Summary: Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy–hypoxaemia–re‐oxygenation cycles can escalate to airway loss and the ‘can't intubate, can't ventilate’ scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high‐flow humidified oxygen, initially to provide pre‐oxygenation, and continuing as post‐oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive‐pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw‐thrust. Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25–81]) years. The median (IQR [range]) Mallampati grade was 3 (2–3 [2–4]) and direct laryngoscopy grade was 3 (3–3 [2–4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9–19 [5–65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post‐apnoea end‐tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9–15.3]) kPa. The rate of increase in end‐tidal carbon dioxide was 0.15 kPa.min ⁻¹ . We conclude that THRIVE combines the benefits of ‘classical’ apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow‐dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop–start process to a smooth and unhurried undertaking.

Background— Myocardial and renal injury commonly contribute to perioperative morbidity and mortality after abdominal aortic aneurysm repair. Remote ischemic preconditioning (RIPC) is a phenomenon whereby brief periods of ischemia followed by reperfusion in one organ provide systemic protection from prolonged ischemia. To investigate whether remote preconditioning reduces the incidence of myocardial and renal injury in patients undergoing elective open abdominal aortic aneurysm repair, we performed a randomized trial. Method and Results— Eighty-two patients were randomized to abdominal aortic aneurysm repair with RIPC or conventional abdominal aortic aneurysm repair (control). Two cycles of intermittent crossclamping of the common iliac artery with 10 minutes ischemia followed by 10 minutes reperfusion served as the RIPC stimulus. Myocardial injury was assessed by cardiac troponin I (>0.40 ng/mL), myocardial infarction by the American College of Cardiology/American Heart Association definition and renal injury by serum creatinine (>177 μmol/L) according to American Heart Association guidelines for risk stratification in major vascular surgery. The groups were well matched for baseline characteristics. RIPC reduced the incidence of myocardial injury by 27% (39% versus 12% [95% CI: 8.8% to 45%]; P =0.005), myocardial infarction by 22% (27% versus 5% [95% CI: 7.3% to 38%]; P =0.006), and renal impairment by 23% (30% versus 7%; [95% CI: 6.4 to 39]; P =0.009). Multivariable analysis revealed the protective effect of RIPC on myocardial injury (OR: 0.22, 95% CI: 0.07 to 0.67; P =0.008), myocardial infarction (OR: 0.18, 95% CI: 0.04 to 0.75; P =0.006) and renal impairment were independent of other covariables. Conclusions— In patients undergoing elective open abdominal aortic aneurysm repair, RIPC reduces the incidence of postoperative myocardial injury, myocardial infarction, and renal impairment.

Advances in our understanding and practice of airway management necessitate contemporary guidelines for tracheal intubation. The Difficult Airway Society (DAS) therefore produced recommendations to improve the efficacy and safety of tracheal intubation. We conducted a systematic review and a three-round Delphi process to formulate multidisciplinary, evidence-based, expert consensus recommendations. We invited 20 external experts to guide recommendations on emergency front-of-neck airway and engaged DAS members and 16 international airway experts to provide feedback. Twelve members of the guidelines group participated in 65 meetings over 3 years, and 1241 papers were included after a systematic review. Sixty-five recommendations were made in relation to tracheal intubation. These included airway assessment and planning; peroxygenation; postintubation care; rapid sequence induction and intubation; the physiologically difficult airway; obesity; human factors; point-of-care ultrasound; documentation; and education and training. We maintain the concept of a linear algorithm encompassing tracheal intubation (Plan A); supraglottic airway device ventilation (Plan B); facemask ventilation (Plan C); and emergency front-of-neck airway (Plan D). The recommendations prioritise continuous oxygen delivery throughout airway management; maximising the likelihood of successful tracheal intubation at the first attempt; confirmation of ventilation with waveform capnography; progressing through the algorithm in the event of failure; multidisciplinary teamwork; and ongoing education and training. These guidelines are designed to support clinicians in delivering airway management that prioritises efficacy and safety. Overall, we emphasise the importance of maximising the chances of success, rather than the avoidance and management of failure, to improve outcomes for patients undergoing airway management.