Airway Complications in Intubated Versus Laryngeal Mask Airway–Managed Dentistry: A Meta-Analysis

Objective: Serious airway complications can occur with inadequate airway management during general anesthesia (GA). This meta-analysis investigated randomized controlled trials that compared perioperative technique failures and airway complications, including hypoxia, during GA for dentistry using endotracheal intubation or a laryngeal mask airway (LMA) for airway management. Methods: A systematic search of electronic databases and gray literature was completed. Independent reviewers assessed eligibility, performed data extraction, completed risk of bias assessment, and judged the quality of results through Grading of Recommendations, Assessment, Development, and Evaluation. Risk ratios (RRs) for airway complications, with 95% CIs, were calculated. Heterogeneity was quantified using the I2 statistic. Sensitivity and age-subgroup analyses were explored. Results: Six trials were deemed eligible from a total of 9076 identified reports. The airway management intervention for these trials was LMA. Technique failures or effect differences in airway complications were not detected except for postoperative hypoxia, where LMA use had a decreased risk (RR, 0.22; 95% CI, 0.06-0.77; I2 = 0%; moderate quality). A similar effect was seen in the pediatric analysis (RR, 0.10; 95% CI, 0.01-0.84; I2 = 0%; moderate quality). Additionally, LMA use reduced pediatric sore throat risk (RR, 0.08; 95% CI, 0.04-0.15; I2 = 0%; moderate quality). Conclusion: Use of an LMA in dentistry may have the potential to reduce the risk of postoperative hypoxia, particularly in pediatric patients, although further study is required.

Airway Management in Head and Neck Pathology

Studies have demonstrated that poor assessment and planning contribute to airway complications and that current airway assessment strategies have a poor diagnostic accuracy in predicting difficult intubation in the general population. There is a higher risk for difficulties during airway management in patients with pathologies arising from the head and neck region and are more likely to need emergency surgical access. Therefore, thorough assessment and adequate knowledge about the various head and neck pathologies is mandatory. In this chapter, we will briefly go through the preoperative assessment and history & clinical assessment, the investigations. Also we will discuss the airway management at various pathologies involving the head and neck region whether benign/malignant pathologies, OSA (obstructive sleep apnea) and post head & neck operative airway management.

GlideScope® Versus C-MAC® Video Laryngoscopy in Pediatric Intubation. Does Time Matter?

Background: The emergence of video laryngoscopy in the management of pediatric airways has been invaluable as it has been known that these patients are prone to airway complications. Video laryngoscopes are proven to improve glottic view in both normal and difficult airways in pediatric patients. The time taken to intubate using these devices is inconsistent. Objectives: This study was designed to compare the time to intubate using two common video laryngoscopes, C-MAC®, and GlideScope®, aimed at pediatric patients age 3 - 12 years old. Methods: A Randomized controlled trial was conducted in 65 ASA I or II patients, aged 3 - 12 years old who underwent elective surgery using endotracheal tube. They were divided into group 1 patients who were intubated using C-MAC® video laryngoscope versus group 2 patients who were intubated with GlideScope® video laryngoscope. Laryngoscopists were all anesthetists with experience in both C-MAC® and GlideScope® intubation. Time to intubate and intubation attempts were measured. Any extra maneuver, airway complications, and laryngoscopist satisfaction scores were also recorded. Results: Total time to intubate was significantly longer in GlideScope® group than in C-MAC® group (P < 0.001). Both devices managed to achieve excellent glottic views. The first pass attempt success rate was similar between both devices. There was no difference between requirement of extra maneuvers to assist intubations. There were also no adverse events associated with all the intubations. The satisfaction score of anesthetists was comparable to each other. Conclusions: Even though intubation time using GlideScope® is longer, both devices give excellent glottic view, comparable success intubation, and anesthetists satisfaction score.

Carboxymethyl-γ-cyclodextrin, a novel selective relaxant binding agent for the reversal of neuromuscular block induced by aminosteroid neuromuscular blockers: an ex vivo laboratory study

Background Residual neuromuscular block at the end of surgery may compromise the patient’s safety. The risk of airway complications can be minimized through monitoring of neuromuscular function and reversal of neuromuscular block if needed. Effective reversal can be achieved with selective relaxant binding agents, however, sugammadex is the only clinically approved drug in this group. We investigated the concentration–response properties of a novel selective relaxant binding agent, carboxymethyl-γ-cyclodextrin for the reversal of neuromuscular block. We evaluated the hypothesis that it is equally potent for reversing neuromuscular block as sugammadex. Methods Phrenic nerve – hemidiaphragm tissue preparations were isolated from male Wistar rats and suspended in a tissue holder allowing electrical stimulation of the nerve and monitoring of muscle contraction force. Concentration–response relationships were constructed for the neuromuscular blocking agents rocuronium, pipecuronium, and vecuronium. The half-effective concentrations of sugammadex and carboxymethyl-γ-cyclodextrin for reversal of neuromuscular block were determined. Results The half effective concentrations (95% confidence interval, CI) were 7.50 (6.93–8.12) μM for rocuronium, 1.38 (1.33–1.42) μM for pipecuronium, and 3.69 (3.59–3.80) μM for vecuronium. The half effective concentrations (95% CI) of carboxymethyl-γ-cyclodextrin and sugammadex were 35.89 (32.67–39.41) μM and 3.67 (3.43–3.92) μM, respectively, for the reversal of rocuronium-induced block; 10.14 (9.61–10.70) μM and 0.67 (0.62–0.74) μM, respectively, for the reversal of pipecuronium-induced block; and 376.1 (341.9–413.8) μM and 1.45 (1.35–1.56) μM, respectively, for the reversal of vecuronium-induced block. Conclusions Carboxymethyl-γ-cyclodextrin is an effective, but less potent agent for reversal of neuromuscular block than sugammadex.

Large airway complications in COVID-19 pneumonia

COVID-19 pneumonia can cause respiratory failure which requires specialist management. However the inflammatory nature of the condition and the interventions necessary to manage these patients such as endotracheal intubation and tracheostomy can lead to large airway pathology which may go unrecognised. We describe five of the 44 (11%) consecutive patients referred to our specialist ARDS team between April and June 2020 with confirmed COVID-19 pneumonia who developed diverse large airway pathology which comprised of: supraglottic oedema, tracheal tear, tracheal granulation tissue formation, bronchomalacia, and tracheal diverticulum. Large airway pathology may be underappreciated in severely ill patients with COVID-19 pneumonia and should be considered in patients with unexplained air leak, prolonged need for mechanical ventilatory support, and repeated failed extubation or decannulation. If suspected, such patients should be managed by a team with expertise in large airway intervention and early specialist advice should be sought.