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   Table of Contents - Current issue
January-April 2023
Volume 6 | Issue 1
Page Nos. 0-41

Online since Thursday, April 20, 2023

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Airway Fellowship p. 0
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About Medknow p. 0
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Airway Flier p. 0
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Artificial intelligence in airway management and anaesthesia Highly accessed article p. 1
Sohan Lal Solanki
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Predictive machine learning algorithms in anticipating problems with airway management p. 4
Muthapillai Senthilnathan, Pankaj Kundra
Machine learning is artificial intelligence (AI) which can predict the output variable with the fed input features. This allows computers to learn from experience without being programmed. The outcome variable in machine learning algorithm may be continuous variable or categorical variable. Supervised machine learning is commonly applied artificial intelligence (AI) in medical field. Decision tree, gradient boost machine (GBM) learning, extreme GBM (XGBM), Support vector machine, K nearest neighbour and multi-layer perceptron are few machine learning algorithms which are being utilised to address the classification and regression problems. Though the incidence of difficult intubation (DI) is rare, occurrence of such event in an unanticipated situation can result in development of arrhythmias due to desaturation and cardiac arrest if not intervened on time. It is preferred to choose the physical parameters that can predict the difficult airway more accurately in clinical scenario and train the algorithm rather than including all the non-specific parameters. Body mass index (BMI) [>30 kg.m-2: anticipated difficult mask ventilation (DMV), direct laryngoscopy (DL) and DI], inter-insicor distance (IID) (<2 cm: anticipated DL), modified Mallampati (MMP) (Grade 1 and 2: Ease of intubation; Grade 3 and 4: anticipated DI), temporomandibular distance (TMD) (<6.5 cm - anticipated DI), restriction of neck extension (if present: anticipated DL and DI), receded mandible (if present: anticipated DL and DI), and poor submandibular space compliance (if present: anticipated DL and DI) parameters which are used to predict DA by clinical assessment, can be used to feed to train the machine learning algorithm. Despite using these sophisticated tools, extubation may fail and patients require reintubation in ICU. It is very challenging to assess the lung compliance in spontaneously breathing patients as compliance will be overestimated due to generation of negative pressure. Cause for which patient has been placed on mechanical ventilation is resolved/resolving, BMI (>30 kg.m-2), intact sensorium (absence of delirium), absence of consolidation, absence of copious secretions, oxygenation status (PaO2/FiO2: >250), ventilation status (paCO2: 30-45 mmHg), measure of work of breathing (respiratory rate, rapid shallow breathing index), heart rate and blood pressure during spontaneous breathing trial (SBT) and diaphragmatic thickness fraction can be used as input features to predict the success of extubation in critically ill patients. With widespread utility of applications in medical fraternity, applications for prediction of difficult airway (or for weaning success) can be programmed which can be accessed by the clinicians to predict DA, thereby all the preparations for managing DA may be done to prevent adverse consequences of unanticipated difficult airway.
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Comparison between dexmedetomidine and fentanyl on intubating condition to facilitate awake oral fibreoptic intubation under topical anaesthesia – A randomised controlled trial Highly accessed article p. 10
Vishnu Panwar, Sushil Krishnan, Anil Kumar Sharma
Background and Aims: Awake fibreoptic intubation (AFOI) is the standard method of airway management in the anticipated difficult airway. While many drugs have been employed for sedation, there is no single drug that can be recommended as the drug of choice. Dexmedetomidine is characterised by effects of sedation, analgesia, amnesia and lack of respiratory depression. Hence, we hypothesised that dexmedetomidine should be suitable for AFOI and compared it to the control drug fentanyl. This study assesses the level of sedation and intubating conditions using dexmedetomidine or fentanyl during awake fibreoptic orotracheal intubation. Methods: Sixty adult patients, American Society of Anaesthesiology class I and II, who required orotracheal intubation during general anaesthesia with the normal airway were randomised to receive dexmedetomidine 0.6 μg/kg (Group A) or fentanyl 1.0 μg/kg (Group B) intravenous infusion for 10 min, after topical anaesthesia to the airway. A total of 60 patients were allocated, 30 patients in each group. The primary objective was to assess the intubating conditions with dexmedetomidine compared to fentanyl. Results: The intubation score for vocal cord movement (1.57 ± 0.68 in Group A vs 1.93 ± 0.75 in Group B) and cough (1.50 ± 0.78 in Group A vs 1.90 ± 0.72 in Group B), endoscopy score (2.17 ± 0.59 in Group A vs 2.47 ± 0.69 in Group B), sedation score (4.73 ± 0.5 in Group A vs 4.47 ± 0.57 in Group B) and patient satisfaction score (1.20 ± 0.41 in Group A vs 1.47 ± 0.68 in Group B) were statistically significant in patients receiving dexmedetomidine. During the procedure, there was a statistically and clinically significant increase in heart rate of 1.5% in Group A versus 22% in Group B, and an increase in mean arterial pressure of 1.95% in Group A versus and 10.27% in the Group B. Conclusion: Dexmedetomidine provided better intubation conditions than fentanyl, with greater haemodynamic stability, better sedation and greater patient satisfaction score compared to fentanyl during awake fibreoptic oral intubation.
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Standard technique versus rotational technique of insertion of Baska mask® p. 17
Sheetal , Seema Jindal, Gurkaran Kaur Sidhu, Swati Jindal, Sandeep Kaur
Background and Aims: Baska Mask® is a new third-generation supraglottic airway device (SGAD). The placement of Baska Mask® using the standard technique causes posterior displacement of the tongue, leading to incorrect positioning and insertion failure. The rotation technique may alleviate this obstacle during insertion by decreasing resistance between the airway and tongue. The primary objective of this study was to compare the insertion time between the standard versus rotational technique of Baska Mask®, and the secondary outcome measures were ease of insertion, number of attempts and postoperative airway morbidity with both techniques. Methods: One hundred consenting adults of the American Society of Anaesthesiologists I-II, aged 20–65 years of either gender scheduled for a variety of surgical procedures under general anaesthesia in a tertiary care hospital (May 2019 to November 2020), were included in the study. The patients were randomly allocated to Group S and Group R using the standard and rotation techniques, respectively. All statistical analyses were done using the SPSS (Statistical Package for the Social Sciences) software. The comparison of quantitative variables between the study groups was done using the Student's t-test and Mann–Whitney test. For comparing categorical data, the Chi-square χ2 test was performed. Results: The mean insertion time was significantly higher with the standard compared to the rotation technique of Baska Mask (20.90 ± 3.13 vs. 14.84 ± 1.11 s, P = 0.000). Device insertion was easy in rotation compared to the standard technique (P = 0.031). The number of attempts required for insertion was more with the standard technique than with the rotation technique (P = 0.011). Conclusion: Although the standard technique of Baska Mask® remains the first choice, the rotational technique of Baska Mask® has a higher success of insertion with fewer complications than the standard technique; hence, it can be accepted as an alternative.
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Anaesthetic concerns in a case of spasmodic dysphonia p. 23
Priya Rudingwa, Rajasekar Ramadurai, Banupriya Ravichandrane, Kishore Kumar Madhanagopal
Spasmodic dysphonia (SD) is a voice disorder resulting from involuntary laryngeal muscle movements. An anaesthesiologist might encounter patients with SD arriving for surgical treatment of the primary pathology or other surgical procedures. One must exercise caution while providing anaesthesia to such patients and consider any factor that may precipitate airway obstruction. Symptoms might get exacerbated following anaesthesia involving airway intervention that might warrant immediate airway control. Airway techniques that have minimal manipulation and vigilant observation of the patient for any symptom of airway compromise postextubation are recommended. SD, though manifesting just as a voice change, has a significant impact on anaesthesia management, and as an anaesthesiologist, one should be aware of its implications while handling these patients.
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Direct laryngoscopy-assisted flexible bronchoscopic intubation in a difficult airway p. 26
Harshal D Wagh
Neck masses may distort the airway and make even fibreoptic intubation difficult. A large mass may prevent the negotiation of a flexible bronchoscope beyond the obstruction. A combined direct laryngoscopy-assisted flexible bronchoscopy must be considered an option that can help intubation in select difficult airway situations and may prove lifesaving as it did in this case.
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Bronchoscopic guided intubation through laryngeal mask airway in a patient with ankylosing spondylitis p. 29
Senthilkumar Praveenkumar, Hemlata Kapoor, Deepika Malapaka
Patients with ankylosing spondylitis present with airway difficulties. There are various techniques to secure a definitive airway for general anaesthesia in these patients. We report the case of an ankylosing spondylitis patient with fixed neck deformity for laparoscopic bilateral inguinal hernia repair surgery managed with an Ambu® AuraGain™ laryngeal mask (LM) insertion and followed by a fibreoptic bronchoscopic-aided endotracheal tube insertion for definitive airway through the LM airway according to the All India Difficult Airway Association guidelines.
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Unanticipated difficult intubation due to tracheal stenosis in an adult patient posted for Whipple's surgery p. 32
Pooja K Subbiah, Jitendra S Bapat, Manju T Butani, Arpit P Sharma
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Regularly irregular 'missed mandatory breath' leading to abnormal capnographic waveform p. 34
Lenin Babu Elakkumanan, Mekala Ranjith Kumar, Muthapillai Senthilnathan
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Airway management in an infant with congenital laryngeal web and subglottic stenosis p. 36
Deepak Singla, Barkha Bharati, Priya Thayyile Kandy
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Fishing for a needle in a haystack! retained swivel knife in the adenoids of patient posted for endoscopic septoplasty with inferior turbinate reduction p. 38
Anirudh Elayat, Vinayak Chandran
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Difficult airway management in a case of Lemierre's syndrome with diabetic ketoacidosis p. 40
Karthik Lakshmikanth, Ankur Sharma, Bharat Paliwal, Harshavardhan Kuri
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