of
Anaesthesiology. 2011; 28: 506-10

d. El-Boghdadly K, Wojcikiewicz T, Perlas A. Perioperative point-of-care gastric ultrasound.

British Journal of Anaesthesia Education. 2019; 19: 219-26

e. Identi cation of the cricothyroid membrane with ultrasonography Longitudinal "string of

pearls" approach - video (online)

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AIRWAY PLANNING
| Strategies are essential (NOT just plans) |

Decision making, an important non-technical skill, is a key aspect of safeairway management,

and something that is often not well in training curricula. NAP4 showed that poor judgement was
implicated in many airway complications. This is an issue because we encounter dif cult airways
relatively infrequently, and complications are rarer still. We know that low exposure leads to
higher anxiety. Add in multiple options Huitink & Bouwman suggest more than 1,000,000
combinations of options to oxygenate and things can get complicated. More options can mean
more anxiety; in an emergency, more options are not always useful.

Cognitive load can lead to decision fatigue & increasing bias & poorer decisions. Chew et al
came up with the TWED checklist which can help:

T Threat – de ne problem
W Wrong? What if I’m wrong? What else could it be?
E Evidence to con rm / exclude
D Dispositional factors – environment, hunger, fatigue

The Elaine Bromiley & Gordon Ewing cases are essential reading for people that manage
airways. Both highlight competing problems with task xation and failure to accept safe (but not
necessarily desirably situations). Here are the key issues & a decision cycle as a way of
combating both.

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Situational awareness is key. Notices whats going on around you, take time to Understand it,
Think Ahead (NUTA). @Vapourologist (Tom Lawson) uses this four step approach (below left) with
ADEPT mnemonic.

You’re not alone in having airway skills – remember our surgical colleagues. Involve them early.
BUT remember not all surgeons are equal (same as anaesthetists!) – we all have subspecialty
interests – a rhinologist might not be comfortable performing an eFONA either!

Putting it all together – consider an airway strategy sheet to de ne problems / limits up front,
involve ENT early, de ne plans A, B, C & D – consider all options, but decide on a few.

Here are some papers / links that you might nd interesting:

a. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit
Project: Major complications of airway management in the United Kingdom. 2011 (online)

b. Chrimes N, Fritz P. The Vortex Approach to airway management (online)

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Knowledge of what drugs we can use and how we use them in airway management is
indispensable – especially where planning is concerned. Drugs affect the airway in one of three
ways:

a. Direct action e.g. local anaesthetics or bronchodilators

b. Indirect action e.g. volatile anaesthetics or respiratory stimulants

c. Adverse reaction e.g. as a result of anaphylaxis

The three main effects drugs have on the airway are be changing:

a. Airway patency – usually by reducing muscle tone

b. Airway reactivity – airways can be irritated either by central or local effects

c. Aspiration protection – may be reduced (e.g. drugs that reduce conscious level) or
improved (e.g. PPI)

Drug controversies in dif cult airways:

• To paralyse or not

• Spontaneous Ventilation or IPPV during induction of anaesthesia

Key points:

- Paralysis can be reversible – have a plan

- Maintaining spontaneous ventilation can be inconsistent

2 simple rules for drugs:

1. Use drugs that are easily titratable & reversible

2. Plan for failure

Some people use a ‘wake up tray’ with NRDS drugs drawn up and ready to go

N – Naloxone

R – Reversal (Glyc/Neostig)

D – Doxapram

S – Sugammadex (if applicable)

2 main drugs:

1. Sedatives

2. Local anaesthetics

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https://www.youtube.com/watch?v=epGFFQcwjBA

Key is that local anaesthetic needs to be in the right place. If it is you don’t need much. This is
@vapourologist after gargling 10ml instilagel with 10ml water for 2 mins.

Here are some papers / links that you might nd interesting:

a. Consilvio C, Kuschner WG, Lighthall GK. The pharmacology of airway management in

critical care. Journal of Intensive Care Medicine. 2012; 27: 298-305

b. Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI)
- video (online)

c. Johnston KD, Rai MR. Conscious sedation for awake breoptic intubation: a review of the
literature. Canadian Journal of Anaesthesia. 2013; 60: 584-99

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BASIC AIRWAY EQUIPMENT

| Good workers know their tools |

Good workers know their tools – knowing our equipment is essential! See the #OnePagers for the
fundamentals of masks, NP/OPs, SADs, ETTs and Frova intubating introducer.

Speci c airway devices such as Cook airway exchange catheters, Aintree Intubation Catheters,
Staged Extubation Kits, OLV equipment, Tracheostomies, are covered later in the compilation.

Here are some papers / links that you might nd interesting:

a. Laurie A, Macdonand J. Equipment for airway management. Anaesthesia and Intensive

Care Medicine. 2018; 19: 389-96

b. Bjurström MF, Bodelsson M, Sturesson LW. The Dif cult Airway Trolley: A Narrative Review
and Practical Guide. Anesthesiology Research and Practice. 2019

c. Chishti K. Setting up a Dif cult Airway Trolley. 2015 (online)

d. Gibbins M, Kelly FE, Cook TM. Airway management equipment and practice: time to
optimise institutional, team, and personal preparedness. British Journal of Anaesthesia.
2020; 125: 221-4

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AIRWAY LARYNGOSCOPY
| DL, VL or Combined FB:VL? |

Laryngoscopy, as a prelude to tracheal intubation, is an essential skill for airway managers. There
is a wide array of laryngoscope types and approaches used to achieve this view of the glottis.

Broadly speaking, laryngoscopy can be direct (DL) or indirect (VL) and can involve a rigid or a
exible device. All devices and approaches require speci c skills and may require additional
intubation aids, such as a stylet. The term ‘videolaryngoscopy’ has now been adopted for all
rigid laryngoscopes that deliver an indirect view of the glottis. Innovators will develop new
techniques, such as combining videolaryngoscopy and exible bronchoscopy, to overcome
dif culty.

It is important to understand the Cormack and Lehane classi cation, universally adopted for
grading of direct laryngoscopy view. This becomes less relevant with indirect laryngoscopy,
where there is no agreed classi cation system. The Video Classi cation of Intubation (VCI)
score is a potential model (*inclusion in this material does not constitute DAS endorsement).

Here are some papers / links that you might nd interesting:

a. Jackson, C. The technique of insertion of intratracheal insuf ation tubes. Surgery,

Gynecology and Obstetrics. 1913; 17: 507-9

b. Knill RL. Dif cult laryngoscopy made easy with a "BURP". Canadian Journal of Anaesthesia.
1993; 40: 279-82

c. Chaggar RS, Shah SN, Berry M, Saini R, Soni S, Vaughan D. The Video Classi cation of
Intubation (VCI) score: a new description tool for tracheal intubation using
videolaryngoscopy: A pilot study. European Journal of Anaesthesiology. 2021; 38: 324-6

d. Lewis SR, Butler AR, Parker J, Cook TM, Scho eld-Robinson OJ, Smith AF.
Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal
intubation: a Cochrane Systematic Review. British Journal of Anaesthesia. 2017; 119:
369-83

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CAPNOGRAPHY & OESOPHAGEAL

INTUBATION
| with thanks to Tim Cook and Barry McGuire for their expert contributions |

This is one of the most essential pieces of monitoring equipment needed during airway
management. But its presence isn’t enough, correct interpretation is vital. Capnography is
primarily an AIRWAY monitor.

Oesophageal intubation still occurs & EtCO2 is a key tool to help prevent avoidable deaths such
as Glenda Logsdail’s. Key message is that at or no trace indicates oesophageal intubation until
proven otherwise.

This thread by Professor Tim Cook is fantastic and we recommend everyone read it! He also has
an article in FICM’s Critical Eye.

The Royal College of Anaesthetists and DAS video “Capnography: No Trace = Wrong Place” is
essential viewing for all airway managers.

https://www.youtube.com/watch?v=t97G65bignQ&t=8s

The RCoA have a number of other videos available on their website on a page dedicated to the
prevention of future deaths.

We also recommend all airway managers read this DAS ezine article by Barry McGuire Imran
Ahmad, Alistair McNarry, Abhijoy Chakladar and Lewys Richmond.

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https://vimeo.com/662046937/ad4217b155

Another reported case in Australia has further emphasised this is not just a UK problem, it is a
global issue. But as Professors Ellen O’Sullivan and Tim Cook have pointed out there is an almost
100% “Capnography Gap” in LIC (audits completed in Malawi & Uganda) which must be
addressed

See this recent series from Anaesthesia Journal on unrecognised oesophageal intubation

• Editorial

• Broadcast

• Podcast

Here are some other papers / links that you might nd interesting:

a. Cook, T.M., Kelly, F.E. and Goswami, A. ‘Hats and caps’ capnography training on intensive
care. Anaesthesia, 2013; 68: 421

b. Joy P, Kelly FE. Unrecognised Oesophageal Intubation. Anaesthesia News. 2022 (online)

c. Cook TM, Harrop-Grif ths W. Capnography prevents avoidable deaths. British Medical
Journal. 2019; 364: l439

d. CORONERS COURT OF NEW SOUTH WALES Inquest into the death of Emiliana Obusan.
2021 (online)

e. MILTON KEYNES CORONER’S COURT Inquest into the death of Glenda May Logsdail
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

f. Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE.
Paediatric intensive care and neonatal intensive care airway management in the United
Kingdom: the PIC-NIC survey. Anaesthesia. 2018; 73:1337-44

g. Collins J, Ní Eochagáin A, O'Sullivan EP. A recurring case of 'no trace, right place' during
emergency tracheal intubations in the critical care setting. Anaesthesia. 2021; 76 :1671

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HIGH FLOW NASAL OXYGEN

| with thanks to Anil Patel for his expert contributions |

This has been a game-changer in recent years. Thank you Professor Anil Patel and S Nouraei for
your amazing landmark paper on THRIVEl!

Oxygen consumption continues during apnoea, gradual loss of alveolar volume/reduction in

pressure. If upper airway remains patent, gas can be drawn into lower airways and oxygenation
can continue and delay desaturation.

HFNO / THRIVE works by a combination of the delivery of humidi ed and warmed high ow air /
oxygen, generation of positive airway pressure, improved respiratory mechanics, pharyngeal
deadspace washout, apnoea oxygenation and ventilation.

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Limitations:

1. Airway must be patent but can be signi cantly reduced

2. Secretions can accumulate

3. Morbid Obesity – shorter duration of apnoea before desaturation, more rapid desaturation

4. CO2 accumulation – without hypoxia / raised ICP

5. Epistaxis and skull fractures with the potential risk of airway soiling and pneumocephalus

Here are some papers / links that you might nd interesting:

a. Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange

(THRIVE): a physiological method of increasing apnoea time in patients with dif cult
airways. Anaesthesia. 2015; 70: 323-9

b. Hermez LA, Spence CJ, Payton MJ, Nouraei SAR, Patel A, Barnes TH. A physiological
study to determine the mechanism of carbon dioxide clearance during apnoea when using
transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE). Anaesthesia. 2019;
74: 441–9

c. Mir F, Patel A, Iqbal R, Cecconi M, Nouraei SAR. A randomised controlled trial comparing
transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE) pre-oxygenation with
facemask pre-oxygenation in patients undergoing rapid sequence induction of
anaesthesia. Anaesthesia. 2017; 72: 439–43

d. Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal

humidi ed rapid-insuf ation ventilatory exchange (THRIVE) in children: a randomized
controlled trial. British Journal of Anaesthesia. 2017; 118: 232–8

e. Lodenius å., Piehl J, Östlund A, Ullman J, Jonsson Fagerlund M. Transnasal humidi ed

rapid-insuf ation ventilatory exchange (THRIVE) vs. facemask breathing pre-oxygenation
for rapid sequence induction in adults: a prospective randomised non-blinded clinical trial.
Anaesthesia. 2018; 73: 564–71

f. Patel A, El‐Boghdadly K. Apnoeic oxygenation and ventilation: go with the ow.

Anaesthesia. 2020; 75: 1002–5

g. Sud A, Patel A. THRIVE: ve years on and into the COVID-19 era. British Journal of
Anaesthesia. 2021;126: 768-73

h. Patel A, El-Boghdadly K. Facemask or high- ow nasal oxygenation: time to switch?

Anaesthesia. 2022; 77: 7-11

i. Rummens N, Ball DR. Failure to THRIVE. Anaesthesia. 2015. (epub)

j. Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online)

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COOK AIRWAY EXCHANGE

CATHETER
| Useful but use with caution - know its limitations and dangers! |

A useful piece of equipment, but one not everyone will be familiar with. Main function is as a stop-
gap to maintain tracheal access & facilitate ETT exchange. They are long, hollow, radiopaque,
soft-tipped tubes – types for use with single / double lumen tubes.

There are different sizes for different functions (see chart). All users MUST be trained &
knowledgeable of how to use such devices together with their limitations and dangers. The
Gordon Ewing case makes for tragic reading – but highlights this point. Essential reading for
airway practitioners.

NEVER insert beyond 26cm and NEVER insuf ate with an oxygen ow >2L/min. (or just NEVER
insuf ate with oxygen)

Here are some papers / links that you might nd interesting:

a. Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in

Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online)

b. Benumof JL. Airway exchange catheters: simple concept, potentially great danger.
Anesthesiology. 1999; 91: 342-4

c. Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the
potentially dif cult extubation: a case report. AANA Journal. 2002; 70: 275-8

d. A dangerous tracheal tube exchange from AOD. 2016 - video (online)

e. Change of Endotracheal tube over tube exchanger. 2019 - video (online)

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COOK AINTREE INTUBATION

CATHETER
| So useful, but know its limitations! |

An amazingly useful piece of equipment – every airway practitioner should be familiar with. Main
function of the Aintree Intubation Catheter is to facilitate intubation through a supraglotttic airway
device because it is designed to t over a 4mm exible bronchoscope. It is a long, 56cm, hollow,
semi-rigid, powder blue, polyurethane catheters which accommodates an ETT 7mm or larger.

NEVER insert beyond 26cm and NEVER insuf ate with an oxygen ow >2l/min (..or just NEVER
insuf ate)

Here are some papers / links that you might nd interesting:

a. Padmanabhan R, McGuire B, Morris A. Fibreoptic guided tracheal intubation through

supraglottic airway device (SAD) using aintree intubation catheter. 2011 (online)

b. Gruenbaum SE, Gruenbaum BF, Tsaregorodtsev S, Dubilet M, Melamed I, Zlotnik A. Novel use
of an exchange catheter to facilitate intubation with an Aintree catheter in a tall patient with a
predicted dif cult airway: a case report. Journal of Medical Case Reports. 2012; 13:108

c. Phipps S, Malpas G, Hung O. A technique for securing the Aintree Intubation Catheter™ to a
exible bronchoscope. Canadian Journal of Anaesthesia. 2018; 65: 329-30

d. Cook Medical. Aintree Intubation Catheter (online)

e. Gloucestershire Hospitals NHS Foundation Trust. Fibreoptic Guided Intubation through SGA
using Aintree Intubation Catheter - video (online)

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AWAKE TRACHEAL INTUBATION

(ATI)
| with thanks to Imran Ahmad for his expert contributions |

Awake Techniques – there are key skill for an airway manager.

Topicalization is key (if right, may not need sedation). Top tips:

• Know nerve supply – CN V, IX & X.

• Block Ant.ethmoidal AND Sphenopalatine ganglion supply nasal septum

• Often you don’t need high dose LA if in right spot – this video is Tom Lawson after only
gargling instilagel.

https://www.youtube.com/watch?v=Pzo_1TJZSEY

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Fibreoptic scopes have advanced in recent years. It is important for airway managers to be
familiar with and have knowledge of the ergonomics and the basics of the exible bronchoscope.

• Know your equipment – set-up, usage and limitations

• Two positions for scope handling – Bazooka (facing patient) or Statue of Liberty (standing at
head end)

Ancillary equipment can make or break an awake intubation. These can be broken down into 3
main types:

• Those which aid oxygen delivery

• Those which aid drug delivery

• Those which aid scope delivery (oral airways)

There are many different recipes for ATI. It is worth being familiar with the different drugs that can
be used and recommend using the DAS approach to ATI.

There are a lot of potential problems that can be encountered during ATI – these need to be
planned for. Be familiar with the basics of troubleshooting, complications and how to manage
unsuccessful ATI.

Remember HFNO can help and a good knowledge of airway pharmacology is essential for
awake techniques.

Here are some papers / links that you might nd interesting:

a. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel
A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation
(ATI) in adults. Anaesthesia. 2020; 75: 509-28

b. Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI)
- video (online)

c. Bailin S. Awake Tracheal Intubation - video (online)

d. Awake Airway Management. Videolaryngoscopic awake tracheal intubation, no sedation -

video (online)

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JET VENTILATION
| niche anaesthesia, but fascinating |

This is a bit more niche in anaesthesia / airway management, but fascinating. There are 2 modes
of jet ventilation:

• Low Frequency (<60 jets/min) &

• High Frequency (>60).

Frequency determines device. 2 commonly used devices are the Manujet (modi ed hand
operated Sanders injector) or Monsoon (specialised jet ventilator).

There are several different potential mechanisms to apnoic oxygenation during High Frequency
Jet Ventilation, including:

• Bulk ow
• Laminar ow
• Taylor dispersion
• Pendelluft
• Molecular diffusion
• Cardiogenic mixing

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Key clinical pearl is the critical airway diameter for exhalation. Dworkin et al showed that jetting
across a glottis <4.0 - 4.5mm in diameter leads to gas trapping, independent of jet ventilator
settings. There MUST be a path for exhalation.

3 route for jet ventilation:

• Supraglottic – attached to a surgical laryngoscope

• Subglottic – using a specialised jet ventilation catheter

• Transtracheal – using a cannula via the cricothyroid membrane

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Increasingly jet ventilation is being used outside of ENT, in interventional radiology and cardiac
catheter labs to improve image quality.

Here are some papers / links that you might nd interesting:

a. Pearson KL, McGuire BE. Anaesthesia for laryngo-tracheal surgery, including tubeless eld
techniques. British Journal of Anaesthesia Education. 2017; 17: 242-8

b. Patel C. Chet Patel describes the anaesthetic technique of jet ventilation - video (online)

c. Anaesthesia Galway. Manujet Ventilator - video (online)

d. Sivasambu B, et al. Initiation of a High-Frequency Jet  Ventilation Strategy for

Catheter  Ablation for Atrial Fibrillation: Safety and Outcomes Data. JACC Clinical
Electrophysiology. 2018; 4: 1519-25

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ONE LUNG VENTILATION

| Physiology in action |

There are several indications for One Lung Ventilation (OLV). The commonest are thoracic
surgery & some oesophagectomies. There are essentially three ways to achieve OLV:

• Use of a double lumen tube

• Use of a bronchial blocker

• Elective endobronchial intubation

The key physiological change is the creation of a large shunt – deoxygenated blood (which
would normally be oxygenated), returns to the left heart resulting in hypoxaemia.

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Often OLV is done in the lateral decubitus position. This has several effects on V/Q relations. As
we can see in this diagram.

Evolution is amazing, because we have a friend to help us deal with shunt – hypoxic pulmonary
vasoconstriction. The bottom line is the mechanism is complicated - it’s biphasic, aims to
decrease shunt to non-ventilated lung and can be in uenced by several factors.

Tips for One Lung Ventilation:

• Choose your airway wisely – get it right rst time – use a beroptic scope

• If using bronchial blocker – consider going outside ETT.

• Be aware of physiological interplay

• Plan to deal with hypoxaemia

A knowledge of bronchoscopic anatomy is incredibly useful in anaesthesia / critical care –

especially when performing OLV.

Here are some papers / links that you might nd interesting:

a. Ashok V, Francis J. A practical approach to adult one-lung ventilation. British Journal of

Anaesthesia Education. 2018; 18: 69-74

b. Bronchoscopy Simulator (online)

c. Gloucestershire Hospitals NHS Foundation Trust. Double Lumen Tube Training video. 2020
- video (online)

d. Bronchial Blocker Insertion. 2012 - video (online)

e. Bronchial Blockers: EZ-Blocker. 2016 - video (online)

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TRACHEOSTOMIES (AND
LARYNGECTOMIES)
| with thanks to Brendan McGrath for his expert contributions |

More than just an ETT through the neck. Tracheostomies have

potentially been performed since ancient Egypt. The rst non-
emergency tracheostomy was thought to be performed by Asclepiades.
He was also a proponent of music therapy – might be of interest to
Veena.

There are 4 basic indications for tracheostomy:

1. Facilitate prolonged (or weaning from) mechanical ventilatory

support.

2. Provide a patent airway in cases of actual or threatened upper airway obstruction.

3. Provide a degree of airway protection, usually associated with central neurological or

bulbar neuromuscular conditions.

4. Facilitate clearance of pulmonary secretions where coughing is inadequate.

What physiological changes are associated with tracheostomies?

1. Upper airway natural humidi cation is completely or at least partially bypassed –

additional humidi cation is essential

2. Reduced dead space – may help with work of breathing

3. Dif cult or impossible vocalisation without dedicated strategies

4. Impaired swallowing

Tracheostomies can be performed using either a surgical or percutaneous technique. There are 3
main surgical techniques:

• Surgical window

• Slit type

• Björk ap - There are 2 reasons to mention Björk aps really – 1 they often have a confusing
anterior suture which needs to be noted on the bedhead sign; and the Swedish
cardiothoracic surgeon who described them has one of the best names in medicine: Viking
Björk!

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An important difference is time for tract maturity:

• Percutaneous = 7 - 10 days

• Surgical = 2 - 4 days

Also important in decannulation as a false tract can occur if re-inserting before tract maturity!

MUST establish whether upper airway is present – i.e. tracheostomy or laryngectomy (neck-only
breather). All patients with a tracheostomy or laryngectomy should have the appropriate bed
head sign indicating type, size and date of insertion. NTSP have great resources available on
their website to support this.

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NAP4 & NCEPOD show poor outcomes still occur. NTSP has fantastic algorithms for both
emergency tracheostomy and laryngectomy management.

There’s a lot of important aspects to tracheostomy care – check out this amazing resource from
Portsmouth Intensive Care Unit.

Here are some papers / links that you might nd interesting:

a. McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project.
Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway
emergencies. Anaesthesia. 2012; 67: 1025-41

b. National Tracheostomy Safety Project (NTSP) resources (online)

c. Lewith H, Athanassoglou V. Update on management of tracheostomy. British Journal of

Anaesthesia Education. 2019; 19: 370-376

d. Paulich S, Kelly FE, Cook TM. 'Neck breather' or 'neck-only breather': terminology in
tracheostomy emergencies algorithms. Anaesthesia. 2019; 74: 947

e. Pracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, Narula A, Patel A.
Surgical intervention during a Can't intubate Can't Oxygenate (CICO) Event: Emergency
Front-of-neck Airway (FONA)? British Journal of Anaesthesia. 2016; 117: 426-8

f. El-Wajeh Y, Varley I, Raithatha A, Glossop A, Smith A, Mohammed-Ali R. Opening

Pandora's box: surgical tracheostomy in mechanically ventilated COVID-19 patients. British
Journal of Anaesthesia. 2020; 125: e373-5

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PLAN D: EFONA
| with thanks to Alistair McNarry for his expert contributions |

Language around this scenario is continually evolving. Whether its referred to as CICO - Can’t
intubate, Cant Oxygenate or CICV - Cant Intubate, Cant Ventilate; it is important to recognise this
is a scenario. They all describe the scenario where all other attempts at airway management and
oxygen delivery have failed. Whereas eFONA (emergency front-of-neck airway) is a procedure
carried out in response to a CICO scenario.

This is a rare event and raises a dichotomy.

i. If when conducting an airway assessment you feel an eFONA might be required, STOP, get
help and consider an airway management plan that avoids this requirement (eg an awake
technique - see section on awake tracheal intubation)

ii. However, if you are managing a patient’s airway and all other attempts at oxygenation have
failed then you must PROCEED to eFONA without delay.

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Before commencing an eFONA technique ensure that a large dose of neuromuscular blocking
agent has been given (treats laryngospasm and paralyses the patient).

Know your technique before you are ever required to do it, rehearse it mentally

i. where would you stand

ii. who would you send for equipment

iii. how would you extend the neck etc

In adults DAS guidelines recommend scalpel eFONA techniques ( nal common pathway of
CICO), however cannula technique is advocated in children between 1 and 8 years in a Can’t
Intubate Can’t Oxygenate scenario (see the DAS APA guidelines). For more on the cannula
technique check out Dr Andy Heard’s work at the Perth ‘wet’ lab.

There are 2 anatomical scenarios for eFONA – palpable and impalpable anatomy.

DAS guidelines recommend everyone should know scalpel eFONA techniques (scalpel bougie
tube (palpable anatomy), scalpel nger bougie tube (impalpable anatomy).

https://www.youtube.com/watch?v=B8I1t1HlUac

The most dif cult part of the process is making the decision to pick up the scalpel. Mental
models and thinking tools like the Vortex can be useful. Check out Nicholas Chrimes & Peter
Fritz's work.

Remember you’re not alone in having airway skills. Remember your surgical colleagues &
involve them early. But also remember not all surgeons will feel comfortable in performing an
eFONA - in that it case it will have to be YOU!

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Training in eFONA is vital - not just for you. Train everyone who might be involved in an eFONA
event - nursing staff, anaesthetic assistants, scrub nurses (they are always there when you are
doing an operation regardless of the time of the day).

Training MUST use the locally available equipment - please make sure that your plan for eFONA
is deliverable where you work (and remember that can change from hospital to hospital).

Here are some papers / links that you might nd interesting:

a. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall
NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway
Society 2015 guidelines for management of unanticipated dif cult intubation in adults.
British Journal of Anaesthesia. 2015; 115: 827-48

b. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM;

Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal
College of Anaesthetists. Guidelines for the management of tracheal intubation in critically
ill adults. British Journal of Anaesthesia. 2018; 120: 323-52

c. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus

guidelines for managing the airway in patients with COVID-19: Guidelines from the Dif cult
Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of
Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75:
785-99

d. Heard A, Dinsmore J, Douglas S, Lacquiere D. Plan D: cannula rst, or scalpel only? British
Journal of Anaesthesia. 2016; 117: 533-5

e. Mann CM, Baker PA, Sainsbury DM, Taylor R. A comparison of cannula insuf ation device
performance for emergency front of neck airway. Pediatric Anesthesia. 2021; 31: 482-90

f. Chrimes N, Fritz P. The Vortex Approach to airway management (online)

g. Heard AM. DrAMBHeardAirway YouTube Channel (online)

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THE OBSTRUCTED AIRWAY

| with thanks to Anil Patel, Elizabeth Ross, Sadie Khwaja and Adam Donne |

| for their expert contributions |

The Obstructed Airway - think: NOLIMBS

• Nose, Nasal Cavity and Nasopharynx

• Oral Cavity and Oropharynx

• Larynx, Laryngopharynx and Extra-thoracic (subglottic) Trachea

• Intra-thoracic

• Malacias

• Bleeding

• SVC Obstruction

Nasopharyngeal and Oropharyngeal Airway Obstruction

Possible issues:

• Risk of total obstruction with low tone

• Distorted anatomy and/or trismus

• Nasopharyngeal/Oropharyngeal airway too short?

• Strong jaw thrust may/may not relieve obstruction

• Dif cult mask ventilation and/or laryngoscopy

• Repeated laryngoscopy may make a manageable airway unmanageable.

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Planning in airway obstruction is key. Nasendoscopy can save lives here! ASSESSMENT informs
STRATEGY. Remember the decision-making process is multifactorial and it is important to
maintain situational awareness.

In severe Nasal/Oral and Naso-Oro-Pharyngeal obstruction an awake technique may be

advantageous. Options may include:

• HFNO as a helpful stop-gap measure

• Standard Intubation

• ATI/AFOI

• Awake/asleep FOI +/- transtracheal catheter

• Awake/asleep tracheostomy

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Laryngeal / Laryngopharyngeal Airway Obstruction (Periglottic)

Often the most challenging for the general anaesthetist. Issues:

• Must discuss with ENT colleagues

• Preoperative nasendoscopy by experienced nasendoscopist is very helpful

• AFOI may worsen obstruction – cork in bottle

• Inhalational induction will be dif cult

Key Q's

• Is the obstruction static or dynamic?

• Can an ETT be passed through the airway?

Options:

• May be able to pass ETT depending on narrowing - consider using a micro laryngeal tube
or jet ventilation catheter.

• Apnoeic (HFNO) or intermittent oxygenation/intubation technique – depending on type of

surgery (elective/emergent)

• Awake Tracheal Intubation

• Transtracheal catheter (+/- subsequent jet ventilation)

• Awake tracheostomy

Here are some papers / links that you might nd interesting:

a. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel
A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation
(ATI) in adults. Anaesthesia. 2020; 75: 509-28

b. Lynch J. Crawley SM. Management of airway obstruction. British Journal of Anaesthesia

Education. 2017; 18: 46-51

c. Bryant H. Batuwitage B. Management of the Obstructed Airway. Anaesthesiology: Tutorial

of the Week. 2016 (online)

d. Bruce IA, Rothera MP. Upper airway obstruction in children. Pediatric Anesthesia. 2009;
19(S1): 88-99

e. McAvoy J, Ewing T, Nekhendzy V. The value of preoperative endoscopic airway

examination in complex airway management of a patient with supraglottic cancer. Journal
of Head & Neck Anesthesia. 2019; 3: e19

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Larynx and Extrathoracic Tracheal Airway Obstruction

Presents a unique set of challenges. Physiology:

• In theory a xed obstructive lesion (eg tracheal stenosis) is unaffected by the respiratory
cycle or anaesthesia induction

• Extrathoracic lesions tend to be better in expiration as positive pressure splints the airway
open

Issues:

• Laryngoscopy likely to be uneventful – however the major concern is the inability to pass
an ETT atraumatically beyond the level of obstruction

• Nasendoscopy can be useful to view lesion

• AFOI may cause ‘cork in bottle’ effect depending on lesion size and location of the
obstruction or stenosis

• Consider use of tubeless techniques for airway intervention where possible eg foreign body
removal or tumour debulking

Here are some papers / links that you might nd interesting:

a. Nouraei SAR, Girgis M, Shorthouse J, El-Boghdadly K, Ahmad I. A multidisciplinary

approach for managing the infraglottic dif cult airway in the setting of the Coronavirus
pandemic. Operative Techniques in Otolaryngology Head and Neck Surgery. 2020; 31:
128-37

b. Scholz A, Srinivas K, Stacey MR, Clyburn P. Subglottic stenosis in pregnancy. British

Journal of Anaesthesia. 2008; 100: 385-8

c. Ellis H, Iliff HA, Lahloub FMF, Smith DRK, Rees GJ. Unexpected dif cult tracheal intubation
secondary to subglottic stenosis leading to emergency front-of-neck airway. Anaesthesia
Reports. 2021; 9: 90-94

d. Phillips JJ, Sansome AJ. Acute infective airway obstruction associated with subglottic
stenosis. Anaesthesia. 1990; 45: 34-5

e. Bulbulia BA, Ahmed R. Anaesthesia and subglottic airway obstruction. South African
Journal of Anaesthesia and Analgesia. 2011; 17: 182-4

f. Venugopal N, Youssef M, Nortcliffe S. Airway management in a case of critical sub-glottic

stenosis: The use of a preformed tracheal tube. The Internet Journal of Anesthesiology.
2007; 15:

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Intrathoracic Airway Obstruction

Again, presents its own set of challenges. Issues:

• Upper and mid lesions are usually considered lower risk – due to potential to pass
reinforced ETT beyond the level of obstruction

• Lower tracheal / Bronchial lesions are high risk and best managed in specialist centres due
to increased dif culty siting an endobronchial tube and rigid bronchoscope as a rescue
manoeuvre beyond level of obstruction

• A CT scan is mandatory (except in life-threatening scenarios)

• Sudden obstruction can occur at ANY time

• Remember there is potential for compression of the heart or great vessels

Severe Obstruction Considerations:

• Maintain the patient’s preferred position

• Spontaneous ventilation may bene cial - negative intrapleural pressure helps splint airway
open and IPPV may cause airway collapse

• Many centres use IV induction techniques

• Ketamine - preserves chest wall tone and FRC

• Have a back up plan

Potential rescue manoeuvres:

In an emergency – consider passing an ETT tube & then placing a jet catheter (e.g. Cook or
Aintree) beyond obstruction. Alternatively, most MLTs are long enough to reach the carina and
should be available when managing patients with airway obstruction.

Here are some papers / links that you might nd interesting:

a. Kapnadak SG, Kreit JW. Stay in the loop! Annals of the American Thoracic Society. 2013;
10: 166-71

b. Nakajima A, Saraya T, Takata S, Ishii H, Nakazato Y, Takei H, Takizawa H, Goto H. The saw-
tooth sign as a clinical clue for intrathoracic central airway obstruction. BMC Research
Notes. 2012; 5: 388

c. Ahuja S, Cohen B, Hinkelbein J, Diemunsch P, Ruetzler K. Practical anesthetic

considerations in patients undergoing tracheobronchial surgeries: a clinical review of
current literature. Journal of Thoracic Disease. 2016; 8: 3431-41

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Malacias

Malacias are a cause of rare dynamic airway obstruction (congenital or acquired) due to loss of
support (by widening of both the cartilaginous arch and the membranous trachealis)

• Decreased intratracheal pressure + increased intrathoracic pressure lead to airway

compression

• Severity is proportional to expiratory force

• Intrathoracic and extrathoracic malacia may collapse at different points in the respiratory
cycle

Issues:

• Obstruction can occur even in asymptomatic patients

• Aim to maintain spontaneous ventilation

• Emergency management = Positive pressure (to splint airways open) or bypassing

obstruction

• Surgery depends on the anatomical location and extent

• Consider extubating deep (to avoid coughing) or directly to CPAP or HFNO

Bleeding & Airways

Need to consider “WHERE” the bleeding is coming from. In general there are 3 possibilities:

• Above (Nasal Cavity / Nasopharynx / Oral Cavity / Oral Cavity / Laryngopharynx)

• Below (Tracheal / Lung / Oesophagus / GI)

• Around airway (consider full circumference of airway - any haematoma in the airway can
cause localised airway oedema and/or airway compression)

Airway obstruction due to neck haematoma:

• Can be fatal

• Is normally due to laryngeal oedema NOT tracheal compression

• Need to open wound immediately and manually evacuate haematoma to relieve pressure –
think SCOOP

See guidelines from DAS, BAETS and ENT-UK.

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SVC Obstruction

Obstruction below the thoracic inlet (cancer / vascular / infection / thrombosis).

• Pemberton’s sign useful (face ushing on raising arms)

• Valsalva challenge - syncope indicates a risk of complete vascular obstruction

• Severe cases need treatment (intravascular stenting by interventional radiology) BEFORE

general anaesthesia

Airway Options

• Depend on level and degree of obstruction

• If the obstruction is at or above thoracic inlet standard laryngoscopy, jet ventilation or rigid
bronchoscopy tend to suf ce

• If the obstruction is below the thoracic inlet - awake techniques, jet ventilation or rigid
bronchoscopy may be preferred.

If the patient cannot be treated preoperatively

• Keep the patient sat up

• High ow O2 or HFNO

• Vascular Access:
✦ Large bore, lower limb IV access – consider Rapid Infusion Catheter or Swann
Introducer
✦ Arterial line - consider lower limb also

• Smooth IV induction to avoid coughing (may be slow)

• There is potential for cerebral oedema which may lead to slow wakening and/or recovery

Here are some papers / links that you might nd interesting:

1. Austin J, Ali T. Tracheomalacia and bronchomalacia in children: pathophysiology,

assessment, treatment and anaesthesia management. Pediatric Anesthesia. 2003; 13: 3-11

2. Findlay JM, Sadler GP, Bridge H, Mihai R. Post-thyroidectomy tracheomalacia: minimal risk
despite signi cant tracheal compression. British Journal of Anaesthesia. 2011; 106: 903-6

3. Sajid B, Rekha K. Airway Management in Patients with Tracheal Compression Undergoing

Thyroidectomy: A Retrospective Analysis. Anesthesia Essays Researches. 2017; 11: 110-6

4. Chaudhary K, Gupta A, Wadhawan S, Jain D, Bhadoria P. Anesthetic management of superior

vena cava syndrome due to anterior mediastinal mass. Journal of Anaesthesiology Clinical
Pharmacology. 2012; 28: 242-6

5. Kristensen MS, McGuire B. Managing and securing the bleeding upper airway: a narrative
review. Canadian Journal of Anesthesia. 2020; 67: 128-140

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THE PAEDIATRIC AIRWAY

| with thanks to Alistair Baxter and Adam Donne for their expert contributions |

The dif cult paediatric airway = #SCARY but rare! Upper airway obstruction in children – broad
range of presentations, three important diagnoses; Croup, Epiglottitis and Inhaled Foreign Body.

Remember 2 types of airway obstruction- anatomical and physiological.

Top tip from Alistair Baxter: Remember that a Macintosh blade is in effect a hyperangulated blade
in an infant and requires an intubation stylet shaped to match the curve of the blade.

TIVA is ever increasing in popularity as is “O”s up the nose and HFNO which is generally well
tolerated, allows a true tubeless eld, and can buy time during a dif cult intubation.

Videolaryngoscopy as a rst choice is evidently a better technique in children of all ages - see
PeDI registry data.

Fibreoptic intubation is an advanced technique that requires attention to detail and practice to
understand all the steps involved. Intubation via a SAD is a nice technique and evidence is
increasing that it can be used in children of all ages as a second choice technique.

Here are some papers / links that you might nd interesting:

a. Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal

humidi ed rapid-insuf ation ventilatory exchange (THRIVE) in children: a randomized
controlled trial. British Journal of Anaesthesia. 2017; 118: 232-8

b. Bagshaw O, McCormack J, Brooks P, Marriott D, Baxter A. The safety pro le and

effectiveness of propofol-remifentanil mixtures for total intravenous anesthesia in children.
Pediatric Anesthesia. 2020; 30: 1331-9

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c. The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines (online)

d. Von Ungern-Sternberg BS, Boda K, Chambers NA, Rebmann C, Johnson C, Sly PD, Habre
W. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective
cohort study. Lancet. 2010; 376: 773-83

e. Dif cult Airway Society and Association of Paediatric Anaesthetists. Paediatric Dif cult
Airway Guidelines (online)

f. Engelhardt T, Virag K, Veyckemans F, Habre W; APRICOT Group of the European Society of

Anaesthesiology Clinical Trial Network. Airway management in paediatric anaesthesia in
Europe-insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a
prospective multicentre observational study in 261 hospitals in Europe. British Journal of
Anaesthesia. 2018; 121: 66-75

g. Jagannathan N, Sohn L, Fiadjoe JE. Paediatric dif cult airway management: what every
anaesthetist should know! British Journal of Anaesthesia. 2016; 117: i3-5

h. Walas W, Aleksandrowicz D, Kornacka M, Gaszyński T, Helwich E, Migdał M, Piotrowski A,

Siejka G, Szczapa T, Bartkowska-Śniatkowska A, Halaba ZP. The management of
unanticipated dif cult airways in children of all age groups in anaesthetic practice - the
position paper of an expert panel. Scandinavian Journal of Trauma Resuscitation and
Emergency Medicine. 2019; 27: 87

i. King MR, Jagannathan N. Best practice recommendations for dif cult airway management
in children-is it time for an update? British Journal of Anaesthesia. 2018; 121: 4-7

j. Sun Y, Lu Y, Huang Y, Jiang H. Pediatric video laryngoscope versus direct laryngoscope: a

meta-analysis of randomized controlled trials. Pediatric Anesthesia. 2014; 24: 1056-65

k. Klabusayová E, Klučka J, Kosinová M, Ťoukálková M, Štoudek R, Kratochvíl M, Mareček L,

Svoboda M, Jabandžiev P, Urík M, Štourač P. Videolaryngoscopy vs. Direct Laryngoscopy
for Elective Airway Management in Paediatric Anaesthesia: A prospective randomised
controlled trial. European Journal of Anaesthesiology. 2021; 38: 1187-93

l. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI,
Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX Jr, Litman
RS, Kovatsis PG. Airway management complications in children with dif cult tracheal
intubation from the Pediatric Dif cult Intubation (PeDI) registry: a prospective cohort
analysis. Lancet Respiratory Medicine. 2016; 4: 37-48

m. Gupta A, Sharma R, Gupta N. Evolution of videolaryngoscopy in pediatric population.

Journal of Anaesthesiology Clinical Pharmacology. 2021; 37: 14-27

n. Anderson BJ, Bagshaw O; Practicalities of Total Intravenous Anesthesia and Target-

controlled Infusion in Children. Anesthesiology. 2019; 131: 164–185.

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THE OBSTETRIC AIRWAY

| with thanks to Nuala Lucas for her expert contributions |

Let’s start with some decision tools from a great review article.

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Failed intubation requires a different approach in Obstetrics. The 2015 OAA/DAS guidelines are
really helpful for this! Covering planning to maximise safety for obstetric GA and the
management of failed intubation.

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The 2015 OAA/DAS guidelines also cover decision making – when to bail out / when to
proceed and aftercare – which mustn’t be overlooked!

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Here are some other papers / links that you might nd useful:

a. Bonnet MP, Mercier FJ, Vicaut E, Galand A, Keita H, Baillard C; CAESAR working group.
Incidence and risk factors for maternal hypoxaemia during induction of general
anaesthesia for non-elective Caesarean section: a prospective multicentre study. British
Journal of Anaesthesia. 2020; 125: e81-7

b. Howle R, Onwochei D, Harrison SL, Desai N. Comparison of videolaryngoscopy and

direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic
review and meta-analysis. Canadian Journal of Anesthesia. 2021; 68: 546-65

c. Odor PM, Bampoe S, Moonesinghe SR, Andrade J, Pandit JJ, Lucas DN; Pan-London
Perioperative Audit and Research Network (PLAN), for the DREAMY Investigators Group.
General anaesthetic and airway management practice for obstetric surgery in England: a
prospective, multicentre observational study. Anaesthesia. 2021; 76: 460-71

d. McGuire B, Lucas DN. Planning the obstetric airway. Anaesthesia. 2020; 75: 852-5

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THE TRAUMATIC AIRWAY

| One part of a wider critically ill patient |

These can be particularly stressful airways to manage. It is important to remember they are one
part of a wider critically ill patient.

The principles of treatment/management are:

• Beware the isolated environment

• Plan for uncooperative patient

• Prevent aspiration

• Protect C-spine

• Plan for dif cult airway

De ne type of trauma early – blunt vs

penetrating (neck divided into 3
zones), and assess for:

• Distorted anatomy

• Bleeding

• Subcutaneous Emphysema –
injury to gas containing structure

• Other traumatic injury – e.g.

head, thorax, abdomen, etc

Here are some papers / links that you might nd interesting:

a. Jain U, McCunn M, Smith CE, Pittet JF. Management of the Traumatized Airway.
Anesthesiology. 2016; 124: 199-206

b. Brown CVR, Inaba K, Shatz DV, Moore EE, Ciesla D, Sava JA, Alam HB, Brasel K,
Vercruysse G, Sperry JL, Rizzo AG, Martin M. Western Trauma Association critical
decisions in trauma: airway management in adult trauma patients. Trauma Surgery & Acute
Care Open. 2020; 5: e000539

c. Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P. Systematic review of the
anaesthetic management of non-iatrogenic acute adult airway trauma. British Journal of
Anaesthesia. 2016; 117: i49-59

d. National Institute of Health and Care Excellence. Quality Statement 1: Airway Management.
In: Trauma Quality Standard [QS166]. 2018 (online)

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e. Crewdson K, Lockey D, Voelckel W, Temesvari P, Lossius HM; EHAC Medical Working

Group. Best practice advice on pre-hospital emergency anaesthesia & advanced airway
management. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.
2019; 27: 6

f. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM;

Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal
College of Anaesthetists. Guidelines for the management of tracheal intubation in critically
ill adults. British Journal of Anaesthesia. 2018; 120: 323-52

g. Wiles MD. Manual in-line stabilisation during tracheal intubation: effective protection or
harmful dogma? Anaesthesia. 2021; 76: 850-3

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THE NEUROSURGICAL AIRWAY

| with thanks to Sarah Muldoon for her expert contributions |

Head Vs Spine. Elective Vs Emergency, So many points of interest for airway managers.

Key principles:

• Prevent rises in ICP

• Avoid hypoxia & low BP

• Consider potential for c-spine injury

• Be aware of positioning

• Beware potential dif cult airway in neurosurgical pathology

• Beware of post-op issues e.g. haematoma post-ACDF

We can, in general, divide acute / emergency patients into 2 groups:

1. Cooperative – awake techniques may be the best option in anticipated dif culty

2. Uncooperative – asleep laryngoscopy or asleep FOI (consider LMA conduit)

Here are some papers / links that you might nd interesting:

a. Elwishi M, Dinsmore J. Monitoring the brain. British Journal of Anaesthesia Education. 2019;
19: 54-9

b. Perelló-Cerdà L, Fàbregas N, López AM, Rios J, Tercero J, Carrero E, Hurtado P, Hervías A,

Gracia I, Caral L, de Riva N, Valero R. ProSeal Laryngeal Mask Airway Attenuates Systemic
and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A
Randomized Clinical Trial. Journal of Neurosurgical Anesthesiology. 2015; 27: 194-202

c. Lockey DJ, Wilson M. Early airway management of patients with severe head injury:
opportunities missed? Anaesthesia. 2020; 75: 7-10

d. McCredie VA, Ferguson ND, Pinto RL, Adhikari NK, Fowler RA, Chapman MG, Burrell A,
Baker AJ, Cook DJ, Meade MO, Scales DC; Canadian Critical Care Trials Group. Airway
Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider
Extubation. A Prospective Cohort Study. Annals of the American Thoracic Society. 2017;
14: 85-93

e. Langford RA, Leslie K. Awake breoptic intubation in neurosurgery. Journal of Clinical

Neuroscience. 2009; 16: 366-72

f. Yi P, Li Q, Yang Z, Cao L, Hu X, Gu H. High- ow nasal cannula improves clinical ef cacy of

airway management in patients undergoing awake craniotomy. BMC Anesthesiology. 2020;
20: 156

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THE BARIATRIC AIRWAY

| with thanks to Andrew McKechnie and SOBA for their expert contributions |

Key principles:

• Ensure good positioning & adequate logistics

• Good preoxygenation with tight seal is essential

• Timely ETT placement

• Beware of extubation - risk of hypoxia /airway obstruction – minimise PEEP loss

Patients living with obesity frequently suffer from obstructive sleep apnoea. A sound
understanding of its pathophysiology, investigation, diagnosis and perioperative management is
really helpful

Here are some papers / links that you might nd interesting:

a. Society for Obesity and Bariatric Anaesthesia. Anaesthesia of the Obese Patient. 2020
(online)

b. Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Wetterslev J. High body mass index is
a weak predictor for dif cult and failed tracheal intubation: a cohort study of 91,332
consecutive patients scheduled for direct laryngoscopy registered in the Danish
Anesthesia Database. Anesthesiology. 2009; 110: 266-74

c. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible
mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009; 110: 891-7

d. Association of Anaesthetists and Society for Obesity and Bariatric Anaesthesia. Peri-
operative management of the obese surgical patient. 2015 (online)

e. Hashim MM, Ismail MA, Esmat AM, Adeel S. Dif cult tracheal intubation in bariatric surgery
patients, a myth or reality? British Journal of Anaesthesia. 2016; 116: 557-8

f. Fox WT, Harris S, Kennedy NJ. Prevalence of dif cult intubation in a bariatric population,
using the beach chair position. Anaesthesia. 2008; 63: 1339-42

g. Moon TS, Fox PE, Somasundaram A, Minhajuddin A, Gonzales MX,

Pak TJ, Ogunnaike B. The in uence of morbid obesity on dif cult
intubation and dif cult mask ventilation. Journal of Anesthesia.
2019; 33: 96-102

SOBA-UK Website

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EXTUBATION AND THE COOK

STAGED EXTUBATION SET
| don’t take off if you haven’t considered how to land the plane |

Needs planning, just like intubation.

Key principles:
• Most airway complications occur during extubation
• Extubation = elective event
• Get it right rst time
• Consider risk factors for dif cult extubation AND dif cult re-intubation

See the DAS extubation guidelines

Pre-extubation risk assessment can include:

• Arterial blood gas - to assess adequacy of gas exchange, if in doubt
• Direct laryngoscopy or beroptic examination of laryngopharynx +/- other structures
• Leak test

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Potential options for dif cult extubation:

• Extubation directly onto HFNO or CPAP
• Airway exchange catheter / staged extubation catheter
• Switch to Supraglottic Airway Device under GA
• Remifentanil technique
• Prolonged intubation and sedation
• Tracheostomy

Looking speci cally at the Cook Staged Extubation Set: An excellent, but maybe underknown
piece of equipment. Consider in patients that may have:
• Inability to tolerate extubation / need for reintubation – e.g. obstruction, poor ventilation/
oxygenation, unable to protect airway
• Dif culty in re-establishing airway – known dif culty with intubation, injury, emergency, etc

Set consists of a wire, placed pre-extubation, & left in-situ post-extubation (usually well-tolerated)
allows for rapid re-intubation via tapered catheter. Check out this video.

https://www.youtube.com/watch?v=iuICquziUM8

Here are some papers / links that you might nd interesting:

a. Batuwitage B, Charters P. Postoperative management of the dif cult airway. British Journal
of Anaesthesia Education. 2017; 17: 235-41

b. Parotto M, Cooper RM, Behringer EC. Extubation of the Challenging or Dif cult Airway. Curr
ent Anesthesiology Reports. 2020; 10: 334-40

c. Hagberg CA, Artime CA. Extubation of the perioperative patient with a dif cult airway.
Colombian Journal of Anesthesiology. 2014; 42: 295-301

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d. Cavallone LF, Vannucci A. Review article: Extubation of the dif cult airway and extubation
failure. Anesthesia and Analgesia. 2013; 116: 368-83

e. D'Silva DF, McCulloch TJ, Lim JS, Smith SS, Carayannis D. Extubation of patients with
COVID-19. British Journal of Anaesthesia. 2020; 125: e192-5

f. Furyk C, Walsh ML, Kaliaperumal I, Bentley S, Hattingh C. Assessment of the reliability of

intubation and ease of use of the Cook Staged Extubation Set-an observational study.
Anaesthesia and Intensive Care. 2017; 45: 695-9

g. McManus S, Jones L, Anstey C, Senthuran S. An assessment of the tolerability of the Cook

staged extubation wire in patients with known or suspected dif cult airways extubated in
intensive care. Anaesthesia. 2018; 73: 587-93

h. Corso RM, Sorbello M, Mecugni D, Seligardi M, Piraccini E, Agnoletti V, Gamberini E,

Maitan S, Petitti T, Cataldo R. Safety and ef cacy of Staged Extubation Set in patients with
dif cult airway: a prospective multicenter study. Minerva Anestesiologica. 2020; 86: 827-34

i. Gentek Medical. Staged Extubaiton Set - video (online)

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GUIDELINES, GUIDELINES,
GUIDELINES
| “Guidelines are like toothbrushes. They are also like floss” |

| @GongGasGirl #GAMC2021 |

DAS are probably best known for our guidelines. Recently, we have updated our methodology to
ensure all guidelines documents are of suf cient rigour to include best evidence and the most
clinically relevant recommendations. However, it is important to recognise they are just that –
recommendations and guidelines. Guidelines are not intended to represent a minimum standard
of practice, nor are they to be regarded as a substitute for good clinical judgement. They present
key principles and suggested strategies for the management of certain clinical scenarios. They
are intended to guide appropriately trained healthcare professionals.

We have many DAS guidelines and have contributed to many others in partnership with other
organisations, here are links to some:

a. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall
NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway
Society 2015 guidelines for management of unanticipated dif cult intubation in adults.
British Journal of Anaesthesia. 2015; 115: 827-48

b. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM;

Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal
College of Anaesthetists. Guidelines for the management of tracheal intubation in critically
ill adults. British Journal of Anaesthesia. 2018; 120: 323-52

c. Dif cult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A,
Swampillai C, Higgs A. Dif cult Airway Society Guidelines for the management of tracheal
extubation. Anaesthesia. 2012; 67: 318-40

d. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel
A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation
(ATI) in adults. Anaesthesia. 2020; 75: 509-28

e. Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC;
Obstetric Anaesthetists' Association; Dif cult Airway Society. Obstetric Anaesthetists'
Association and Dif cult Airway Society guidelines for the management of dif cult and
failed tracheal intubation in obstetrics. Anaesthesia. 2015; 70: 1286-306

f. Dif cult Airway Society and Association of Paediatric Anaesthetists. Paediatric Dif cult
Airway Guidelines (online)

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g. Iliff HA, El-Boghdadly K, Ahmad I, Davis J, Harris A, Khan S, Lan-Pak-Kee V, O'Connor J,

Powell L, Rees G, Tatla TS. Management of haematoma after thyroid surgery: systematic
review and multidisciplinary consensus guidelines from the Dif cult Airway Society, the
British Association of Endocrine and Thyroid Surgeons and the British Association of
Otorhinolaryngology, Head and Neck Surgery. Anaesthesia. 2022; 77: 82-95

h. McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project.
Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway
emergencies. Anaesthesia. 2012; 67: 1025-41

Our guidelines have also been adapted to guide management of patients with COVID-19:

a. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus

guidelines for managing the airway in patients with COVID-19: Guidelines from the
Dif cult Airway Society, the Association of Anaesthetists the Intensive Care Society, the
Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia.
2020; 75: 785-99

Other airway organisations also have their own guidelines. Here are just a few from America,
Canada and Australia and New Zealand (there are many more).

a. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE,
Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A.
2022 American Society of Anesthesiologists Practice Guidelines for Management of the
Dif cult Airway. Anesthesiology. 2022; 136: 31-81

b. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM,
Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey
S, Turkstra TP, Wong DT; Canadian Airway Focus Group. The dif cult airway with
recommendations for management--part 1--dif cult tracheal intubation encountered in an
unconscious/induced patient. Canadian Journal of Anesthesia. 2013; 60: 1089-118

c. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM,
Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey
S, Turkstra TP, Wong DT; Canadian Airway Focus Group. The dif cult airway with
recommendations for management--part 2--the anticipated dif cult airway. Canadian
Journal of Anesthesia. 2013; 60: 1119-38

d. Australian and New Zealand College of Anaesthesia & Faculty of Pain Medicine. Guideline
for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t
Oxygenate airway emergency. 2017 (online)

Note: we have not provided the one pagers for this tweetorial as they are all freely available
from the hyperlinks previous and are best viewed with the accompanying text.

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DIFFICULT AIRWAY CONDITIONS

| there are LOADS! |

The following pages do not form a de nitive list.

Here are some papers / links on some lesser known eponymous syndromes that you might nd
interesting:

a. Crawley SM, Dalton AJ. Predicting the dif cult airway. British Journal of Anaesthesia
Education. 2015; 15: 253-7

b. Phulkar P, Waghalkar P. Anaesthetic Management of a Patient with West Syndrome. Journal

of Anaesthesia & Critical Care Case Reports. 2018; 4: 11-13

c. Gurumurthy T, Shailaja S, Kishan S, Stephen M. Management of an anticipated dif cult

airway in Hurler's syndrome. Journal of Anaesthesiology Clinical Pharmacology. 2014; 30:
558-61

d. Park SJ, Choi EK, Park S, Bae K, Lee D. Successful dif cult airway management using
GlideScope video laryngoscope in a child with Cornelia de Lange Syndrome. Yeungnam
University Journal of Medicine. 2018; 35: 219-21

e. Sequera-Ramos L, Duffy KA, Fiadjoe JE, Garcia-Marcinkiewicz AG, Zhang B, Perate A,

Kalish JM. The Prevalence of Dif cult Airway in Children With Beckwith-Wiedemann
Syndrome: A Retrospective Cohort Study. Anesthesia and Analgesia. 2021;133: 1559-67

f. Venkat Raman V, de Beer D. Perioperative airway complications in infants and children with
Crouzon and Pfeiffer syndromes: A single-center experience. Pediatric Anesthesia. 2021;
31: 1316-24

g. Oliveira CRD. Pediatric syndromes with noncraniofacial anomalies impacting the airways.
Pediatric Anesthesia. 2020; 30: 304-10

h. Oe Y, Godai K, Masuda M, Kanmura Y. Dif cult airway associated with bi d glottis and
coexistent subglottic stenosis in a patient with Pallister-Hall syndrome: a case report. JA
Clinical Reports. 2018; 4: 20

i. Chura M, Odo N, Foley E, Bora V. Cervical Deformity and Potential Dif cult Airway
Management in Klippel-Feil Syndrome. Anesthesiology. 2018; 128:1007

j. Bangera A, Shetty D. Management of a case of anticipated dif cult airway in a patient with
Moebius syndrome. Indian Journal of Anaesthesia. 2020; 64: 985-6

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FURTHER READING
| note: this may not be an exhaustive list |

Miscellaneous

1. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit
Project: Major complications of airway management in the United Kingdom. 2011 (online)

2. Cook TM, Kristensen MS. Core Topics in Airway Management. 3rd Edition. Cambridge
University Press. Cambridge, United Kingdom. 2020

3. Aston D, Rivers A and Dharmadasa A. Equipment in Anaesthesia and Critical Care. A

complete guide for the FRCA. Scion Publishing Limited. United Kingdom. 2014

4. Hagberg C. Benumof and Hagberg’s Airway Management. 3rd Edition. Elsevier Inc. 2013

5. Popat M. Dif cult Airway Management. Oxford University Press. Oxford, United Kingdom.
2009

6. Levine AI, Govindaraj S, DeMaria S. Anesthesiology and Otolaryngology. Springer Science

and Business Media. New York. 2013

7. Abdlmalak B, Doyle J. Anesthesia for Otolaryngologic Surgery. Cambridge University Press.

Cainmbridge, United Kingdom. 2012

Oxygenation

8. Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange (THRIVE):
a physiological method of increasing apnoea time in patients with dif cult airways.
Anaesthesia. 2015; 70: 323-9

9. McNamara MJ, Hardman JG. Hypoxaemia during open-airway apnoea: a computational

modelling analysis. Anaesthesia. 2005; 60: 741-6

10. Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online)

11. Teller LE, Alexander CM, Frumin MJ, Gross JB. Pharyngeal insuf ation of oxygen prevents
arterial desaturation during apnea. Anesthesiology. 1988; 69: 980-2

12. Taha SK, Siddik-Sayyid SM, El-Khatib MF, Dagher CM, Hakki MA, Baraka AS.
Nasopharyngeal oxygen insuf ation following pre-oxygenation using the four deep breath
technique. Anaesthesia. 2006; 61: 427-30

13. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during
prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen
administration. Journal of Clinical Anesthesia. 2010; 22:164-8

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Airway Assessment

14. Samsoon GI, Young JR. Dif cult tracheal intubation: a retrospective study. Anaesthesia.
1987; 42: 487-90

15. Bellhouse CP, Dore C. Criteria for estimating likelihood of dif culty of endotracheal intubation
with the Macintosh laryngoscope. Anaesthesia and Intensive Care Medicine. 1988; 16:
329-37

16. Takenaka I, Aoyama K and Kadoya T. Mandibular Protrusion Test for Prediction of Dif cult
Mask Ventilation. Anesthesiology. 2001; 94: 935

17. Frerk C. Predicting dif cult intubation. Anaesthesia. 1991; 46: 1005-8

18. Murphy MF, Wall RM. The dif cult and failed airway. In: Manual of Emergency Airway
Management. Chicago, IL. Lippincott Williams and Wilkins; 2000: 31-39

19. Dif cult Airway Management in the Pregnant Patient. Anaesthesia Key. 2016 (online)

20. Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H. Airway physical
examination tests for detection of dif cult airway management in apparently normal adult
patients. Cochrane Database of Systematic Reviews. 2018 (online)

21. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic
accuracy of anaesthesiologists' prediction of dif cult airway management in daily clinical
practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database.
Anaesthesia. 2015; 70: 272-81

22. Dif cult Airway Society. How to perform a nasendoscopy - video by DAS members. (online)

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23. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B. Prediction of

dif cult mask ventilation. Anesthesiology. 2000; 92:1229-36

24. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask
ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009; 110: 891-7

25. Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict dif culty at
intubation in the emergency department? Emergency Medicine Journal. 2005; 22: 99-102

26. Detsky ME, Jivraj N, Adhikari NK, et al. Will This Patient Be Dif cult to Intubate? The Rational
Clinical Examination Systematic Review. JAMA. 2019; 321: 493–503

De ning the Dif cult Airway

27. Huitink JM, Bouwman RA. The myth of the dif cult airway: airway management revisited.
Anaesthesia. 2015; 70: 244-9

28. Snowdon DJ and Boone, ME. A Leader’s Framework for Decision Making. Harvard Business
Review. 2007 (online)

29. Luft J and Ingram H. The Johari window, a graphic model of interpersonal awareness. 1982
(online)

30. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit
Project: Major complications of airway management in the United Kingdom. 2011 (online)

31. Grey AJG, Hoile RW, Ingram GS, Sherry KM. The Report of the National Con dential Enquiry
into Perioperative Deaths 1996/1997. 1998 (online)

32. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic
accuracy of anaesthesiologists' prediction of dif cult airway management in daily clinical
practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database.
Anaesthesia. 2015; 70: 272-81

Airway Investigations, Lung Function Tests and Airway Ultrasound

33. Crawley SM and Dalton AJ. Predicting the dif cult airway, British Journal of Anaesthesia
Education, 2015; 15: 253–7

34. Ahmad I, Millhoff B, John M, Andi K, Oakley R. Virtual endoscopy--a new assessment tool in
dif cult airway management. Journal of Clinical Anesthesia. 2015; 27: 508-13

35. Zhou Z, Zhao X, Zhang C, Yao W. Preoperative four-dimensional computed tomography

imaging and simulation of a breoptic route for awake intubation in a patient with an epiglottic
mass. British Journal of Anaesthesia. 2020;125: e290-2

36. Chambers D, Huang C, Matthews G. Spirometry. In: Basic Physiology for Anaesthetists.
Cambridge, UK. Cambridge University Press, 2018: 56-63

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37. Chambers D, Huang C, Matthews G. Alveolar Diffusion. In: Basic Physiology for
Anaesthetists. Cambridge, UK. Cambridge University Press, 2018: 40-44

38. Modi P, Cascella M. Diffusing Capacity Of The Lungs For Carbon Monoxide. In: StatPearls
2022 (online)

39. Cotes JE, Chinn DJ, Quanjer PhH, Roca J, Yernault JC. Standardization of the measurement
of transfer factor (diffusing capacity). European Respiratory Journal 1993 6: 41-52

40. Zhao Y, Hernandez AM, Boone JM, Molloi S. Quanti cation of airway dimensions using a
high-resolution CT scanner: A phantom study. Medical Physics. 2021; 48: 5874-83

41. Grenier PA, Beigelman-Aubry C, Fétita C, Prêteux F, Brauner MW, Lenoir S. New frontiers in
CT imaging of airway disease. European Radiology. 2002; 12: 1022-44

42. Radiopaedia (online)

43. Kristensen MS. Ultrasound for safe airway management (online)

44. Kristensen MS, Teoh WH, Graumann O, Laursen CB. Ultrasonography for clinical decision-
making and intervention in airway management: from the mouth to the lungs and pleurae.
Insights Imaging. 2014; 5: 253-79

45. Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiologica
Scandinaviaica. 2011; 55: 1155-73

46. Kristensen MS, Teoh WH. Ultrasound identi cation of the cricothyroid membrane: the new
standard in preparing for front-of-neck airway access. British Journal of Anaesthesia. 2021;
126: 22-27

47. Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identi cation of the cricothyroid
membrane: best evidence, techniques, and clinical impact. British Journal of Anaesthesia.
2016; 117: i39-i48

48. Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark
identi cation for cannula cricothyroidotomy. Anaesthesia. 2010; 65: 889-94

49. Dinsmore J, Heard AM, Green RJ. The use of ultrasound to guide time-critical cannula
tracheotomy when anterior neck airway anatomy is unidenti able. European Journal of
Anaesthesiology. 2011; 28: 506-10

50. El-Boghdadly K, Wojcikiewicz T, Perlas A. Perioperative point-of-care gastric ultrasound.

British Journal of Anaesthesia Education. 2019; 19: 219-26

51. Identi cation of the cricothyroid membrane with ultrasonography Longitudinal "string of
pearls" approach - video (online)

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Airway Planning

52. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit
Project: Major complications of airway management in the United Kingdom. 2011 (online)

53. Huitink JM, Bouwman RA. The myth of the dif cult airway: airway management revisited.
Anaesthesia. 2015; 70: 244-9

54. Chew KS, Durning SJ, van Merriënboer JJ. Teaching metacognition in clinical decision-
making using a novel mnemonic checklist: an exploratory study. Singapore Medical Journal.
2016; 57: 694-700

55. Bromiley M. The Case of Elaine Bromiley (online)

56. Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in
Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online).

57. Chrimes N, Fritz P. The Vortex Approach to airway management (online)

58. Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular
blockade on mask ventilation. Anaesthesia. 2011; 66:163-7

59. Nouraei SA, Giussani DA, Howard DJ, Sandhu GS, Ferguson C, Patel A. Physiological
comparison of spontaneous and positive-pressure ventilation in laryngotracheal stenosis.
British Journal of Anaesthesia. 2008; 101: 419-23

60. Bennett JA, Abrams JT, Van Riper DF, Horrow JC. Dif cult or impossible ventilation after
sufentanil-induced anesthesia is caused primarily by vocal cord closure. Anesthesiology.
1997; 87: 1070-4

61. Patel A. Approaches to Anaesthetic Management of the Shared Airway. 2019 (online)

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62. Dif cult Airway Society. How to perform a nasendoscopy - video by DAS members. (Online)

63. Consilvio C, Kuschner WG, Lighthall GK. The pharmacology of airway management in critical
care. Journal of Intensive Care Medicine. 2012; 27: 298-305

64. Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI) -
video (online)

65. Johnston KD, Rai MR. Conscious sedation for awake breoptic intubation: a review of the
literature. Canadian Journal of Anesthesia. 2013; 60: 584-99

66. Scarth E, Smith S. Drugs in Anaesthesia and Intensive Care. Fifth Edition. Oxford, UK. Oxford
University Press. 2016

Basic Airway Equipment

67. Laurie A, Macdonand J. Equipment for airway management. Anaesthesia and Intensive Care
Medicine. 2018; 19: 389-96

68. Bjurström MF, Bodelsson M, Sturesson LW. The Dif cult Airway Trolley: A Narrative Review
and Practical Guide. Anesthesiology Research and Practice. 2019

69. Chishti K. Setting up a Dif cult Airway Trolley. 2015 (online)

70. Gibbins M, Kelly FE, Cook TM. Airway management equipment and practice: time to optimise
institutional, team, and personal preparedness. British Journal of Anaesthesia. 2020; 125:
221-4

71. Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in
Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online)

72. Physics and modelling of the Airway. 2015 (online)

73. Cook Medical. Frova Intubating Introducer (online)

Airway Laryngoscopy

74. Jackson, C. The technique of insertion of intratracheal insuf ation tubes. Surgery,
Gynecology and Obstetrics. 1913; 17: 507-9

75. Magill IW. Endotracheal anesthesia. American Journal of Surgery. 1936; 34: 450-455

76. Bannister F, Macbeth R. Direct laryngoscopy and tracheal intubation. Lancet. 1944; 244:
651-654

77. Chrimes N. Flextension. 2020 (online)

78. Cook TM. Bath Technique. 2021 (online)

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79. Biro, P; Spahn, D R. The dif cult intubation drill at the University Hospital Zürich. Jurnalul
Român de Anestezie Terapie Intensivã. 2009 16:147-153.

80. Cook TM. A new practical classi cation of laryngeal view. Anaesthesia. 2000; 55: 274-9

81. Chaggar RS, Shah SN, Berry M, Saini R, Soni S, Vaughan D. The Video Classi cation of
Intubation (VCI) score: a new description tool for tracheal intubation using
videolaryngoscopy: A pilot study. European Journal of Anaesthesiology. 2021; 38: 324-6

82. Knill RL. Dif cult laryngoscopy made easy with a "BURP". Canadian Journal of Anesthesia.
1993; 40: 279-82

83. Lewis SR, Butler AR, Parker J, Cook TM, Scho eld-Robinson OJ, Smith AF.
Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation:
a Cochrane Systematic Review. British Journal of Anaesthesia. 2017; 119: 369-83

Capnography and Oesophageal Intubation

84. Joy P, Kelly FE. Unrecognised Oesophageal Intubation. Anaesthesia News. 2022 (online)

85. Judiciary.UK. In the Milton Keynes Coroner’s Court. Inquest into the death of Glenda May
Logsdail, Regulation 28: report to prevent future deaths. 2021. (online)

86. CORONERS COURT OF NEW SOUTH WALES Inquest into the death of Emiliana Obusan.
2021 (online)

87. Cook TM, Harrop-Grif ths W. Capnography prevents avoidable deaths. British Medical
Journal. 2019; 364: l439

88. Cook TM. Preventing Undetected Oesophageal Intubation - a twitter thread. 2021 (online)

89. Royal College of Anaesthetists. Prevention of future deaths 2021 (online)

90. Ahmad I, McGuire B, McNarry A, Chakladar A, Richmond L. Unexpected Oesophageal

Intubation. DAS Members EZINE. 2022 (online)

91. Jooste R, Roberts F, Mndolo S, Mabedi D, Chikumbanje S, Whitaker DK, O'Sullivan EP. Global
Capnography Project (GCAP): implementation of capnography in Malawi - an international
anaesthesia quality improvement project. Anaesthesia. 2019; 74: 158-166

92. Pandit JJ, Young P, Davies M. Why does oesophageal intubation still go unrecognised?
Lessons for prevention from the coroner's court. Anaesthesia. 2022 Feb; 77: 123-128

93. Twitter Broadcast: Why does oesophageal intubation still go unrecognised? - Anaesthesia
(online)

94. Podcast: Why does oesophageal intubation still go unrecognised? - Anaesthesia (online)

95. Collins J, Ní Eochagáin A, O'Sullivan EP. A recurring case of 'no trace, right place' during
emergency tracheal intubations in the critical care setting. Anaesthesia. 2021; 76 :1671

186

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96. Cook, T.M., Kelly, F.E. and Goswami, A. ‘Hats and caps’ capnography training on intensive
care. Anaesthesia, 2013; 68: 421

97. Royal College of Anaesthetists. Capnography: No Trace = Wrong Place - video (online)

98. Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE.
Paediatric intensive care and neonatal intensive care airway management in the United
Kingdom: the PIC-NIC survey. Anaesthesia. 2018; 73:1337-44

99. Kodali BS. Capnography. 12th Edition. 2022 (online)

100.Eipe N, Doherty DR. A review of pediatric capnography. Journal of Clinical Monitoring and
Computing. 2010; 24: 261-8

High Flow Nasal Oxygen

101.Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange

(THRIVE): a physiological method of increasing apnoea time in patients with dif cult airways.
Anaesthesia. 2015; 70: 323-9

102.Hermez LA, Spence CJ, Payton MJ, Nouraei SAR, Patel A, Barnes TH. A physiological study
to determine the mechanism of carbon dioxide clearance during apnoea when using
transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE). Anaesthesia. 2019;
74: 441–9

103.Mir F, Patel A, Iqbal R, Cecconi M, Nouraei SAR. A randomised controlled trial comparing
transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE) pre-oxygenation with
facemask pre-oxygenation in patients undergoing rapid sequence induction of anaesthesia.
Anaesthesia. 2017; 72: 439–43

104.Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidi ed

rapid-insuf ation ventilatory exchange (THRIVE) in children: a randomized controlled trial.
British Journal of Anaesthesia. 2017; 118: 232–8

105.Lodenius å., Piehl J, Östlund A, Ullman J, Jonsson Fagerlund M. Transnasal humidi ed

rapid-insuf ation ventilatory exchange (THRIVE) vs. facemask breathing pre-oxygenation for
rapid sequence induction in adults: a prospective randomised non-blinded clinical trial.
Anaesthesia. 2018; 73: 564–71

106.Patel A, El‐Boghdadly K. Apnoeic oxygenation and ventilation: go with the ow. Anaesthesia.
2020; 75: 1002–5

107.Sud A, Patel A. THRIVE: ve years on and into the COVID-19 era. British Journal of
Anaesthesia. 2021;126: 768-73

108.Patel A, El-Boghdadly K. Facemask or high- ow nasal oxygenation: time to switch?

Anaesthesia. 2022; 77: 7-11

109.Rummens N, Ball DR. Failure to THRIVE. Anaesthesia. 2015. (epub)

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110.Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online)

111.Papazian L, Corley A, Hess D, Fraser JF, Frat JP, Guitton C, Jaber S, Maggiore SM, Nava S,
Rello J, Ricard JD, Stephan F, Trisolini R, Azoulay E. Use of high- ow nasal cannula
oxygenation in ICU adults: a narrative review. Intensive Care Med. 2016; 42:1336-49

Cook Airway Exchange Catheter

112.Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in

Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online)

113.Benumof JL. Airway exchange catheters: simple concept, potentially great danger.
Anesthesiology. 1999; 91: 342-4

114.Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the
potentially dif cult extubation: a case report. AANA Journal. 2002; 70: 275-8

115.A dangerous tracheal tube exchange from AOD. 2016 - video (online)

116.Change of Endotracheal tube over tube exchanger. 2019 - video (online)

117.Cook Medical. Cook® Airway Exchange Catheter (online)

Cook Aintree Intubation Catheter

118.Padmanabhan R, McGuire B, Morris A. Fibreoptic guided tracheal intubation through

supraglottic airway device (SAD) using aintree intubation catheter. 2011 (online)

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119.Gruenbaum SE, Gruenbaum BF, Tsaregorodtsev S, Dubilet M, Melamed I, Zlotnik A. Novel

use of an exchange catheter to facilitate intubation with an Aintree catheter in a tall patient
with a predicted dif cult airway: a case report. Journal of Medical Case Reports. 2012;
13:108

120.Phipps S, Malpas G, Hung O. A technique for securing the Aintree Intubation Catheter™ to a
exible bronchoscope. Canadian Journal of Anesthesia. 2018; 65: 329-30

121.Cook Medical. Aintree Intubation Catheter (online)

Awake Tracheal Intubation

122.Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A,
Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in
adults. Anaesthesia. 2020; 75: 509-28

123.Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI) -
video (online)

124.Bailin S. Awake Tracheal Intubation - video (online)

125.Awake Airway Management. Videolaryngoscopic awake tracheal intubation, no sedation -

video (online)

126.Coleman L, Żakowski M, Gold JA, Ramanathan S. Functional Anatomy of the Airway.

Anaesthesia Key. 2017 (online)

127.Shorten GD, Opie NJ, Graziotti P, Morris I, Khangure M. Assessment of upper airway
anatomy in awake, sedated and anaesthetised patients using magnetic resonance imaging.
Anaesthesia and Intensive Care. 1994; 22: 165-9

128.DAS/RCoA Teaching Material for the Novice Anaesthetist. Anatomy: From Airway Matters -
MOOC (online)

129.Scarth E, Smith S. Drugs in Anaesthesia and Intensive Care. Fifth Edition. Oxford, UK. Oxford
University Press. 2016

130.Johnston KD, Rai MR. Conscious sedation for awake breoptic intubation: a review of the
literature. Canadian Journal of Anesthesia. 2013; 60: 584-99

Jet Ventilation

131.Yartsev A. Physiology of gas exchange in high oscillatory ventilation (HFOV). Deranged

Physiology. 2015 (online)

132.Dworkin R, Benumof JL, Benumof R, Karagianes TG. The effective tracheal diameter that
causes air trapping during jet ventilation. Journal of Cardiothoracic Anesthesia. 1990; 4:
731-6

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133.Calder I, Pearce A. Core Topics in Airway Management. Cambridge, UK. Cambridge

University Press. 2011

134.Pearson KL, McGuire BE. Anaesthesia for laryngo-tracheal surgery, including tubeless eld
techniques. British Journal of Anaesthesia Education. 2017; 17: 242-8

135.Patel C. Chet Patel describes the anaesthetic technique of jet ventilation - video (online)

136.Anaesthesia Galway. Manujet Ventilator - video (online)

137.Sivasambu B, et al. Initiation of a High-Frequency Jet  Ventilation Strategy for

Catheter  Ablation for Atrial Fibrillation: Safety and Outcomes Data. JACC Clinical
Electrophysiology. 2018; 4: 1519-25

One Lung Ventilation

138.Lohser J, Ishikawa S. Physiology of the Lateral Decubitus Position, Open Chest and One-
Lung Ventilation. In: Principles and Practice of Anaesthesia for Thoracic Surgery. 2011

139.Longnecker DE, Brown DL, Newman MF, Zapol WM: Anaesthesiology, 2nd Edition. McGraw
Hill

140.Petersson J, Glenny RW. Gas exchange and ventilation-perfusion relationships in the lung.
The European Respiratory Journal. 2014; 44: 1023-41

141.Sommer N, Strielkov I, Pak O, Weissmann N. Oxygen sensing and signal transduction in

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269.Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines
for managing the airway in patients with COVID-19: Guidelines from the Dif cult Airway
Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive
Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-99

270.Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE,
Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A.
2022 American Society of Anesthesiologists Practice Guidelines for Management of the
Dif cult Airway. Anesthesiology. 2022; 136: 31-81

271.Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F,
Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G;
Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based
recommendations for management of the dif cult airway: part 1. Dif cult airway management
encountered in an unconscious patient. Canadian Journal of Anesthesia. 2021; 68: 1373-404

272.Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Kovacs G, Lemay F,
Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Jones PM;
Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based
recommendations for management of the dif cult airway: part 2. Planning and implementing
safe management of the patient with an anticipated dif cult airway. Canadian Journal of
Anesthesia. 2021; 68: 1405-1436

273.Australian and New Zealand College of Anaesthesia & Faculty of Pain Medicine. Guideline
for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t
Oxygenate airway emergency. 2017 (online)

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Dif cult Airway Conditions

274.Phulkar P, Waghalkar P. Anaesthetic Management of a Patient with West Syndrome. Journal

of Anaesthesia & Critical Care Case Reports. 2018; 4: 11-13

275.Gurumurthy T, Shailaja S, Kishan S, Stephen M. Management of an anticipated dif cult

airway in Hurler's syndrome. Journal of Anaesthesiology Clinical Pharmacology. 2014; 30:
558-61

276.Park SJ, Choi EK, Park S, Bae K, Lee D. Successful dif cult airway management using
GlideScope video laryngoscope in a child with Cornelia de Lange Syndrome. Yeungnam
University Journal of Medicine. 2018; 35: 219-21

277.Crawley SM, Dalton AJ. Predicting the dif cult airway. British Journal of Anaesthesia
Education. 2015; 15: 253-7

278.Herd RS, Sprung J, Weingarten TN. Primary osteolysis syndromes: beware of dif cult airway.
Pediatric Anesthesia. 2015; 25: 727-37

279.Sequera-Ramos L, Duffy KA, Fiadjoe JE, Garcia-Marcinkiewicz AG, Zhang B, Perate A,

Kalish JM. The Prevalence of Dif cult Airway in Children With Beckwith-Wiedemann
Syndrome: A Retrospective Cohort Study. Anesthesia and Analgesia. 2021;133: 1559-67

280.Venkat Raman V, de Beer D. Perioperative airway complications in infants and children with
Crouzon and Pfeiffer syndromes: A single-center experience. Pediatric Anesthesia. 2021; 31:
1316-24

281.Oliveira CRD. Pediatric syndromes with noncraniofacial anomalies impacting the airways.
Pediatric Anesthesia. 2020; 30: 304-10

282.Oe Y, Godai K, Masuda M, Kanmura Y. Dif cult airway associated with bi d glottis and
coexistent subglottic stenosis in a patient with Pallister-Hall syndrome: a case report. JA
Clinical Reports. 2018; 4: 20

283.Packiasabapathy S, Chandiran R, Batra RK, Agarwala S. Dif cult airway in Mowat-Wilson

syndrome. Journal of Clinical Anesthesia. 2016; 34: 151-3

284.Chura M, Odo N, Foley E, Bora V. Cervical Deformity and Potential Dif cult Airway
Management in Klippel-Feil Syndrome. Anesthesiology. 2018; 128:1007

285.Ozkan AS, Akbas S, Yalin MR, Ozdemir E, Koylu Z. Successful dif cult airway management
of a child with Cof n-siris syndrome. Clinical Case Reports. 2017; 5: 1312-14

286.Bangera A, Shetty D. Management of a case of anticipated dif cult airway in a patient with
Moebius syndrome. Indian Journal of Anaesthesia. 2020; 64: 985-6

287.Taharabaru S, Sato T, Nishiwaki K. Dif cult Airway Management in a Patient With Nicolaides-
Baraitser Syndrome Who Had a Small Jaw and Limited Mouth Opening. Anesthesia Progress.
2021; 68: 47-9

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288.Pérez Fernández-Escandón Á, Hevia Sánchez V, Llorente Pendás S, Molina Montalva F.

Dif cult airway management in a patient with Treacher Collins syndrome using two-part
surgery. Revista Española de Anestesiología y Reanimación (English Edition). 2019; 66: 230-4

289.Bhat R, Mane RS, Patil MC, Suresh SN. Fiberoptic intubation through laryngeal mask airway
for management of dif cult airway in a child with Klippel-Feil syndrome. Saudi Journal of
Anaesthesia. 2014; 8: 412-4

290.Khanna P, Ray BR, Govindrajan SR, Sinha R, Chandralekha, Talawar P. Anesthetic

management of pediatric patients with Sturge-Weber syndrome: our experience and a review
of the literature. Journal of Anesthesia. 2015; 29: 857-61

291.Ghaffar WB, Haq IU, Shahid A, Ismail S. Anaesthetic Challenges in a Paediatric Patient with
Escobar Syndrome-Dif cult Airway and Postoperative Pneumothorax. Turkish Journal of
Anaesthesiology and Reanimation. 2021; 49: 486-9

292.España Fuente L, Méndez Redondo RE, González González JL. Use of Clarus Video
System® in expected dif cult airway in a patient with Rett syndrome. Revista Española de
Anestesiología y Reanimación (English Edition). 2017; 64: 50-4

293.Rawat RS. Congenital syndromes affecting heart and airway alike. Annals of Cardiac
Anaesthesia. 2017; 20: 393-4

294.Dwivedi D, Bhatnagar V, Tandon U, Jinjil K. Pediatric dif cult intubation in a rare genetic
disorder made easy with Airtraq laryngoscope. Anesthesia, Essays and Researches. 2016;
10: 684-5

295.Oliveira CRD. Anaesthesia in patients with unusual genetic diseases. Anaesthesia, Pain &
Intensive Care. 2019; 23: 5-8

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#JanuAIRWAY
Brought to you by @dastrainees @Vapourologist and #DASeducation

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 Dif cult Airway Society Newsletter Winter 2019

© Di cult Airway Society 2022

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