Awake intubation is indicated in difficult airways if attempts at securing the airway after induction of general anesthesia may lead to harm due to potential difficulties or failure in those attempts. Conventional awake flexible bronchoscopic intubation is performed via the nasal, or less commonly, oral route. Awake oral flexible bronchoscopic intubation (FBI) via a supraglottic airway device (SAD) is a less common technique; we refer to this as 'supraglottic airway guided' FBI (SAGFBI). We describe ten cases with anticipated difficult airways in which awake SAGFBI was performed. After sedation and adequate airway topicalization, an Ambu AuragainTM SAD was inserted. A flexible bronchoscope, preloaded with a tracheal tube, was then inserted through the SAD. Finally, the tracheal tube was railroaded over the bronchoscope, through the SAD and into the trachea. The bronchoscope and the SAD were carefully removed, whilst keeping the tracheal tube in-situ. The technique was successful and well tolerated by all patients, and associated complications were rare. It also offered the advantages of performing an 'awake test insertion' of the SAD, an 'awake look' at the periglottic region, and an 'awake test ventilation.' In certain patients, awake SAGFBI offers advantages over conventional awake FBI or awake videolaryngoscopy. More research is required to evaluate its success and failure rates, and identify associated complications. Its place in difficult airway algorithms may then be further established.

Introduction: The management of head and neck surgical patients is associated with increased morbidity and mortality, and so anticipating the difficult airway is important. Methods: We undertook a prospective survey on consecutive adult patients scheduled on the elective operating lists of four head and neck consultant surgeons. Data were collected over a 36 month period. Data included: patient characteristics; routine predictors of difficulty in airway management (bedside tests of the airway, a history of previous surgery or radiotherapy and the presence of airway symptoms); laryngoscopy grade; method of anaesthesia and airway management; and any airway complications arising during induction of anaesthesia and extubation. Results: The ‘study’ group consisted of 818 patients. The ‘direct laryngoscopy’ group contained 674 patients, that is, patients who had direct laryngoscopy and could therefore be classified as easy or difficult intubation. The prevalence of difficult intubation was 12.6%. Factors or tests that were statistically significantly associated with difficult intubation were: history of difficult airway; previous head or neck radiotherapy treatment; presence of airway symptoms; presence of moderate or severe limited neck movement; and short interdental distance. The sensitivity, specificity and positive predictive values were: history of difficult airway 16.5%, 98.6% and 63.6%; previous radiotherapy 12.9%, 96.6% and 35.5%; airway symptoms 42.9%, 69.6% and 15.9%; moderate/severe neck limitation 16.7%, 97.2% and 46.7%; Mallampati score 3 or 4, 38.8%, 83.8% and 25.8%; and interdental distance 9.4%, 98.8% and 53.3%, respectively. The Bonfils intubation fibrescope was the most commonly used indirect laryngoscopy device (63.9% of all such cases). Twenty-six patients (3.2%) had complications during their initial airway management after induction of anaesthesia. There was one case of ‘cannot intubate, cannot oxygenate’, which required an emergency tracheostomy. Conclusion: The prevalence of difficult intubation in head and neck surgical patients was higher than in the general population, but predictive tests for difficult intubation have poor to moderate value. In our study, rates of difficult face mask ventilation, failed intubation and complications during induction and extubation were low. However, serious morbidity, although rare, can still be encountered. Head and neck surgical patients can be managed safely in a tertiary centre where there is appropriate surgical and anaesthetic expertise in managing difficult airways.

The use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU). An online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed. A large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB. PRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.