Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.
UNASSIGNED: Die Sicherung der Atemwege ermöglicht die Oxygenierung und Ventilation der Lungen und stellt eine potenziell lebensrettende medizinische Maßnahme dar. Insbesondere bei Neugeborenen und Säuglingen kommt es gehäuft zu unerwünschten und kritischen Ereignissen während des Atemwegsmanagements. Die multifaktoriellen Gründe dafür umfassen patientenabhängige, anwenderabhängige, aber auch externe Faktoren. Im Folgenden wird die neu erschienene internationale Leitlinie zur Atemwegssicherung bei Neugeborenen und Säuglingen fokussierend auf die klinische Anwendung zusammengefasst. Während die Originalpublikation der Leitlinie darauf fokussiert, auf Basis der systematisch erfassten Evidenz formale Empfehlungen zu benennen, stellt diese Zusammenfassung v. a. die Praktikabilität ihrer Umsetzung in den Fokus.

The use of video laryngoscopes has enhanced the visualization of the vocal cords, thereby improving the accessibility of tracheal intubation. Employing artificial intelligence (AI) to recognize images obtained through video laryngoscopy, particularly when marking the epiglottis and vocal cords, may elucidate anatomical structures and enhance anatomical comprehension of anatomy. This study investigates the ability of an AI model to accurately identify the glottis in video laryngoscope images captured from a manikin. Tracheal intubation was conducted on a manikin using a bronchoscope with recording capabilities, and image data of the glottis was gathered for creating an AI model. Data preprocessing and annotation of the vocal cords, epiglottis, and glottis were performed, and human annotation of the vocal cords, epiglottis, and glottis was carried out. Based on the AI\'s determinations, anatomical structures were color-coded for identification. The recognition accuracy of the epiglottis and vocal cords recognized by the AI model was 0.9516, which was over 95%. The AI successfully marked the glottis, epiglottis, and vocal cords during the tracheal intubation process. These markings significantly aided in the visual identification of the respective structures with an accuracy of more than 95%. The AI demonstrated the ability to recognize the epiglottis, vocal cords, and glottis using an image recognition model of a manikin.

The aim of this study was to assess the usefulness of an attachable video laryngoscope (AVL) by attaching a camera and a monitor to a conventional Macintosh laryngoscope (CML). Normal and tongue edema airway scenarios were simulated using a manikin. Twenty physicians performed tracheal intubations using CML, AVL, Pentax Airwayscope® (AWS), and McGrath MAC® (MAC) in each scenario. Ten physicians who had clinical experience in using tracheal intubation were designated as the skilled group, and another ten physicians who were affiliated with other departments and had little clinical experience using tracheal intubation were designated as the unskilled group. The time required for intubation and the success rate were recorded. The degree of difficulty of use and glottic view assessment were scored by participants. All 20 participants successfully completed the study. There was no difference in tracheal intubation success rate and intubation time in the normal airway scenario in both skilled and unskilled groups. In the experienced group, AWS had the highest success rate (100%) in the tongue edema airway scenario, followed by AVL (60%), MAC (60%), and CML (10%) (p = 0.001). The time required to intubate using AWS was significantly shorter than that with AVL (10.2 s vs. 19.2 s) or MAC (10.2 s vs. 20.4 s, p = 0.007). The difficulty of using AVL was significantly lower than that of CML (7.8 vs. 2.8; p < 0.001). For the experienced group, AVL was interpreted as being inferior to AWS but better than MAC. Similarly, in the unskilled group, AVL had a similar success rate and tracheal intubation time as MAC in the tongue edema scenario, but this was not statistically significant. The difficulty of using AVL was significantly lower than that of CML (8.8 vs. 3.3; p < 0.001). AVL may be an alternative for VL.

UNASSIGNED: The aim of this study was to compare the performance of the HugeMed® videolaryngoscope with a direct Macintosh laryngoscope for nasotracheal intubation.
UNASSIGNED: Eighty-eight children aged 4-10 years were randomly assigned to either the HugeMed® videolaryngoscope (HVL) or the Macintosh direct laryngoscope (MDL) group. Intubation difficulty, glottic view grade, time-to-intubation, number of tracheal intubation attempts, use of external laryngeal manipulation and Magill forceps, recovery time, pediatric-anesthesia-delirium-scale (PAEDS) scores, pain due to tracheal intubation, and laryngeal bleeding were evaluated.
UNASSIGNED: Easy tracheal intubation incidence was higher in the HVL group than that in the MDL group (p = 0.001). Glottic view was better in the HVL group as compared to the MDL group (p = 0.027). There was no difference between the groups in terms of time-to-tracheal intubation, number of tracheal intubation attempts, Magill forceps usage, pain, and bleeding due to tracheal intubation. The need for external laryngeal manipulation (p = 0.004) and PAEDS scores (p = 0.006) were higher in the MDL group than those in the HVL group.
UNASSIGNED: HugeMed® videolaryngoscope may provide easier tracheal intubation, create a better glottic view, and significantly reduce the need for additional manipulation compared to the Macintosh direct laryngoscope, for nasotracheal intubation.
UNASSIGNED: www.clinicaltrial.gov identifier is NCT05121597.

UNASSIGNED: Video laryngoscopes are commonly used along with Macintosh and McCoy laryngoscopes for Nasotracheal intubation (NTI). The purpose of this study was to evaluate the performance of McCoy, Macintosh, and Truview laryngoscopes during bougie-aided NTI with respect to intubation time, success rate, and hemodynamic changes during the procedure.
UNASSIGNED: Forty-five American Society of Anesthesiologists (ASA) I-II adult patients, with Mallampati grade 1-4, requiring NTI, were enrolled after taking written informed consent. ASA III/IV, restricted mouth opening, and body mass index >30 were excluded from the study. Patients were randomly allocated to intubate with one of the three laryngoscopes (McCoy, Macintosh, and Truview) and the anesthesiologists were well experienced with all of them. The primary outcome was intubation time and secondary outcomes included first attempt success rate, external laryngeal manipulation, Cormack-Lehane (CL) grade, and hemodynamic responses.
UNASSIGNED: The intubation time of McCoy, Macintosh, and Truview, was 86.87 ± 15.92, 82.87 ± 16.46, and 79.93 ± 14.53 (mean ± standard deviation) seconds, respectively, which is comparable with Truview being the shortest. CL grade 1 was obtained more in the Truview group (53.3%) compared to the other two groups, while CL grade 3 was obtained in 20% each in McCoy and Macintosh groups.
UNASSIGNED: McCoy, Macintosh, and Truview laryngoscopes were comparable in performance during bougie-aided NTI, with Truview having the shortest intubation time and better visualization.

BACKGROUND: Pediatric airway management requires careful clinical evaluation and experienced execution due to anatomical, physiological, and developmental considerations. Video laryngoscopy in pediatric airways is a developing area of research, with recent data suggesting that video laryngoscopes are better than standard Macintosh blades. Specifically, there is a paucity of literature on the advantages of the C-MAC D-blade compared to the McCoy direct laryngoscope.
METHODS: After Ethics Committee approval, 70 American Society of Anesthesiologists physical status 1 and 2 children aged 4-12 years scheduled for elective surgery under general anesthesia were recruited. Patients were randomly allocated to intubation using a C-MAC video laryngoscope size 2 D-blade (Group 1) and a McCoy laryngoscope size 2 blade (Group 2). The Intubation Difficulty Scale (IDS) for ease of intubation was the primary outcome, while Cormack-Lehane grades, duration of laryngoscopy and intubation, hemodynamic responses, and incidence of any airway complications were secondary outcomes.
RESULTS: Both groups were comparable in terms of patient characteristics. The median (IQR) Intubation Difficulty Scale (IDS) score was better but was statistically nonsignificant with C-MAC (0 [0-0] vs. 0 [0-2], p = .055). The glottic views were superior (CL grade I in 32/35 vs. 23/35, p = .002), and the time to best glottic view (6 s [5-7] vs. 8.0 s [6-10], p = .006) was lesser in the C-MAC D-blade group while the total duration of intubation was comparable (20 s [16-22] vs. 18 s [15-22], p = .374). All the patients could be successfully intubated on the first attempt. None of the patients had any complications.
CONCLUSIONS: The C-MAC video laryngoscope size 2 D-blade provided faster and better glottic visualization but similar intubation difficulty compared to McCoy size 2 laryngoscope in children. The shorter time to achieve glottic view demonstrated with the C-MAC failed to translate into a shorter total duration of intubation when compared to the McCoy laryngoscope attributable to a pronounced curvature of the D-blade.

Pediatric difficult airway management is more challenging for an anesthesiologist due to anatomical and physiological differences as compared to adults. Moreover, the familiarity with the use of difficult airway equipment in adults does not equate to proficiency for the same in children. So, here we are presenting the management of a unique case of a difficult airway due to postburn neck contracture in a 4-year-old child, which was managed successfully with the help of a video laryngoscope after the failure attempt with a flexible fiberoptic bronchoscope.

Minimally invasive surfactant therapy (MIST) has emerged as a preferred method of surfactant delivery. Pioneers of this technique have described the use of direct laryngoscopy (DL) for MIST. With the increasing application of video laryngoscopy (VL) for neonatal airway management, it is speculated that MIST techniques can be adapted for use with VL.
OBJECTIVE: To compare procedural success, operator ease of use, and complication of MIST using VL vs. MIST using DL.
METHODS: This was a retrospective, observational cohort study conducted at a tertiary-level neonatal intensive care unit after obtaining ethical approval. We included neonates who received MIST between 1 October 2020 and 31 October 2022. Baseline demographic characteristics, along with procedural data, were collected. Primary outcome measures included the overall procedural success rate, the need for multiple attempts, and the total number of attempts. Secondary outcome measures included the occurrence of adverse events, the need for a second dose of surfactant, and the need for intubation within 7 days of the procedure. Means and SDs, independent t-tests, frequencies, and chi-square were used as appropriate. p-values < 0.05 were considered statistically significant.
RESULTS: Of the 79 neonates included, 37 neonates received MIST via VL, while 42 received MIST via DL. The median gestational age was lower in the VL group at 29.0 weeks vs. 30.5 weeks (p = 0.011) in the DL group. The median birthweight in the VL group was 1260 g, IQR (1080, 1690), which was significantly lower than the DL group, which was 1575 g, IQR (1220, 2251), p = 0.028. Purpose-built catheter use was higher in the DL group. The overall procedural success was similar between groups. The need for multiple attempts was lower with VL in comparison to DL [4 (11%) vs. 13 (31%); p = 0.034)] at the univariate level but not significant at multivariate analysis (p = 0.131). Procedural complications, the need for a second dose of surfactant, the need for mechanical ventilation post-MIST, and operator ease of use were similar. User comments emphasized the value of VL in providing real-time visual information to confirm catheter placement and guide operators/trainees.
CONCLUSIONS: Overall, in our cohort, despite VL being a more recently adapted technology used more in smaller, sicker, and more premature neonates, procedural success, complications, and operator ease of use for MIST using VL and DL were comparable. Our findings show the successful application of VL for MIST and suggest procedural advantages that might facilitate universal adoption.

UNASSIGNED: The 25°back-up position is proposed to increase the efficacy of preoxygenation and provide better tracheal intubating conditions when using a direct laryngoscope. This study aimed to compare the ease of tracheal intubation between supine and 25° back-up positions when using two video laryngoscopes (VLS).
UNASSIGNED: One hundred adults with normal airways and belonging to the American Society of Anesthesiologists physical status classes I and II, requiring general anaesthesia, were randomised in groups K and M. The trachea was intubated using King Vision and McGrath VLS in either supine (groups K1 and M1) or 25° back-up (groups K2 and M2) positions. The 25° backup position was given by raising the operating table from the horizontal position by flexing the torso at the hips so that an imaginary line connected the patient\'s external auditory meatus to the sternal notch. Modified Intubation Difficulty Scale (mIDS) was the primary outcome, and intubation time, the number of intubation attempts, vital parameters, and complications were compared secondarily. Statistical analysis was done using MedCalc software by applying an independent t-test for parametric data and a Chi-square test for categorical data and finding the risk ratio.
UNASSIGNED: Mean (Standard deviation) mIDS was significantly reduced using both VLS in the 25° back-up position [0.92 (0.75) versus 0.48 (0.58), P = 0.025, degree of freedom (DF): 48, mean difference (95% confidence interval [CI]):-0.44 (-0.821 to - 0.059) in group K1 versus group K2 and 0.76 (0.59) versus 0.36 (0.48), P = 0.012, DF: 48, mean difference (95% CI): -0.40(-0.706 to - 0.094) in group M1 versus group M2, respectively]. The risk ratio comparing both the positions for the total number of patients requiring manoeuvres during intubation using both the VLS was 0.48 with P = 0.0004 and 95% CI = 0.305 - 0.765. Intubation time was shorter in the 25° backup position by using King Vision (P = 0.005) and McGrath (P = 0.042) VLS.
UNASSIGNED: The 25° backup position helps provide ease of intubation using both the channelled (King Vision) and non-channelled (McGrath) VLS.

Arytenoid cartilage dislocation can occur as a complication of tracheal intubation and laryngeal trauma, but its occurrence with indirect video laryngoscopy has not been reported. This paper reports anterior arytenoid dislocation occurring after nasotracheal intubation performed under indirect laryngoscopy using a video laryngoscope (McGRATH MAC; Medtronic). The dislocation is presumed to have resulted from the laryngoscope blade being initially inserted too deeply and applying pressure to the posterior aspect of the left cricoarytenoid joint. This patient\'s anterior arytenoid dislocation was treated conservatively using speech therapy with resolution occurring approximately 40 days postoperatively. On the 74th day after surgery, fibroscopic examination confirmed recovery and healing of the dislocation. However, other types of arytenoid dislocations and laryngeal injuries may require alternative treatment. Early consultation with an otolaryngologist is recommended if arytenoid dislocation is suspected.