During airway surgery, the anaesthetist may be required to manipulate or withdraw the endotracheal tube. Traditional surgical head drapes often make access to the tube difficult, therefore limiting control of the airway and risking de-sterilisation of the surgical field. We report a new method of draping for major neck operations that permits easy access to the endotracheal tube while maintaining sterility of the operative field.

Severe stridor of recent onset is a challenge to deal with because of the lack of investigations on which to base the management plan. We describe a case of an elderly lady who presented to us with a short history of severe stridor. We encountered unanticipated difficulties with tracheostomy under local anaesthesia as the thyroid was replaced by a diffuse mass and the airway had to be secured by an awake fibre-optic intubation. Awake fibre-optic intubation is thought to be a relative contraindication in acute upper airway obstruction, but occasionally tracheostomy under local anaesthesia may not be possible and in experienced hands an awake fibre-optic intubation is a reasonable alternative.

Background and objective: The study aimed to evaluate and improve airway management in the prehospital setting, i.e. physicians working on board ambulances. A quality control programme focusing on anaesthesia was instituted to improve the time taken to perform endotracheal intubation.

Methods: All consecutive patients requiring tracheal intubation were prospectively analysed before (first period) and after the training programme focusing on anaesthetic protocols for tracheal intubation (second period). The number of attempts at laryngoscopy, the time taken to achieve tracheal intubation, the difficulties encountered and the related complications of the anaesthetic technique were recorded. At the end of the first period, the results were reported to the whole staff of the unit and the anaesthesia protocols were then modified by introducing succinylcholine into the induction sequence, as part of a training programme.

Results: Two-hundred-and-eighty patients were evaluated (97 in the first period, 183 in the second). All patients were successfully intubated in both periods. The percentage of difficult intubations (as assessed by the physician) was lower in the second period (20 versus 35%, respectively; P < 0.01). The success rate at the first attempt was significantly higher (74% [68–80] 95% CI versus 55% [45–65] 95% CI, P < 0.01) and the duration of intubation was significantly shorter in the second period than in the first (1.4 ± 3.2 vs. 4.1 ± 6.7 min, respectively; P < 0.001). The incidence of complications (hypoxaemia, laryngospasm, bronchospasm) was lower in the second period (15 versus 31%, P < 0.01).

Conclusions: The time to perform tracheal intubation can be improved by the introduction of succinylcholine into the prehospital anaesthetic protocol. Rapid sequence induction should be taught as a way of improving tracheal intubation in the prehospital setting.

The intubating laryngeal mask airway is a modification of the conventional laryngeal mask and is used as a tool for difficult intubation. It can be inserted without placing the head and neck in the Magill position and has been used successfully in cervical spine injuries. Reported is a case of successful insertion of the intubating laryngeal mask and subsequent intubation through it in a patient with ankylosing spondylitis with cervical involvement resulting in a fixed flexion deformity who underwent coronary artery bypass grafting.

Background and objective: To evaluate the ease with which successful insertion of a laryngeal mask airway can be performed in comparison with endotracheal intubation by medical personnel wearing chemical protective equipment.

Methods: Anaesthetists and non-anaesthetists (each n = 20) participated in the prospective comparative trial in an animal laboratory. The time and success rates of laryngeal mask airway vs. endotracheal tube insertions were measured as performed on anaesthetized monkeys.

Results: The results showed that the laryngeal mask airway was inserted more rapidly than the endotracheal tube by both groups (3.6 s and 28.6 s, P < 0.0001). Failed intubation occurred in 35% (anaesthetists) vs. 55% (non-anaesthetists) (P = 0.17).

Conclusions: In view of the 100% success rate of insertion even in unfavourable conditions, the possible role of the laryngeal mask airway in the scenario of a toxic mass casualty event should be considered.

Background and objective: To compare the application of the cuffed oropharyngeal airway and the laryngeal mask airway on anaesthetized adult patients undergoing minor outpatient surgery.

Methods: One hundred patients received intravenous fentanyl, propofol and N2O for the induction and maintenance of anaesthesia. The patients were randomly divided into two groups: a cuffed oropharyngeal airway group (n = 50) and a laryngeal mask airway group (n = 50). After insertion of the device, fibreoptic laryngoscopy was attempted and the degree of success scored. We then compared the first application success rate of both procedures while judging airway intervention requirement, fibreoptic scores, adverse airway events and haemodynamic tolerance.

Results: Both devices had an almost similar first-time placement rate (cuffed oropharyngeal airway 84% versus laryngeal mask airway 96%). The cuffed oropharyngeal airway required a higher number of airway interventions (P < 0.001). The laryngeal mask airway had a significantly better fibreoptic view compared with the cuffed oropharyngeal airway (P < 0.001). However, the number of adverse airway events was lower in the cuffed oropharyngeal airway group; there were no significant differences in adverse events and haemodynamic variables between the said two groups.

Conclusions: The results suggest that the cuffed oropharyngeal airway was an effective alternative airway in spontaneously breathing patients during short procedures.

Background and objective: The effects of remifentanil, alfentanil and fentanyl were compared on cardiovascular responses to laryngoscopy and endotracheal intubation in morbidly obese patients.

Methods: Eighty morbidly obese ASA I–II patients were included in the study. Patients were randomly divided into four groups to receive either 1 μg kg−1 fentanyl (Group F), 10 μg kg−1 alfentanil (A), 1 μg kg−1 followed by an infusion of 0.5 µg kg min−1 remifentanil (R) or saline (P). The patients corrected weight was used to calculate the drug doses. Body mass indices (range) were: 54.3 ± 7.37 (49–78.4), 55.67 ± 7.44 (48.5–78.4), 53.17 ± 5.36 (48.1–63.2), and 56.3 ± 6.09 (46.6–67.7) kg m−2, in Groups F, R, A and P respectively. Systolic, diastolic and mean arterial pressures and heart rate were measured non-invasively at three time points, which were 2 min before induction, 2 min after induction and 2 min after endotracheal intubation.

Results: After induction of anaesthesia, arterial pressures decreased significantly in all groups, but the decrease was more pronounced in Groups A and R. After induction, heart rate decreased significantly in all groups except in Group P. After intubation, haemodynamic responses were similar in the remifentanil, fentanyl and alfentanil groups and were within normal limits. In Group P, arterial pressures and heart rates were significantly higher.

Conclusions: Alfentanil, fentanyl and remifentanil in the doses described had similar effects in controlling the haemodynamic response to tracheal intubation in ASA I–II morbidly obese patients.

Background and objective The intubating laryngeal mask is designed to act as a ventilatory device and as an aid to blind tracheal intubation in adults. The aim of this study was to evaluate the efficacy of the intubating laryngeal mask for ventilation of the lungs and tracheal intubation in children using video-endoscopic control.

Methods The handling and efficacy of the size 3 intubating laryngeal mask for tracheal intubation in 80 children weighing ≥ 25 kg were assessed under video-endoscopic control. Ease of intubating laryngeal mask insertion, adequacy of lung ventilation through the intubating laryngeal mask and airway sealing pressures were recorded. Tracheal intubation was performed blindly by the intubator, while the supervisor observed the procedure on the video display. If blind intubation failed at the first attempt, the monitor view was used to guide the tracheal tube into the trachea. The success rate and time required for successfully placing the tracheal tube were recorded.

Results Insertion of the intubating laryngeal mask was easy in all children. Lung ventilation through the intubating laryngeal mask was uniformly excellent. Blind tracheal intubation at the first attempt was successful in 53 children (66%) within 18.8 ± 4.1 s. Twenty-four of the 27 failed blind intubation attempts were successfully intubated with video-endoscopic guidance within 28.6 ± 9.4 s. Two children required replacing the intubating laryngeal mask, one child had to be intubated conventionally.

Conclusions The size 3 intubating laryngeal mask provides an airway that is easy to establish in children ≥ 25 kg with excellent ventilation conditions and allows blind tracheal intubation at the first attempt with a high success rate. Endoscopic monitoring improves its safety and intubation success rate.

Muscle relaxants are given as part of a rapid-sequence induction to facilitate tracheal intubation. Among all the muscle relaxants available, succinylcholine is the only one with a fast (≅1 min) onset and a fast recovery. Therefore it is still the most frequently used muscle relaxant for rapid-sequence induction despite its well-known side-effects. The short duration of action of succinylcholine is, however, no substitute for aggressive airway management in the case of an unexpectedly difficult intubation in order to prevent life-threatening hypoxia. A preoperative assessment of the airway is mandatory in any patient and may indicate the need for using intubation techniques without a muscle relaxant. Rocuronium in large doses (i.e. ≥1 mg kg−1) is an alternative to succinylcholine in a classical rapid-sequence setting under relatively light anaesthesia. With respect to rapid tracheal intubation, the timing and priming principles offer little advantage over the use of rocuronium in doses of 0.6 mg kg−1 in combination with an appropriate induction technique (i.e. including an opioid) or over the use of larger doses of rocuronium (≥1.0 mg kg−1) under relatively light anaesthesia, and may even be potentially harmful.

In contrast to rocuronium, the use of rapacuronium in a rapid-sequence setting has been associated with dose-dependent respiratory side-effects that limit its usefulness in doses higher than 1.5 mg kg−1 for this indication.

The choice of hypnotics and opioids for rapid-sequence induction, and the use of premedication, is influenced by the choice of the muscle relaxant. Anaesthetic agents have a major influence on the quality of intubation when rapid-sequence induction is achieved without a muscle relaxant. Premedication is important, along with a high dose of propofol (2.5 mg kg−1 or more) and a short-acting opioid such as alfentanil (30–40 μg kg−1) or remifentanil (up to 4 μg kg−1). It has also been demonstrated that i.v. lidocaine can improve intubating conditions. When a muscle relaxant is used, the choice of the anaesthetic agents depends on the onset of action of the relaxant. With a rapid-acting compound such as rocuronium at a dose of 0.6 mg kg−1, the hypnotic agents need to be supplemented with only a small dose of opioids, e.g. alfentanil 10–20 μg kg−1. When succinylcholine, rocuronium 1.0 mg kg−1 or rapacuronium 1.5 mg kg−1 are used, excellent intubating conditions may be obtained by relatively smaller doses of hypnotic agents even without opioids; however, haemodynamic and intraocular pressure changes are better controlled when small doses of opioids are administered.

Backgound and objective A postal survey was conducted in order to investigate current practice in airway management amongst Dutch anaesthetists and to investigate the role of recent training and the role of an ‘Access to the Airway’ airway management course.

Methods A questionnaire containing 27 questions was sent to all practising anaesthetists in The Netherlands. Questionnaires were returned anonymously and were analysed using the Pearson χ2-test (P < 0.05) with the SPSS® version 8.0 statistical software program.

Results The response rate was 42%. Of the respondents, 78% claim often or always to assess the expected degree of difficulty in tracheal intubation as part of routine preoperative assessment. The American Society of Anesthesiologist’s Difficult Airway Algorithm was used by 19% of respondents. A wide variety of airway management techniques is being used. In 36% of all general anaesthetics a laryngeal mask airway is used. In 1.1% of all general anaesthetics tracheal intubation is performed with the flexible fibrescope.

Conclusions Dutch anaesthetists, who commenced anaesthetic training after 1988, and those who attended the airway management course ‘Access to the Airway’ are significantly more likely to follow the American Society of Anesthesiologist’s Difficult Airway Algorithm and to use adjunctive techniques for airway management.

Rapacuronium is a new non-depolarizing relaxant with a fast onset and rapid recovery. It was approved for the market in the United States in August 1999. The reasons for its acceptance in practice and the niche it fills are the subject of this review. Rapacuronium has been accepted wherever rapid onset and short duration of action are advantageous. It has received the greatest acceptance in brief outpatient procedures that require tracheal intubation. The average time of recovery to a train-of-four ratio of 80% is about 25 min after a usual intubating dose of 1.5 mg kg−1, when block is reversed. Its rapid onset has led some to use it in rapid-sequence induction, but the exact place in this scenario is still being defined. Its spontaneous recovery is rapid enough that many practitioners do not reverse the block if the procedure is long enough. Data suggest that this is reasonable after 60 min and may even be earlier, even 30 min, if verified by monitoring. The main adverse effects of rapacuronium are bronchospasm, hypotension and tachycardia. Of these, only bronchospasm has had significant clinical impact. These effects are dose related and the recommended dose of 1.5 mg kg−1 may keep problems to a minimum. Because rapacuronium is a new drug with unique properties its use gradually increased in its first year. Because of the problems associated with succinylcholine, rapacuronium may have advantages for brief outpatient procedures and in cases where rapid termination of block is desired, provided its adverse effects can be minimized.

Difficult airway management represents a challenge in anaesthesia. In the last decades airway difficulty awareness has improved as a result of better anticipation and decision-making. Airway algorithms and protocols have a more prominent role in training and in clinical anaesthesia practice. In addition, several new instruments and therefore new techniques have been developed. These have improved possibilities for the clinician to secure the airway. Clinicians should become familiar with this equipment and techniques by using them on a regular basis in elective cases. The instruments available must be selected by the characteristics of the patient population, the local circumstances and the experience of the anaesthesiologist. The aim of this paper is to provide some practical guidelines with respect to airway difficulty predictors and airway instrument choice.

Background and objective The intubating laryngeal mask (intubating laryngeal mask airway) was designed to facilitate blind intubation. Its value as an adjunct to fibreoptic laryngoscopy has not been evaluated. This study compares the intubating laryngeal mask airway with the standard laryngeal mask airway as conduits for fibreoptic laryngoscopy.

Methods The fibreoptic view of the laryngeal inlet was graded via both devices in 60 anaesthetized patients. The fibreoptic view through the intubating laryngeal mask airway was assessed after the central epiglottic elevator bar had been lifted out of the field of vision by an 8-mm Euromedical® tracheal tube, which was inserted to a depth of 18 cm. The fibreoptic view from the aperture bars of the laryngeal mask was recorded.

Results The vocal cords were viewed less frequently through the intubating laryngeal mask airway (52%) than through the laryngeal mask airway (92%) [difference = 40% (95% CI = 26% to 54%), P < 0.0001].

Conclusion The view of the laryngeal inlet is better through the laryngeal mask airway than through a tracheal tube inserted to 18 cm in the intubating laryngeal mask.

Background and objective Minimal- and low-flow anaesthesia (fresh gas flow below 1 L min−1) provide many advantages, including reduced cost, conservation of body heat and airway humidity. An airtight seal is essential between the airway device and the airway of the patient. Therefore, we investigated whether the airtight seal created by a laryngeal mask airway allows controlled ventilation of the lungs when the fresh gas flow is reduced to 0.5 L min−1 and compared this with an endotracheal tube.

Methods In a prospective clinical study, 207 patients were managed using a laryngeal mask or an endotracheal tube. After intravenous induction of anaesthesia and 15 min of high fresh gas flow, the flow was reduced to 0.5 L min−1. The breathing system was monitored for airway leaks, and the patients were assessed for complications after airway removal and postoperative discomfort.

Results Both the laryngeal mask and endotracheal tube allowed fresh gas flow reduction to 0.5 L min−1 in 84.7% and 98.3% of cases respectively (small leaks: 12% laryngeal mask, 1.7% endotracheal tube). Three patients with the laryngeal mask (3.3%l) had airway leaks that were too large to permit any reduction in the fresh gas flow.

Conclusions The use of the laryngeal mask airway was more likely to be associated with a gas leak than use of an endotracheal tube; however, if modern anaesthesia machines and monitors are used, in 96.7% of the patients managed with a laryngeal mask a reduction in the fresh gas flow to 0.5 L min−1 was possible. The incidence of coughing and postoperative complaints (sore throat, swallowing problems) was higher after use of an endotracheal tube.

Background and objective Situations may occur in anaesthetic practice where the use of neuromuscular blocking drugs is unsuitable or contraindicated. We investigated the use of propofol given 5 min after fentanyl to permit endotracheal intubation in children. Methods We studied the intubating conditions and cardiovascular parameters in 60 ASA I and II children. Intravenous midazolam (0.1mgkg−1) was given as premedication 5 min before the induction of anaesthesia. The children received different doses of propofol (group I, 2.5mgkg−1; group II, 3.0mgkg−1; group III, 3.5mgkg−1) preceded by fentanyl (3.0 μgkg−1) given 5 min earlier. No neuromuscular blocking agents were administered. The intubating conditionswere assessed using a four-point scoring system based on the degree of difficulty of laryngoscopy, the position of vocal cords and the intensity of coughing.

Results Tracheal intubating conditions were adequate in 20% of the patients in group I, in 75% of the patients in group II and in 80% of the patients in group III (P < 0.05 for group I vs. groups II and III). Haemodynamic changes were not significantly different between the groups.

Conclusions Propofol (3.0mgkg−1) preceded by fentanyl (3.0 μgkg−1) was adequate for the induction of anaesthesia in children and provided adequate tracheal intubating conditions without significant haemodynamic changes. This method represents a useful alternative technique for tracheal intubation when neuromuscular blocking drugs are contraindicated or should be avoided.