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Background The Mallampati examination is a standard component of an airway risk assessment. Existing evidence suggests that cervical spine extension improves the predictive power of the Mallampati examination for detecting difficult laryngoscopy and tracheal intubation, but a comparative effectiveness study has not been conducted. Methods The extended Mallampati examination (EMS) was introduced to the standard preoperative airway assessment, in addition to the standard Modified Mallampati examination (MMP). This study compared the accuracy of both Mallampati examinations on the prediction of difficult laryngoscopy, tracheal intubation, and bag mask ventilation. Univariate and adjusted analyses were performed. Results 80 801 patients with recorded MMP and EMS, and subsequent glottic view obtained during direct laryngoscopy, were examined. There was increased specificity (88.7% cf. 81.9%) but reduced sensitivity (33.3% cf. 45.7%) in the detection of difficult direct laryngoscopy with use of the EMS. The area under the receiver operating characteristic curve of each test performed in combination with other airway predictors for the models predicting difficult laryngoscopy was 0.740 (95% CI 0.731–0.753) for MMP and 0.739 (95% CI 0.729–0.752) for EMS. The area under the receiver operating characteristic curve of each test, performed in combination with other airway predictors for the models predicting difficult intubation was 0.699 (95% CI 0.688–0.711) for MMP and 0.695 (95% CI 0.683–0.707) for EMS. Conclusions This retrospective observational study demonstrates that cervical extension improves the specificity but decreases sensitivity of Mallampati examination. The Mallampati evaluation should be performed with the cervical spine in the neutral position to maximize test sensitivity.

Background and objectives Recognizing the risk of fire during laser procedures involving the airway, the American Society of Anesthesiologists (ASA) developed recommendations designed to promote safe practice and reduce burn injuries. The aim of this study was to identify how reported anesthetic management of airway laser endoscopies in pediatric patients aligns with the ASA Practice Advisory (ASA-PA). Methods An online survey was created in an iterative process, pilot-tested, and distributed using the Society for Pediatric Anesthesia's (SPA) membership email list. Responses were analyzed using descriptive statistics. Results Responses from 322 respondents were included, 296 (92%) of whom participated in pediatric laser airway procedures. Fifty-nine respondents (20%) reported the use of an inspired fraction of oxygen (FiO 2 ) of 90% or greater during laser activation in patients with a native airway, and 101 (34%) reported not waiting after the reduction of the FiO 2 and laser activation in the airway. Sixty-four (36%) of respondents reporting the use of a non-laser-safe tube during laser airway cases did so due to a lack of availability of a laser specific tube or size limitations. Six respondents (2%) reported an airway fire during a laser procedure in a child under their care. Conclusions Our results indicate that, in general, pediatric anesthesiologists do not adhere to the ASA-PA in several important aspects. Possible explanations might be knowledge deficiencies about the Practice Advisory or a perceived limited clinical applicability in the pediatric setting. Regardless, airway fires during laser airway surgeries in this population do occur, emphasizing the need for safe practice standards for both anesthesiologists and surgeons.