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   Table of Contents - Current issue
Coverpage
January-April 2021
Volume 4 | Issue 1
Page Nos. 0-68

Online since Thursday, April 29, 2021

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AIRWAY FELLOWSHIP  

Airway Fellowship p. 0
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EDITORIAL Top

Back to the drawing board – The culture of reflective practice Highly accessed article p. 1
Venkateswaran Ramkumar
DOI:10.4103/arwy.arwy_19_21  
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REVIEW ARTICLES Top

The physiologically difficult airway Highly accessed article p. 4
Bhavya Vakil, Nishanth Baliga, Sheila Nainan Myatra
DOI:10.4103/arwy.arwy_10_21  
The physiologically difficult airway is defined as one in which severe physiologic derangements place patients at increased risk of cardiovascular collapse and death during tracheal intubation and transition to positive pressure ventilation. Patients with a physiologically difficult airway can be divided into those who are critically ill and those who are not. The critically ill patient with a physiologically difficult airway may present with hypoxaemia, hypotension, right ventricular failure, metabolic acidosis and neurologic injury. Noncritically ill patients with a physiologically difficult airway are patients who are obese, paediatric, pregnant or at risk of aspiration during tracheal intubation (after a meal, with gastroesophageal reflux disease, intestinal obstruction, etc). Recognition of this high-risk group of patients is essential to implement measures to avoid complications during tracheal intubation. Unlike the anatomically difficult airway, where placing the endotracheal tube safely within the trachea is the primary goal, in patients with a physiologically difficult airway, prevention of adverse events is equally important during airway management. Strategies to prevent complications associated with physiologically difficult airway include measures to improve the chance of first-pass success, effective peri-intubation oxygenation and measures to avoid hypotension and haemodynamic collapse.
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Innovations in drug-device combinations for delivering medication to the airways Highly accessed article p. 13
Jyothsna Manikkath
DOI:10.4103/arwy.arwy_15_21  
Airway drug delivery is an effective mode of delivery of drugs for local action in the respiratory tract or for producing faster systemic effect of drugs that have poor oral bioavailability. However, pulmonary drug delivery is incredibly challenging. This article discusses the various types of drug delivery devices, their advantages and limitations. Drugs for pulmonary delivery are typically aerosolised using devices such as pressurised metered-dose inhalers, dry powder inhalers (DPIs), nebulisers, soft-mist inhalers (SMIs) and their variants. The efficiency of drug therapy is influenced both by the drug formulation and the drug-device combination. Further, efficacy of the inhaler and its correct use by the patient are critical issues. Besides the drug component, the incorporation of propellants and other adjuvants in the formulation has been analysed from the perspectives of patient safety and environmental pollution. These devices have evolved with time bringing the advances in technology for use. Feedback mechanisms and particle engineering have been tried and tested.
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SPECIAL ARTICLE Top

A magical journey into knowledge creation in emergency difficult airway access - Planning your journey with ‘research genie’ p. 21
Ramesh A
DOI:10.4103/arwy.arwy_12_21  
This article is the second of a 4-article series intended to ignite the minds of readers and empower them to create new knowledge in the context of ‘emergency difficult airway access'. The aim of this series is to empower readers to create product/process/paradigm/position innovations in emergency difficult airway access for better care of humanity. The reader is familiarised with an educational smart phone-based application - Research Genie. The application has been designed and created by St. John's Medical College Research Society. The reader will be trained in a stepwise manner to use this application. Study design for each domain-specific objective is described. The most appropriate guideline to ensure quality of the study is stated. Explaining study designs using a domain-specific objective imparts ability to choose the most appropriate study design in a particular domain. Nine domains of healthcare have been explored namely description, laboratory range estimation, incidence/prevalence estimation, evaluating therapies, measuring costs in healthcare, critically evaluating new tests, measuring risk, correlating variables and describing experiences, perceptions and beliefs. Principles of sampling strategy have been explained in a simple and lucid manner.
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ORIGINAL ARTICLES Top

Bedside tracheostomy on COVID-19 patients in the intensive care unit: A retrospective study p. 28
Santosh Kumar Swain, Satyabrata Acharya
DOI:10.4103/arwy.arwy_62_20  
Introduction: Currently, coronavirus disease 2019 (COVID-19) infection is a global challenge to the medical community, often resulting in acute respiratory distress syndrome and respiratory failure needing mechanical ventilation. Tracheostomy is needed for prolonged ventilation as the severity of respiratory failure often escalates, needing extended ventilation in an intensive care unit (ICU). Objective: The objective of study was to evaluate clinical details of performing tracheostomy including patient profile, surgical steps, complications and precautions by health-care workers in the ICU of a specially assigned hospital for COVID-19 patients. Patients and Methods: This is a retrospective study of 22 COVID-19 patients who underwent bedside surgical tracheostomy in the ICU. Patient profile such as age, gender, comorbidities, complication of tracheostomy, ventilator withdrawal after tracheostomy and nosocomial infections of health-care workers related to tracheostomy were analysed. Results: In the study period of 6 months, there were 12,850 COVID-19 patients admitted to our COVID-designated hospital, of whom 2452 patients needed ICU care. A total of 610 patients needed ventilatory support, with 22 patients aged between 42 and 75 years (mean age of 64 years) undergoing a tracheostomy (16 males and 6 females). The median duration from the day of the orotracheal intubation to the day of tracheostomy was 13 days. Conclusion: Surgical tracheostomy on COVID-19 patients is a high-risk aerosol-generating procedure for health-care workers. It should be performed with close communication between otorhinolaryngologists, anaesthesiologists and intensivists, along with adequate personal protective equipment for smooth management of the airway.
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Comparison of clinical performance of Ambu Aura40 laryngeal mask airway with Classic laryngeal mask airway for spontaneous ventilation during elective surgeries under general anaesthesia p. 35
Anusha Raj, Reena R Kadni, Varghese K Zachariah
DOI:10.4103/arwy.arwy_64_20  
Background: Introduction of the laryngeal mask airway (LMA) has revolutionised the practice of anaesthesia. This study compares the clinical performance of Ambu Aura40 LMA with Classic LMA in anaesthetised spontaneously breathing patients in terms of its ease of use and side effects. Patients and Methods: In this prospective randomised controlled study, 176 patients were allocated to either the Classic LMA or Ambu Aura40 LMA group according to a pregenerated block randomisation number sequence with concealment method. The allocated LMA was placed under general anaesthesia without muscle relaxant. The time and ease of insertion were noted in addition to any adverse events. Results: It was observed that Ambu Aura40 LMA and the Classic LMA were positioned successfully in the first attempt in 94% and 81% of patients respectively. The Ambu Aura40 LMA was placed in <12 s in 52% of patients, whereas only 2% of patients in the Classic LMA group could have the device placed within 12 s. Ninety-four percent of Classic LMA and 48% of Ambu Aura40 LMA were placed between 12 and 16 s, respectively. Statistically, a significant difference was noted with time and ease of insertion in between the groups. Conclusion: Ambu Aura40 LMA is better in terms of ease of insertion, with reduced time for insertion and lesser incidence of postoperative sore throat in comparison with Classic LMA.
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CASE REPORTS Top

Delayed tracheal rent following total thyroidectomy p. 41
Avanthi Subramanian, Sunil Rajan, Lakshmi Kumar
DOI:10.4103/ARWY.ARWY_33_20  
Tracheal injury associated with thyroidectomy is rare. We report the case of a 41-year-old lady who underwent total thyroidectomy for multinodular goitre. The surgery was uneventful. On postoperative day (POD) 8, she complained of cough followed by a ‘give-way’ sensation over her neck. On POD 10, she presented with dyspnoea after a sudden bout of cough with blood-tinged sputum, stridor and swelling over the surgical site. Computerised tomographic (CT) scan showed a defect on the right anterolateral wall of the trachea at the level of C6 vertebra and subcutaneous emphysema. She underwent emergency tracheostomy under general anaesthesia. Intraoperatively, a 5 mm × 10 mm tracheal rent was visualised between the first and second tracheal rings over the right side with surrounding unhealthy tracheal cartilages. The defect was closed with strap muscles and surgical tracheostomy performed between the 4th and 5th tracheal rings. In patients presenting with respiratory distress and subcutaneous emphysema following thyroid, mediastinal or anterior cervical approach surgery, a high index of suspicion of delayed tracheal injury must be entertained. An X-ray, and more importantly a CT imaging, may be conclusive to identify the site of tracheal rupture. The decision to follow conservative management or consider urgent surgery will depend on patient presentation.
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Airway management in huge ranula p. 45
Priyanka Dwivedi, Suhas Mall, Shahbaz Ahmad, Santosh Sharma
DOI:10.4103/arwy.arwy_3_21  
Airway management in the presence of a large intraoral swelling is always challenging. We report a young boy with a huge ranula occupying the entire oral cavity and protruding from the mouth. Our planned and strategic approach in a resource-limited setting included prior consultation with the ENT surgeon for aspiration of swelling if needed before intubation. Good topical airway anaesthesia followed by gentle videolaryngoscopy resulted in successful airway management.
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Unanticipated intraoperative airway emergency due to near-total transection of endotracheal tube during partial maxillectomy p. 48
Sunil Kumar Valasareddy, Nikhil Kumar Singh, Gayatri Chaudhari, Aseem Mishra
DOI:10.4103/arwy.arwy_4_21  
Endotracheal tube (ETT) damage during head and neck surgeries is an uncommon complication needing quick corrective action to avoid hypoxia and aspiration of blood into lungs. Our case illustrates an unanticipated complication created during partial maxillectomy by a reciprocating motor saw. Accidental near-total transection of ETT was successfully managed by a novel technique of reintubation guided by an airway exchange catheter placed alongside the damaged ETT.
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Post-traumatic tracheal rupture: Anaesthetic management p. 51
Abhilasha Motghare, Nutan Kharge, Rohan Soitkar, Nirav Kotak, Indrani Hemantkumar
DOI:10.4103/arwy.arwy_67_20  
Traumatic tracheobronchial laceration can be potentially life-threatening and pose significant challenges for anaesthetic management. We would like to share our experience of managing a patient who had traumatic tracheal rupture, multiple rib fractures, bilateral pneumothorax and subcutaneous emphysema. Our presentation will briefly cover the challenges faced with regard to airway management and ventilation options for surgical repair.
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Anaesthetic management of subglottic stenosis in granulomatosis with polyangiitis p. 54
Milin Shah, Hemlata Kapoor
DOI:10.4103/arwy.arwy_9_21  
Granulomatosis with polyangiitis, earlier known as Wegener's granulomatosis, is an autoimmune vascular disorder in which small- and medium-sized vessels are affected. Anaesthetic management depends on the extent to which various organs are involved. Subglottic stenosis can complicate this autoimmune vascular condition which can become a challenging airway situation for anaesthesiologists, particularly when administering general anaesthesia.
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Saviour may not always be a saviour! p. 57
Sanjay Kumar, Shalvi Mahajan, Swati Taneja
DOI:10.4103/arwy.arwy_21_21  
The intubating bougie is commonly used to railroad an endotracheal tube in anticipated or unanticipated difficult intubation. However, literature regarding bougie-induced airway trauma and complications resulting from its use is scarce. We describe a case of a 47-year-old male who suffered head injury following a road traffic accident. With deterioration of his neurological status, tracheal intubation and mechanical ventilation were planned. In view of a possible difficult airway, bougie-guided intubation was attempted. Although the airway was secured at the first attempt with a bougie-guided technique, the patient developed a pneumothorax. Later fibreoptic assessment of the tracheobronchial tree revealed a rent in the posterior wall of left main stem bronchus which was managed conservatively. This case underscores the importance of being cautious while using a bougie to secure the airway and also cautions to limit the number of airway interventions to prevent complications.
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LETTERS TO EDITORS Top

Jaw dislocation at end of anaesthesia – A distressing complication revisited p. 61
S Vyshnavi, S Darshini, N Ashwini, Paayal Chandrashekar
DOI:10.4103/arwy.arwy_56_20  
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The ‘hide and seek’ game of airway behind the COVID-19 mask: A new caution for anaesthesiologists p. 63
Reena Ravindra Kadni, K Varghese Zachariah
DOI:10.4103/arwy.arwy_63_20  
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Mucus plug masquerading as an intratracheal mass identified prior to incidental urologic surgery p. 65
Uma Hariharan, Anuj Pandey, Shivpriya PN, Hemant Kumar Goel
DOI:10.4103/arwy.arwy_66_20  
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Volume control mode: Guide for positioning of laryngeal mask airway p. 67
Preety Mittal Roy
DOI:10.4103/arwy.arwy_5_21  
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XII NATIONAL AIRWAY CONFERENCE Top

XII National Airway Conference  
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