Pre-oxygenation is the key step prior to endotracheal intubation, particularly in a critically ill patient, to prevent life-threatening peri-procedural hypoxemia. This narrative review explores the emerging interest of Non-Invasive Positive Pressure Ventilation (NIPPV) as a pre-oxygenation modality in the intensive care unit (ICU) context. We reviewed data from randomized controlled trials (RCTs) and observational studies published from 2000 to 2024 that compare NIPPV to conventional oxygen therapy and High Flow Nasal Cannula Oxygen (HFNCO). The pathophysiological mechanisms for the successful use of NIPPV, including alveolar recruitment, the decrease of shunting, and the maintenance of functional residual capacity, were reviewed in depth. Existing studies show that NIPPV significantly prolongs the apnea time, reduces the rate of peri-intubation severe hypoxaemia in selected patients and is especially effective for patients with acute hypoxaemic respiratory failure. Nevertheless, appropriate patient selection is still crucial because some diseases can contraindicate or even be harmful with NIPPV. We further discussed the practical aspects of how to use this ventilatory support (the best ventilator settings, which interface, and when to apply it). We lastly discuss unanswered questions and offer suggestions and opportunities for future exploration in guiding the role of NIPPV use in the pre-oxygenation of the critically ill patient requiring emergent airway management.

PURPOSE OF REVIEW:This review examines the evolution of the pharmacological approach to rapid sequence induction/intubation (RSII) over the past 55 years, highlighting recent advances and contemporary perspectives on managing full-stomach patients requiring airway control. RECENT FINDINGS:While aspiration remains a significant concern during RSII (occurring in 3-6% of cases), recent data suggests that desaturation, hypoxemia, and hemodynamic instability pose even greater risks, particularly in critically ill patients. Modern RSII approaches have evolved significantly from Safar's original protocol. Cricoid pressure is increasingly questioned, with evidence suggesting it may be unnecessary except when active regurgitation is observed. Gentle ventilation postinduction appears safe and beneficial when desaturation risk is high. Regarding pharmacology, succinylcholine has largely been replaced by rocuronium, while ketamine and etomidate are preferred over propofol for hemodynamically unstable patients. glucagon-like peptide 1 agonists may increase residual gastric content but have not definitively been linked to increased aspiration rates. First-pass success (currently ~84%) is crucial, as complications increase exponentially with multiple attempts. SUMMARY:Contemporary RSII should balance aspiration prevention with avoiding hypoxemia and hemodynamic collapse. This requires thorough patient assessment, appropriate drug selection, optimal positioning, and effective teamwork. The priority should be making the first intubation attempt the best possible attempt, with preintubation optimization and consideration of human factors.

Objective. The competency of using video laryngoscopes (VL) for double-lumen tube (DLT) endobronchial intubations can be improved with constant training as assessed by measuring the learning curves. We hypothesized that the time to DLT intubation would be reduced over the intubation attempts. Design. A crossover manikin study. Settings. University-affiliated hospital. Participants. Forty-two novice medical students unfamiliar with DLT intubation. Interventions. Participants were randomly allocated to two sequences, including DLT intubation, using King Vision and McGrath VLs. Each participant completed 100 DLT intubation attempts on both simulated easy and difficult airways on two different mannikins using the study devices (25 attempts for each). Measurements and Main Results. The primary outcome was the time to DLT intubation. The secondary outcomes included the best glottic view, optimizing maneuvers, and intubation first-pass success. The use of King Vision VL was associated with a significantly shorter time to DLT intubation (P < 0.044 and P < 0.05, respectively) and a higher percentage of glottic opening (POGO) compared to the McGrath VL (P < 0.011 and P < 0.002, respectively) in the simulated "easy" and "difficult" over most of the intubation attempts. In the simulated "easy" airway, the first-pass success ratio was higher when using the King Vision VL (median [Minimum-Maximum] 100% [100%-100%] and 100% [88%-100%], P = 0.012). Conclusion. Novice medical students developed skills over intubation attempts, meaning achievement of a faster DLT intubation, better laryngeal exposure, and higher success rate on simulated "easy" and "difficult" airways. A median of 9 DLT intubations was required to achieve a 92% or greater DLT intubation success rate.

Background Airway management for thoracic surgery represents a high risk setting for SARS-CoV-2 infection diffusion due to complex and invasive airway instrumentation and techniques. Results An 18-item questionnaire was submitted to the 56 members of the Thoracic subcommittee of the SIAARTI Cardio-Thoraco-Vascular Research Group to provide a snapshot of current situation and national variability of devices and procedures for airway management during the COVID-19 pandemic. The response rate was 64%. Eighty-three percent of anesthetists declared that they modified their airway management strategies. The Hospital Management considered necessary to provide a complete level 3 personal protective equipment for thoracic anesthetists only in 47% of cases. Double-lumen tube and bronchial blocker were preferred by 53% and 22% of responders to achieve one-lung ventilation respectively. Over 90% of responders considered the videolaryngoscope with separate screen and rapid sequence induction/intubation useful to minimize the infection risk. Thirty-nine percent of participants considered mandatory the bronchoscopic check of airway devices. Vivasight-DL was considered comfortable by more than 50% of responders while protective box and plastic drape were judged as uncomfortable by most of anesthetists. Conclusions The survey reveals many changes in the clinical practice due to SARS-CoV-2 outbreak. A certain diffusion of new devices such as the VivaSight-DL and barrier enclosure systems emerged too. Finally, we found that most of Italian hospitals did not recognize thoracic anesthesia as a high-risk specialty for risk of virus diffusion.

Massive hematemesis could be challenging situation requiring emergency airway control and urgent surgical treatment. We report a case of difficult airway management with blind intubation through Laryngeal Mask Airway in a 56-year-old patient with massive hematemesis. After failed endoscopic attempts to stop bleeding, worsening of hemodynamics called for emergency intubation and surgery. After failed intubation attempts and face-mask ventilation worsening, a classic LMA was used for rescue ventilation and decision was made to intubate through LMA. The airway exchange was aided by a nasogastric tube (NGT) through LMA, confirmed with capnography and surgery was started successfully and uneventfully. Unexpected difficult airway can be extremely challenging situation, especially in emergency settings with no possibility to delay surgery. In those cases, literature suggests different intubating techniques through LMA. Blind intubation through LMA aided by NGT showed to be a suitable option in resources-limited settings, where advanced supraglottic devices and/or optical devices are not available.

The programme promotes and encourages all departments to increase the use of nonpharmacological procedures (cryotherapy, physiotherapy and positioning of extremities) and focused on consequent prescription of pain medication and established standardised ‘pro re nata’ or ‘as needed’ prescription of analgesics. These efforts reduced the analgesics usage in our clinic additionally. The main objective of changes in pain management is to improve the quality of pain management. Limited hospital budgets have an increasing impact on pain management programmes these days. Our pain management improvement programme leads to an increase in oral analgesics and an increase in the usage of nonpharmacological pain treatments. All through this programme, we discovered decreasing total analgesic expenses. Because of the observational study design, we cannot prove a causative relation between the programme and the observed cost reduction. Nevertheless, these findings should encourage other clinics to initiate programmes to revise their institutional pain management. A major portion of analgesic expenses is often generated by only a few drugs, licensed for parenteral pain treatment. A change from i.v. to oral pain medication as well as avoiding expensive drug preparations (e.g. fixed-dose i.v. combination of orphenadrine and diclofenac, Fig. 2) can help to flatten the analgesics costs. For the detailed analgesics cost analysis, the ABC analysis helps to point out drugs with economic importance.

BACKGROUND Unpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially if difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common clinical screening tests have shown low sensitivity and specificity with a limited predictive value. Ultrasound-based airway assessment has been proposed recently as a useful, simple, noninvasive bedside tool as an adjunct to clinical methods, but to date, few studies are available about the potential role of ultrasound in difficult airway evaluation, and these are mostly limited to specific groups of patients. OBJECTIVES The aim of this study was to determine the correlation between the sonographic measurements of anterior cervical soft tissues thickness and Cormack-Lehane grade view at direct laryngoscopy in patients with normal clinical screening tests. DESIGN Prospective, single blinded, observational study. SETTING Operating theatre of a teaching hospital from May 2017 to September 2017. PATIENTS A total of 301 patients at least 18 years of age undergoing elective surgery under general anaesthesia with tracheal intubation were included in the study. OUTCOME MEASURES Pre-operative evaluation was performed before surgery, demographic variables were collected and clinical screening tests to predict a difficult airway were performed. Patients with predicted difficult intubation were excluded. A 10 to 13-MHz linear ultrasound transducer was placed in the transverse plane and the thickness of the anterior cervical soft tissues was measured at two levels (thyrohyoid membrane (pre-epiglottic space) and vocal cords (laryngeal inlet)] with the patient's head in a neutral position. At each level, the distance from the skin in the median axis and the surrounding area was measured. The laryngoscopic view was graded by a different anaesthetist with more than 5 years of experience with direct laryngoscopy, blinded to the ultrasound assessments. RESULTS The 'pre-epiglottic space thickness' at the level of thyrohyoid membrane was measured as the median distance from skin to epiglottis (mDSE) and the pre-epiglottic area was calculated; the mDSE cut-off value of 2.54 cm (sensitivity 82%, specificity 91%) and the pre-epiglottic area cut-off value of 5.04 cm(2) (sensitivity 85%, specificity 88%) were the best predictors of a Cormack- Lehane grade at least 2b at direct laryngoscopy and of difficult intubation. The cut-off value of mDSE showed greater sensitivity in female patients (94 vs. 86%) and greater specificity in male patients (92 vs. 83%). No correlation was found between difficult laryngoscopy and ultrasound assessments at the level of the vocal cords. CONCLUSION Airways ultrasounds might be considered as a predictor of restricted/difficult laryngoscopy and unpredicted difficult intubation.

Ultrasounds represent one of great innovations in the field of medicine in the last century; thanks to technological development, instrumentation design and portability, they became widespread used in many fields of medicine, including anesthesia. Apart for consolidated role for central venous lines placement and for regional anesthesia, where they succeeded to reduce complication rate while increasing performance, they are now more and more frequently used also for airway management, for different purposes. They are powerful tools for second level airway assessment, with reference to evaluation of anatomy and difficult airway management prediction; they are also used for tube position confirmation (especially in the field of emergency), for cricothyroideal membrane identification, for evaluation of glottic diameter prior to extubation, for airway devices position evaluation (such as LMA), for tube size choice (especially in pediatric patients), for preprocedural evaluation during tracheostomy and for endobronchial diagnosis of lung pathology. Principal applications of ultrasounds in airway management, including literature analysis and identification of evidence based indications are discussed. Acta Medica Medianae 2018;57(2):113-118.