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   Table of Contents - Current issue
Coverpage
January-April 2020
Volume 3 | Issue 1
Page Nos. 1-56

Online since Saturday, May 30, 2020

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EDITORIAL  

First do no harm p. 1
Dilip Pawar
DOI:10.4103/ARWY.ARWY_16_20  
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REVIEW ARTICLES Top

Anatomy of infant larynx and cuffed endotracheal tubes p. 4
Josef Holzki
DOI:10.4103/ARWY.ARWY_17_20  
The anatomy of the infant larynx has been discussed since 1897. Mainly, anatomists have described the particulars of the paediatric airway and have laid the base for tube selection for safe intubation of infants. The findings were similar to what anaesthesiologists, paediatric ENT-surgeons and airway endoscopists encountered in daily practice. However, since 2003, radiologists challenged the findings of anatomists, paediatric ENT-surgeons and airway endoscopists by using radiologic modalities (such as computed tomographic scans and magnetic resonance imaging) to propose quite different anatomical forms of the infant larynx. They thought that the outlet of the cricoid ring was oval shaped and that the funnel shape of the larynx had its narrowest part at the glottic level. This can be found neither in endoscopic investigations nor in fresh autopsies, the most realistic approach to the anatomy of the infant larynx. These aspects will be thoroughly discussed in this article.
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Patient positioning and glottic visualisation: A narrative review Highly accessed article p. 13
V R Hemanth Kumar, Nandhakumar Janani, Maurya Indubala, Velraj Jaya
DOI:10.4103/ARWY.ARWY_3_20  
Optimal glottic view is a prerequisite for successful endotracheal intubation. Several factors such as height of pillow, head position, backup position and head-elevated laryngoscopy position (HELP) have been attributed to improve glottic view. This review of existing literature was conducted to summarise current evidence on the influence of different head positions on glottic view. The search engines used were PubMed, Cochrane Library, Google Scholar and ResearchGate. Keywords used for the search were sniffing position, HELP, backup position and glottic view. The two components of optimal sniffing position used traditionally for laryngoscopy include neck flexion of 35° and face-plane extension of 15° which is supposed to align three axes (oral, pharyngeal and laryngeal axes). Optimal height of pillow used to achieve sniffing position was found to be 9 cm. Since it is difficult to align all the three axes, the two-curve theory was proposed. Advantage of the sniffing position was questioned by various authors who projected the HELP and 25° backup position as better options. Our narrative review suggests that 25° backup and HELP position improves glottic view in comparison to supine sniffing position. To achieve alignment of external auditory meatus to the sternal notch, a small child required a small pillow, an older child or an adult required a bigger pillow and obese patients needed the ramped position/25° head-up position.
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SPECIAL ARTICLES Top

Probability and inferential statistics p. 19
Rakesh Garg, S Bala Bhaskar, Sabyasachi Das, SS Harsoor
DOI:10.4103/ARWY.ARWY_13_20  
Application of statistical tools is essential for appropriate understanding of the collected data in clinical trials. The types of variables for the study are also decided in advance and the relevant statistical tools identified in the planning stage of the study. The tests applied also depend on the distribution of data and hence this assessment needs to be done before application of a particular statistical tool. The variables are summarised to better understand the large pool of collected data, done using descriptive statistics. To compare this summarised data across different study groups, inferential statistics are required. Inferential statistics provide the significance of differences (e.g., P value and confidence intervals) helping the researchers and readers to confirm the differences among the groups. Strong methodology and clinical knowledge of the chosen research question should form the background for statistical analysis. We provide a brief review of the basic statistical tools, including probability and inferential statistics.
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Overcoming the airway eclipse in coronavirus disease 2019 (COVID-19) pandemic p. 25
Heena Garg, Shailendra Kumar, Yudhyavir Singh, Puneet Khanna
DOI:10.4103/ARWY.ARWY_9_20  
Coronavirus disease 2019 (COVID-19) has reached pandemic proportions, with a large number of patients succumbing to the disease and numerous requiring airway interventions. It is imperative in these challenging times for medical personnel involved in airway management and general care of these patients to know about the complexities involved and what additional precautions need to be taken while securing the airway.
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ORIGINAL ARTICLE Top

Neonatal laryngeal disorders: 12-year experience of a multidisciplinary team p. 31
Swati Upadhyay, Femitha Pournami, Sujith Kumar Reddy Gurram Venkata, Shibily Rahman, Anand Nandakumar, Jyothi Prabhakar, Jayakumar R Menon, Naveen Jain
DOI:10.4103/ARWY.ARWY_8_20  
Background: Anatomical, developmental and functional disorders of the larynx and trachea in neonates are a not so uncommon clinical conundrum that may require confirmation with fibreoptic visualisation. The Level IIIB Neonatal Intensive Care Unit of our referral hospital has been associated with an established laryngology service for several years. Aims: The objective was to study the clinical and videolaryngoscopic findings of neonates who required a laryngology consultation. Patients and Methods: This retrospective descriptive study included all neonates who were referred for laryngology evaluation over a 12-year period from 2006 to 2018. The indications for referral, clinical findings and management essentials were retrieved from electronic medical records. Clinical details of 90 infants are described. Results: The most common need for evaluation was stridor, most of whom were diagnosed to have laryngomalacia. Specific surgical interventions were performed according to diagnoses. Tracheostomy was performed with no complications in 12 infants. The absence of neurological concerns and bronchopulmonary dysplasia increased the chances of successful decannulation in the first 2 years of life. Conclusions: Stridor and laryngomalacia are common grounds for seeking subspeciality cross-consultations. Availability of expertise, trained nursing staff and parent–education programmes can improve outcomes.
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CASE REPORTS Top

Airway management in a ‘rigid man’ with severe ankylosing spondylitis p. 35
Sujata S Rawlani, Joseph N Monteiro, Shalini G Saksena
DOI:10.4103/ARWY.ARWY_32_19  
Fibreoptic-guided intubation is the gold standard in managing both the anticipated and unanticipated difficult airway. We report a 34-year-old male, a case of severe ankylosing spondylitis for 10 years which was progressive in nature, posted for elective left-sided hip replacement followed a week later by right-sided hip replacement. The patient had a fixed spine with absent lumbar and thoracic curvatures and had a mouth opening of <1 cm. The neck was fixed in flexion and rotated slightly towards the right as a result of the deformity. Our plan of anaesthetic management was to secure the airway by awake nasal intubation using fibreoptic bronchoscope followed by general anaesthesia. The ultimate challenge was to secure the airway using the fibreoptic bronchoscope in this patient with a flexed and stiff neck. We successfully managed this case using a Portex® north-polar tube placed nasotracheally in the awake state following topical anaesthesia. Based on our experience, we believe that such a procedure should be considered in other similar situations.
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Ambu® Auragain™, an alternative supraglottic airway device for airway management in prone position p. 39
Deepak Dwivedi, Vidhu Bhatnagar, Saurabh Sud, Bhavna Hooda
DOI:10.4103/ARWY.ARWY_33_19  
A 24-year-old male, operated at the age of 4 years for congenital meningomyelocoele, later developed kyphoscoliosis and flaccid paraplegia. He presented to us for debridement of a bedsore in the left gluteal region. Such cases can pose a challenge for anaesthesia both because of the higher chances of pulmonary complications due to pulmonary hypertension and severe restrictive lung pathology and increased sensitivity to muscle relaxants. This case highlights the successful airway management in the prone position with Ambu® AuraGain™, a second-generation laryngeal mask airway, which completely obviated the requirement of intubation and neuromuscular relaxation for a procedure of short duration without increasing the morbidity.
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Management of difficult airway in Scheuermann's disease with trendelenburg position and conventional laryngoscopy p. 41
Nishith Govil, Bhawna Kakkar, Parag Kumar, Surjyendu Ghosh
DOI:10.4103/ARWY.ARWY_1_20  
Scheuermann's disease is a type of progressive hyperkyphosis that commonly involves lower thoracic vertebrae. Deformity is extreme and rigid due to progressive subtle changes in the vertebral endplates. Such severe form of spinal deformity leads to difficult ventilation and airway management. Strategies for approaching such an airway in a resource-limited environment by using special positioning such as the Trendelenburg position have not been reported before. A number of case reports have elaborated the successful airway management of fixed-flexion deformity with the help of supraglottic airway devices, videolaryngoscopes, fibreoptic endoscopes and surgical airways. To facilitate ventilation and intubation with laryngoscopy using the McCoy blade, the patient was placed in a supine position with wedge supportive rolls under his head, neck and upper torso. However, as this position created difficulty in approaching the airway for direct laryngoscopy, the position of the operating table was modified to 30° Trendelenburg position. This made the approach to the airway very easy for the anaesthesiologist performing intubation. Though fibreoptic intubation and videolaryngoscope-aided intubation would have possibly made the airway approach even easier, in our resource-limited conditions, McCoy levering laryngoscope, intubating laryngeal mask airway and intubating bougie were the only airway equipment available to deal with this situation.
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An alternative method for tracheal stent deployment in malignant tracheo-oesophageal fistula p. 45
Rohini Dattatri, Rakesh Garg, Karan Madan, Vijay Hadda, Anant Mohan
DOI:10.4103/ARWY.ARWY_4_20  
Malignant tracheo-oesophageal fistula, a troublesome complication of oesophageal cancer, often requires placement of airway self-expanding metallic stent (SEMS) for palliation. Devices such as SEMS can be deployed by flexible or rigid bronchoscopy under sedation or general anaesthesia. General anaesthesia is preferred as it not only provides better operating conditions to the pulmonologist but also avoids unnecessary patient movement and coughing during stent deployment which could result in stent displacement. However, general anaesthesia can be complicated by the presence of comorbidities, poor general condition and deranged blood gases. A comprehensive perioperative anaesthetic plan with a team approach can reduce complications. Stent deployment can be difficult in a few cases using conventional techniques such as with a rigid bronchoscope. We describe the anaesthetic management of tracheobronchial stent placement by flexible bronchoscopy which is one of the alternate techniques of stent placement.
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Delayed presentation of negative pressure pulmonary oedema p. 49
Rupinder Kaur, B Naveen Naik, Navneh Samagh, Nimish Singh
DOI:10.4103/ARWY.ARWY_5_20  
Negative pressure pulmonary oedema (NPPO) is a life-threatening complication occurring due to large negative intrathoracic pressures created by inspiration against a closed glottis. Timely diagnosis and management is important to prevent any fatal outcome. Although it presents acutely most of the time, its presentation may rarely be delayed. We present a case of a 21-year-old female weighing 40 kg who developed NPPO 1.5 h after warding in the post-anaesthesia care unit. Despite the delayed presentation, she was diagnosed in a timely manner and managed successfully. This case emphasises the need for extended monitoring of all patients with any respiratory difficulty in the perioperative period for delayed development of NPPO.
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Anaesthetic management of a child for excision of extensive facial neurofibroma extending to lower neck with airway compression p. 52
Karthik Chandra Babu, Jacob Mathew, Sunil Rajan, Jerry Paul
DOI:10.4103/ARWY.ARWY_10_20  
A 7-year-old girl presented with a large facial plexiform neurofibroma extending from the left infraorbital region downwards up to the manubrium sternum with laryngeal compression. The child was posted for excision of the tumour, which measured 30 cm × 20 cm. Following anaesthetic induction with inhalation agents, a videoscope-assisted nasal intubation was attempted but failed. Fibreoptic-assisted intubation also failed due to inability to railroad the tube into the trachea. Finally, a stylet was passed from the oral route into the trachea under videoscopic guidance, and a 5.5 mm ID endotracheal tube was passed over it. The intraoperative period was uneventful. The patient developed stridor on extubation in the intensive care unit (ICU) on the 1st postoperative day. Due to failed reintubation in the ICU and in view of need for a secure airway during the postoperative period, a tracheostomy was performed. Flexible bronchoscopy under general anaesthesia administered through the tracheostomy 1 week later revealed oedematous vocal cords, and hence decannulation was deferred. Repeat bronchoscopy after another week showed near-normal vocal cords, larynx and subglottic region. The child was then decannulated and had an unremarkable recovery.
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