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We herein report two expected difficult intubation cases that failed with an angulated-type video laryngoscope (C-MAC D-blade) and were rescued with a channelled-type Airtraq® device. The common signs and characteristics which indicated difficult ventilation and intubation in these patients were Mallampati 4 (with phonation), mandibular protrusion of B, obstructive sleep apnoea disorder, male gender, and thick neck (>46 cm). We had aids ready in the operating theatre for the anticipated difficult intubation. We first attempted to intubate the trachea in two patients with direct laryngoscopy; as expected, the Cormack-Lehane (CL) grades of the two patients were 4, even cricoid pressure was applied. Second, we attempted to intubate with the angulated-type C-MAC D-blade; the CL grades improved to 2. However, despite tube adjustment manoeuvres and use of a rigid stylet, we were unable to insert the tube into the trachea. Then, we attempted to intubate with a channelled-type Airtraq® device. Consequently, without need for a stylet or use of any manoeuvres, we were able to intubate the tracheas at the first attempt.

Background: Pediatric patients with congenital heart diseases may have pathological airway abnormality and delayed development. To predict the appropriate size of endotracheal tube (ETT), a formula between diameter and age has been widely used for Western normal children. However, it is unclear whether this age-based (AB) formula is applicable to Thai pediatric cardiac patients. Objective: Evaluate the effectiveness of uncuffed ETT size by AB formula for pediatric cardiac patients. Methods: A retrospective study was conducted using 320 cases of non-cardiac and cardiac patients aged 2-7 years old who were orally intubated with a regular uncuffed ETT at Siriraj Hospital, Thailand. The exclusion criteria were history of tracheostomy, upper airway obstruction, and expected difficult intubation. Demographic data and final ETT used were recorded. Results: The tube- size predicted by the AB formula could be applied to 54.4% of non-cardiac and 48.1% of cardiac patients (p= 0.314), whereas three sizes of tubes (one above and one below the predicted size) covered 96.9% and 94.4% of non-cardiac and cardiac patients, respectively (p = 0.413). The ETT with 0.5 mm in ID larger than the predicted size were more often used in 35.0% of cardiac patients compared with 22.5% of non-cardiac patients (p= 0.019). There were no significant differences between methods using age (actual, round-up, and truncated) to calculate the AB formula. The Pearson’s correlation between the ID of the ETT with height in non-cardiac and cardiac patients were 0.430 and 0.683, respectively (p

Although standard management of an expected difficult intubation is based on fibre-optic techniques, the application of optical laryngoscopes such as Airtraq is gaining widespread acceptance. We here describe a case where an intubation attempt with the Airtraq laryngoscope was not only unsuccessful, but negatively influenced subsequent use of a flexible fibroscopic approach.

Background Optimal head and neck positioning and clinical experience are important factors for successful endotracheal intubation in patients with a difficult airway. This study aimed to investigate the rate of successful endotracheal intubation between the sniffing and ramped positions in patients with an expected difficult intubation. Methods The study included 204 patients with an expected difficult intubation (airway difficulty score ≥ 8) based on the preoperative airway assessment. The patients were randomized into the following groups: group S was placed in the sniffing position, and group R was placed in the ramped position during direct laryngoscopy. The primary outcome was successful endotracheal intubation and the secondary measure was laryngeal view in the ramped or sniffing position when the operating table was placed at two different heights. Results Group R showed a higher rate of successful endotracheal intubation and better laryngeal view than group S (P < 0.05). The rate of successful endotracheal intubation was higher in group R than in group S at both heights of the operating table; but, it was not different within each group. Laryngeal view was not different between the two groups and within each group when the two heights of the operating table were used. Fully trained and experienced attending anesthesiologists achieved a higher rate of successful endotracheal intubation than less experienced residents in group R (P < 0.05) but not in group S. Conclusions Ramped position and clinical experience can be important factors for laryngeal view and success rate of endotracheal intubation in patients with an expected difficult intubation.

Airway management is important during general anesthesia. Difficulty with a direct laryngoscopy can be routinely successfully managed using a laryngeal mask airway. However, a laryngeal mask airway may not be suitable for the patients having a small oral cavity volume or narrow interincisor distance. A 19-year-old man, scheduled for right clavicular fracture had no specific underlying medical problems. However, he had difficultly opening his mouth, and was Mallampati class IV. Also, he had difficultly in extending his neck. Airway management was successfully performed using a laryngeal tube instead of a laryngeal mask airway. The patient was successfully managed, without complications, until the end of the surgery.