OBJECTIVE: The objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an Intensive Care Unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018.
METHODS: Prospective, observational study comparing all intubations performed in our ICU over 2 periods: pre-protocol (January 2015-January 2019) and post-protocol (February 2019-July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded.
RESULTS: During the study period, 661 patients were intubated - 437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack-Lehane ≥ 2b in 7.6% vs. 29.8%, p < 0.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs. 17.4%, p < 0.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (p = 0.508). We did not find significant differences in complications between the periods studied.
CONCLUSIONS: Intubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients.
An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment.
1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management.
Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Various modifications of the Macintosh blade and direct laryngoscopy have been incorporated into practice to improve the intubation success rate and avoid complications while ensuring patient safety. This study evaluates the usefulness of two different direct laryngoscopy methods used by operators with various level of experience in the Intensive Care Unit.
In a single centre prospective study, C-MAC and Macintosh laryngoscopes were compared in terms of laryngoscopy and intubation outcomes such as glottic visualization, number of intubation attempts, intubation success and satisfaction score.
During the one-year study period, 263 patients were evaluated and data of 218 patients were analyzed. The rate of successful first attempt intubation was higher in the video laryngoscope group (VL) (84% vs 57%; P<0.001). A significantly greater number of patients in the Macintosh laryngoscopy group had difficult visualization of the glottis in terms of the modified Cormack and Lehane classification and Percentage of Glottic Opening scale.
The use of video laryngoscope for intubation in ICU settings results in better visualization of the glottis and a higher incidence of successful intubation attempts.

Treacher Collins syndrome (TCS), Franceschetti-Zwahlen-Klein, or mandibulofacial dysostosis, is a rare disorder of craniofacial development (incidence of approximately 1:50.000 live births). TCS is relevant to the anaesthetist because it can cause difficulties in airway management. A case report is presented of a 24 year-old woman who was referred to our institution for facial reconstruction surgery in two stages. In both surgeries Airtraq™ was essential for airway management. By presenting this case, it is intended to show that planning, communication and teamwork are indispensable for patient safety.

OBJECTIVE: Little information about the performance of videolaryngoscopes outdoors is available. We aimed to test the hypothesis that a Macintosh direct laryngoscope would perform less well than videolaryngoscopes under difficult environmental conditions (high-altitude glacier, sun-reflecting snow).
METHODS: After local research ethics committee approval, this randomized controlled trial enrolled 20 physicians who intubated manikins with limited cervical extension mouth opening under 5 conditions: 1) in hospitals (indoors), 2) indoors at a high altitude, 3) outdoors on a glacier in sunlight without sunglasses, 4) outdoors on a glacier with sunglasses, and 5) outdoors on a glacier with the physician and manikin covered with a blanket. The following devices were compared to the Macintosh laryngoscope, McGrath, Airtraq-SP, GlideScope, KingVision, C-MAC-D-Blade, AP Advance Difficult Airway Blade and Bonfils. The main outcome was first-attempt intubation success; secondary outcomes were intubation time, visibility on the screen, and view of the glottis.
RESULTS: The best intubation success rates were observed indoors asnd on the glacier under a blanket. The Macintosh performed better than the videolaryngoscopes under bright sunlight. We observed significant differences in the performance of devices with built-in screens under varying conditions. Wearing sunglasses improved performance with some but not all devices. Intubation times differed significantly between devices, regardless of the environmental condition (P<0.01). Screen visibility differed significantly between conditions and devices.
CONCLUSIONS: Successful intubation with videolaryngoscopes is less likely under bright sunlight conditions. The Macintosh laryngoscope performs better than videolaryngoscopes. Covering the heads of both the physician and the patient with a dark blanket sufficiently overcomes the detrimental effects of sunlight during intubation.
UNASSIGNED: Existe muy poca información sobre la realización de videolaringoscopias al aire libre. Investigamos el rendimiento de una variedad de dispositivos de intubación en comparación con la laringoscopia directa y bajo condiciones ambientales difíciles (glaciar de gran altitud, nieve con efecto reflectante).
UNASSIGNED: Tras la aprobación por el comité local de ética, este estudio aleatorizó a 20 médicos que intubaron maniquíes con limitación en la apertura bucal y en la extensión cervical, bajo cinco circunstancias: 1) en el interior de hospitales, 2) en interiores a la altitud del glaciar, 3) en un glaciar a plena luz solar, 4) en un glaciar con gafas de sol, y 5) en un glaciar, con el médico y el maniquí cubiertos por una manta. Los dispositivos evaluados fueron: laringoscopio Macintosh y los videolaringoscopios McGrath, Airtraq-SP, GlideScope, KingVision, C-MAC-D-blade, APAdvancedifficult- airway-blade y Bonfils. El resultado principal a analizar fue el éxito de intubación al primer intento; y los resultados secundarios el tiempo de intubación, la visibilidad de de la glotis en la pantalla.
UNASSIGNED: Se observó un mayor índice de éxito de intubación en el interior, así como al aire libre en el glaciar cuando se cubría con una manta. El rendimiento a plena luz del día del Macintosh fue superior a la de los videolaringoscopios. En los dispositivos con pantallas incorporadas se percibieron diferencias significativas en condiciones ambientales cambiantes. El uso de gafas de sol mejoró el rendimiento de algunos dispositivos, pero no de todos. El tiempo de intubación difirió sustancialmente entre los dispositivos, independientemente de las condiciones ambientales (p < 0,01). La calidad de visibilidad de la pantalla varió significativamente según las condiciones y los dispositivos.
UNASSIGNED: El laringoscopio Macintosh se comporta mejor que los videolaringoscopios. Las posibilidades de éxito en la intubación con videolaringoscopios es menor en condiciones de luz solar brillante. Cubrir la cabeza con una manta oscura bloquea suficientemente los efectos perjudiciales de la luz solar durante la intubación a pleno sol.

Amyloidosis is a term that involves a group of diseases characterised by deposition of extracellular monoclonal light-chain fibrillar immunoglobulin aggregates in the body, including many organs, with the larynx among them. A case is presented of a 78 year-old man who was referred to our institution for strangulated umbilical hernia treatment. He suffered from progressive hoarseness and dysphagia for 5months. He had a history of primary laryngeal amyloidosis. Awake intubation was performed successful with the King Vision® video-laryngoscopy. Sedation was achieved using a remifentanil infusion and midazolam. Haemorrhagic lesions are caused by deposition of amyloid in and around vessels, resulting in increased vascular fragility. Therefore, anaesthetists should take care in intubating the tracheas of these patients.

Laryngeal cysts are largely asymptomatic and typically described in the context of incidental discovery on routine laryngoscopy. These cysts, in adults are even rarer and can have catastrophic consequences in an anaesthetized patient if airway management is inappropriate. We describe a case of difficult endotracheal intubation and the treatment of an adult patient with an asymptomatic, giant vallecular cyst that was discovered during rapid-sequence induction of general anesthesia in urgent surgery. In conclusion, vallecular cysts can cause extreme problems in securing the airway. It is important to avoid complications associated with repeated attempts at intubation, airway loss, or cyst rupture causing difficulty visualizing vocal cords and aspiration. The use of King Vision® videolaryngoscope is a good alternative in these cases. Close attention to logistics and the immediate availability of an otolaryngologist is vital.

OBJECTIVE: The aim of this observational prospective study was to evaluate the usefulness of TruviewPCD for tracheal intubation in clinical practice, and to provide data for future studies.
METHODS: A study was conducted on 86 consecutive children undergoing ear, nose and throat (ENT) or paediatric procedures under general anaesthesia with tracheal intubation. Children with two or more difficult airway criteria were excluded. A descriptive statistical analysis was performed.
RESULTS: Eighty-three patients were successfully intubated with TruviewPCD. Demographic data: Age 4.9 (2.8) years, weight 19.5 (7.7)kg. Seventy-nine children needed one attempt and four required two attempts at intubation. Time for glottis view and tracheal intubation was 10.8 (5.6) and 30 [27.9-37] seconds, respectively. Eighty-one patients were classified as easy or very easy to intubate, and only two cases were considered difficult. No significant complications were registered.
CONCLUSIONS: TruviewPCD is a good device for paediatric airway management. It would be interesting to have an intermediate blade between size 1 and 2, as the difference between both is too wide.

Lennox-Gastaut syndrome is a childhood epileptic encephalopathy, and is characterized by frequent and difficult to treat seizures associated with mental retardation. The case is presented of a 21 year-old male with Lennox-Gastaut syndrome, with bilateral cervical facet joint dislocation fracture at C6-C7 and spinal canal compression as a result of a fall during a seizure. In this case the management of the difficult airway expected in an awake and uncooperative patient, with cervical spinal cord injury is described. An airway management strategy was proposed, that allowed a rapid and safe airway control with the best possible tolerance and maintaining the neck immobilised, so as not to increase neurological injury. Within this strategy, plan A was defined as inhalation induction with sevoflurane to maintain spontaneous breathing and tracheal intubation with Airtraq®. We believe that the Airtraq® video laryngoscope with inhalational induction with sevoflurane is a valid and effective alternative in the management of expected difficult airway.