Disposable laryngoscope blades do not interfere with ease of intubation in scheduled general anaesthesia patients

BACKGROUND AND OBJECTIVE: Intubation of the trachea has been a risky cross-contamination procedure over the past decade because no perfect decontamination procedures exist. Infectious agents found on laryngoscopic devices have the potential for devastating spread of the human immunodeficiency virus, hepatitis viruses B and C and transmissible non-conventional agents. The purpose of this prospective observational study was to assess the quality of endotracheal intubation with disposable laryngoscope blades, under normal intubating conditions. METHODS: Anaesthetists were asked to complete daily questionnaires regarding the difficulty of intubation experienced using the Vital View disposable laryngoscope blade (Vital Signs Inc, Totowa, NC, USA). The choice of the type of blade (conventional or disposable blade) for the first attempt at intubation depended only on the operating room assignment. Glottic visualization during laryngoscopy was assessed by the modified Cormack and Lehane classification. Difficult tracheal intubation was evaluated by the intubation difficulty scale (> 5, procedure involving moderate to major difficulty). RESULTS: The anaesthetic staff recorded 219 intubations. One hundred-and-nineteen of first attempts at laryngoscopy were with disposable blades (DB group) and another 100 with conventional blades (CB group). There were no significant differences between the two groups for Cormack and Lehane score 3, for intubation difficulty scale scores > 5 and for intubation difficulty scale score 0. There were 12 blade changes before successful intubation. CONCLUSIONS: In routine use, the Vital View disposable laryngoscope blade appears to be an efficient device because it does not modify the ease of endotracheal intubation in most cases. Nonetheless, it may be advisable to maintain conventional laryngoscopes in reserve for difficult intubations.     

A ventilation-exchange bougie for fibreoptic intubations with the laryngeal mask airway

The ventilation-exchange bougie is a new airway device which can be mounted on a fibreoptic laryngoscope for passage through the larynx into the trachea via a laryngeal mask airway. Subsequent removal of the fibreoptic laryngoscope and laryngeal mask airway allows a tracheal tube to be railroaded into position over the ventilation-exchange bougie. This study described the use of this technique for elective tracheal intubation in two groups of 12 subjects in whom difficulty with intubation was not expected. All the subjects were successfully intubated by one of two anaesthetists, one experienced and the other inexperienced with fibreoptic intubation techniques. Neither had had prior experience with the ventilation-exchange bougie. Because ventilation was maintained throughout the procedure, intubation did not need to be hurried. Cusum analysis confirmed the impression of a learning curve and the technique could be considered learnt after four and six intubations for the experienced and inexperienced fibreoptic larvngoscopists respectively. No difficulty was found either in intubating the larynx with the fibreoptic laryngoscope and ventilation-exchange bougie or when railroading the tracheal tube over the ventilation-exchange bougie. It is suggested that this new device could have an important role in teaching fibreoptic techniques, management of the difficult airway and failed intubations.     

Use of AirWay Scope for tracheal intubation in bright sunlight

BACKGROUND: The AirWay Scope (AWS), which is equipped with a wide-angle LCD monitor, has been developed to achieve accurate and safe tracheal intubation under various conditions, including emergency settings. However, since bright sunlight degrades the image quality of LCDs, we investigated its usefulness outdoors in bright sunlight. METHODS: A single anesthesiologist intubated a mannequin with an AWS and conventional direct laryngoscope indoors and in sunlight outdoors, using 6 trials for each condition. Success rate, Cormack grade, and intubation time from device insertion to removal were recorded. RESULTS: Indoors, all tracheal intubations with both devices achieved Cormack grade 1 and were successful. Outdoors, all the laryngoscopes achieved Cormack grade 1 and intubation was successful, whereas intubation with the AWS was successful in 3 trials, while 2 esophageal intubations and 1 failure also occurred. In addition, sunlight deteriorated the image quality of the LCD and Cormack grade could not be determined. The intubation times for the AWS and laryngoscope indoors were 8.7+/-1.8 and 17.0+/-6.5 sec, and outdoors were 18.7+/-9.0 and 21.3+/-4.9 sec, respectively. CONCLUSIONS: Our findings indicate that successful tracheal intubation with an AWS is difficult to achieve in bright sunlight.     

Anaesthetic management of two paediatric patients with Hecht–Beals syndrome

We undertook the anaesthetic management of two children with Hecht-Beals syndrome for orthopaedic surgery under general anaesthesia. Both patients had arachnodactyly, kyphoscoliosis, and multiple congenital joint contractures, but limited mandible excursion was not obvious preoperatively in either, although mental retardation made it difficult for them to cooperate with mouth examination. They had no apparent difficulties with their mouths in daily activities. The anaesthesia records of one patient showed that intubation had been difficult in an earlier procedure. The other patient also had a history of difficult intubation, with slight tearing of the corners of her mouth during an intubation procedure. During slow induction of general anaesthesia with sevoflurane, face mask ventilation was easily performed. We attempted to visualize the larynx under anaesthesia with muscle relaxation, but we were unsuccessful because of the limited mouth opening. After several trials, blind oral intubations were fortunately successful in both patients. There were no postoperative problems with the airway.     

Tracheal intubation through the intubating laryngeal mask in patients with unstable necks

BACKGROUND: In patients with unstable necks, the neck should be stabilized during induction of anaesthesia, but this may make tracheal intubation difficult. Awake intubation may produce straining, which could be detrimental to the unstable neck. METHODS: We studied 20 patients with unstable necks to examine the efficacy of insertion of the intubating laryngeal mask under conscious sedation (to minimize the possibility of losing a patent airway and to facilitate fibrescope-aided intubation) followed by tracheal intubation through the laryngeal mask after induction of anaesthesia (to reduce stress response to intubation). After the patient had been sedated with midazolam (up to 5 mg) and fentanyl (up to 100 microg), the intubating laryngeal mask was inserted. General anaesthesia was then induced with sevoflurane and tracheal intubation attempted. RESULTS: In all patients, tracheal intubation through the laryngeal mask succeeded without airway obstruction. Neither insertion of the mask under conscious sedation nor tracheal intubation after induction of anaesthesia caused straining, and only two patients moved upper extremities at intubation. Insertion of the laryngeal mask did not significantly alter blood pressure or heart rate. Tracheal intubation significantly increased blood pressure and heart rate, but the increase was considered to be small. CONCLUSIONS: In the patient with an unstable neck with a low risk of pulmonary aspiration, insertion of the intubating laryngeal mask while the patient is sedated may minimize difficulty in obtaining a patent airway before tracheal intubation and may facilitate a fibrescope-aided tracheal intubation; subsequent induction of anaesthesia before tracheal intubation may minimize stress response to intubation.     

Airway management after failure to intubate by direct laryngoscopy: outcomes in a large teaching hospital

PURPOSE: The purpose of this single-centre database review was to establish the incidence of failure to intubate by direct laryngoscopy, to measure morbidity and mortality associated with this event, and to examine the use and efficacy of alternative airway devices. METHODS: Difficult intubation via direct laryngoscopy at Mayo Clinic Rochester is recorded in an electronic database using a functional classification: 0 = no difficulty; 1 = mild to moderate difficulty; and 2 = severe difficulty often requiring a change in intubation technique. Using this database, the total number of intubations was determined for a selected review period and the incidence of failure to intubate by direct laryngoscopy was established. Abstraction of chart data allowed for determination of associated morbidity and mortality, success of alternative airway devices, and case cancellation rate. RESULTS: During the period from August 1, 2001 through December 31, 2002, 37,482 patients underwent general anesthesia with attempted direct laryngoscopy. One hundred sixty-one patients (0.43%) could not be intubated by direct laryngoscopy alone. Morbidity associated with difficult intubation included soft tissue/dental damage (n = 8), intraoperative cardiac arrest (n = 1), and possible aspiration (n = 1). Three patients required intensive care unit admission. There was no associated mortality. The most commonly used alternative airway device was the flexible fibreoptic scope. Five case cancellations resulted from failure to intubate with alternative devices. CONCLUSION: The rate of unexpected failure to intubate by direct laryngoscopy is essentially unchanged from earlier studies. While morbidity was low, continued education and early use of alternative difficult airway devices may further limit complications associated with this event.     

Orotracheal fibreoptic intubation in children under general anaesthesia

Orotracheal fibreoptic intubation under general anaesthesia in children was studied in eleven consecutive patients of three months to eight-years-of-age without anticipated intubation difficulties. One case report is also included. Three fibrescopes with a different diameter were used in the study. The fibrescope used was chosen so that it fitted snugly in the tracheal tube. The fibreoscopy was prolonged in one patient due to mucus and two tries were needed. Resistance to the tracheal tube upon intubation was encountered in five patients, only one of these patients was older than two years. Fibreoptic intubation succeeded in nine patients. Two patients were intubated with the Macintosh laryngoscope. The problems encountered in children during orotracheal fibreoptic intubation under general anaesthesia are the same as with adults: easy fibreoscopy is not always followed by easy tracheal intubation, there may be prolonged fibreoscopy and failed intubations. Manipulation of the tracheal tube can lead to successful tracheal intubation and resistance to the tube is more common in smaller children.     

Changing patterns in endotracheal intubation for anaesthesia trainees: a retrospective analysis of 80,000 cases over 10 years

Several overseas studies have suggested that opportunities for anaesthesia trainees to learn and practise endotracheal intubation have decreased over time. We analysed the operating theatre data collection system at a large Australian metropolitan teaching hospital from 1998 to 2008 to determine if numbers for trainees' caseloads in general, and endotracheal intubation in particular had changed. The total caseload per trainee of approximately 800 cases per year was stable throughout the study period. The number of gastrointestinal endoscopies per trainee increased significantly with a corresponding decrease in the number of other cases. The mean number of endotracheal intubations per trainee per year fell by 10% and of supraglottic devices by 16%, neither of which was statistically significant. Endotracheal intubation for caesarean sections did however fall significantly from an average of nine to an average of six cases per trainee per year. Our findings contrast with other reports of much larger decreases in the number of endotracheal intubations performed by trainees over the last decade, but suggest that our local practice is similar to the international experience of decreasing opportunities for endotracheal intubation in obstetric anaesthesia.     

Patient and surgery factors associated with the incidence of failed and difficult intubation

Estimates of the rate and risk-factors for difficult airway rarely include a denominator for the number of anaesthetics. Approaches such as self-reporting and crowd-sourcing of airway incidents may help identify specific lessons from clinical episodes, but the lack of denominator data, biased reporting and under-reporting does not allow a comprehensive population-based assessment. We used an established state-wide dataset to determine the incidence of failed and difficult intubations between 2015 and 2017 in the state of Victoria in Australia, along with associated patient and surgical risk-factors. A total of 861,533 general anaesthesia episodes were analysed. Of these, 4092 patients with difficult or failed intubation were identified; incidence rates of 0.52% (2015–2016) and 0.43% (2016–2017), respectively. Difficult/failed intubations were most common in patients aged 45–75 and decreased for older age groups, with risk being lower for patients aged >85 than patients aged 35–44. The risk for failed/difficult intubation increased significantly for: patients undergoing emergency surgery (OR 1.80); obese patients (OR 2.48); increased ASA physical status; and increased Charlson Comorbidity Index. Across all age groups, procedures on the nervous system (OR 1.92) and endocrine system (OR 2.03) had the highest risk of failed/difficult intubation. The relative reduced risk for failed/difficult intubations in the elderly population is a novel finding that contrasts with previous research and may suggest a ‘compression of morbidity’ effect as a moderator. Administrative databases have the potential to improve understanding of peri-operative risk of rare events at a population level.     

difficult airway management: comparison of the bullard laryngoscope with the video-optical intubation stylet

PURPOSE: To evaluate, whether the video-optical intubation stylet (VOIS) was more successful for difficult tracheal intubation than the Bullard laryngoscope (BL). METHODS: An intubation mannequin head was modified so that, using a Macintosh blade size 3, only the epiglottis was visible at direct laryngoscopy, representing a grade III laryngoscopic view. Forty anesthesiologists attempted tracheal intubation using each technique. Tracheal intubation with the Bullard laryngoscope was performed using the attached non-malleable intubating stylet preloaded with an endotracheal tube. The video-optical intubation stylet inserted into an endotracheal tube was used with direct laryngoscopy. During conventional laryngoscopy, the video-view from the stylet tip allowed the tracheal tube to be guided behind the epiglottis into the trachea. Ten attempts with each technique were performed by each anesthesiologist in randomized order. Intubation time, and failed intubation (> 60 sec/esophageal intubation) were recorded. The operators assessed the degree of difficulty of each method using a Likert-scale. RESULTS: Mean intubation time (19.2+/-4.5 sec for the BL and 18.8+/-4.6 sec for the VOIS) was almost the identical. The video-optical intubation stylet was associated with fewer failed intubations (8 vs. 41; P<0.005) and had a lower degree of difficulty (1.7+/-0.65 for the VOIS and 2.6+/-0.74 for the BL; P<0.0001). No correlation was found between the anesthesiologist's experience and mean intubation time, estimated degree of difficulty or number of unsuccessful intubation. CONCLUSION: The video-optical intubation stylet was a more effective and simpler intubation device to facilitate difficult tracheal intubation than the Bullard laryngoscope.     

A simple fibreoptic assisted laryngoscope for paediatric difficult intubation: a manikin study*

The fibreoptic assisted laryngoscope is a new airway device. We compared the fibreoptic assisted laryngoscope with the Bullard laryngoscope, Macintosh laryngoscope and fibreoptic bronchoscope in a manikin with a simulated Cormack and Lehane Grade 4 laryngoscopic view. Eighteen anaesthetists intubated the manikin’s trachea using these devices and the success rate of intubation was measured. They were then asked to rate the subjective difficulty of intubation. The success rate (95% confidence interval) was 100% (94.6–100) with the fibreoptic assisted laryngoscope, 88.9% (80.5–97.3) using the Bullard laryngoscope, 37.0% (24.1–49.9) with the Macintosh laryngoscope, and 22.2% (11.1–33.3) using the fibreoptic bronchoscope. Tracheal intubation using the fibreoptic assisted laryngoscope or Bullard laryngoscope is easier than that using the Macintosh laryngoscope or fibreoptic bronchoscope by subjective difficulty score. All of the intubations were successful with the fibreoptic assisted laryngoscope without practice. These results suggest that fibreoptic assisted laryngoscope may be a useful tool for paediatric difficult intubation.     

Performance des glottiscopes : une étude comparative randomisée menée sur simulateur d’intubation difficile

Introduction

We have prospectively compared simulated-difficult tracheal intubation characteristics of four glottiscopes: Airtraq™, GlideScope™, McGrath™, LMA CTrach™ with that of the conventional Macintosh laryngoscope.

Study design

prospective with the airway devices proposed in a randomly assigned order.

Materials and method

Forty-two physicians, naïve to glottiscope handling accepted participating this study after the learning curve of each airway device was completed. Participants were requested to perform two series of five tracheal intubations on the manikin Airman™, the first in standard situation and the second in difficult tracheal intubation simulation. The airway devices were chosen in a randomly assigned order. For each airway tool, the following tracheal intubation characteristics were recorded: laryngeal exposure quality, tracheal intubation and apnea durations. A performance index was calculated and a tracheal intubation difficulty was measured during simulation.

Results

More than 1600 supervised tracheal intubations were performed, including 1000 for the learning process of the glottiscopes, which was completed after 10 uses on the manikin. During standard situation, laryngeal exposure quality was similar with the five airway devices. As compared to the Macintosh laryngoscope, GlideScope™, McGrath™, tracheal intubation duration was shorter (p < 0.05) with the Airtraq™ and longer (p < 0.01) with the LMA CTrach™. During difficult tracheal intubation simulation, laryngeal exposure and tracheal intubation duration was of better quality and shorter with the four glottiscopes as compared to that of LM, respectively. Performance index during difficult tracheal intubation simulation simulation was significantly more important (p < 0.01) with the Airtraq™ and the LMA CTrach™. Airtraq™ and Macintosh laryngoscope were respectively the simplest (p < 0.01) and the most difficult (p < 0.01) airway devices to manage a simulated difficult tracheal intubation.

Conclusion

When difficult airway was simulated on the manikin, the four glottiscopes were superior to the Macintosh laryngoscope to improve laryngeal exposure quality and to reduce duration of tracheal intubation. Airtraq™ and the LMA CTrach™ both demonstrated remarkable advantage over GlideScope™ and McGrath™ for simulated difficult intubation management.     

The Intubation Difficulty Scale (IDS): Proposal and Evaluation of a New Score Characterizing the Complexity of Endotracheal Intubation

Background: A quantitative scale of intubation difficulty would be useful for objectively comparing the complexity of endotracheal intubations. The authors have developed a quantitative score that can be used to evaluate intubating conditions and techniques with the aim of determining the relative values predictive factors of intubation difficulty and of the techniques used to decrease such difficulties.

Methods: An Intubation Difficulty Scale (IDS) was developed, based on parameters known to be associated with difficult intubation. It was then evaluated prospectively in a group of 311 consecutive prehospital intubations and 315 intubations in an operating room. In the operating room, the IDS was compared with two other parameters: the time to completion of intubation and the visual analog scale (VAS). Time was measured by an independent observer. Operators in both groups completed a checklist regarding the conditions of intubation.

Results: There is a good correlation between the IDS scale and the VAS assessment of difficulty and time to completion of intubation. VAS and time to completion have a significant but lesser correlation to each other. Comparison of IDS with operator-assessed subjective categorical impression of difficulty by Kruskall-Wallis was statistically significant.     

A comparison of fiberoptic-compatible oral airways

Fiberoptic-compatible oral airways (FCOAs) combine the simplicity and benefits that traditional oral airways provide, with the advantage of mechanically guiding fiberoptic intubation. This review examines and compares the salient properties of these devices. Of note, the clinician should pay particular attention to the location and depth of the channel. FCOAs, with an anterior channel, may be advantageous for use with difficult intubations arising from an excessively anterior-oriented glottis, whereas a channel with excessive depth may hinder the localization of a glottis which is off-midline. In certain circumstances, channel size will limit tracheal tube size. The intubating Laryngeal Mask Airway (iLMA) is also included in this comparison. Although this device may have an advantage in performing blind intubations, its use, even with a fiberscope, may be limited. This limitation applies to intubations in which mouth opening is restricted, the glottis is off-midline, airway tumors are present, or with the presence of prior cervical radiotherapy. Furthermore, because of its size, the iLMA can potentially cause airway trauma, which could subsequently limit the utility of a fiberscope. In addition, the FCOA can generate greater positive-pressure ventilation, when used with a tight-fitting face mask, than the iLMA. FCOAs offer clinicians the ability to visualize airway anatomy while allowing straightforward access for tracheal intubation.     

Predictors of a difficult intubation in the bariatric patient: does preoperative body mass index matter?

BackgroundThe incidence of difficult intubations in morbidly obese patients has been reported to be 12–20%; however, no well-established predictors of a difficult intubation exist for this patient population. Our objective was to evaluate the factors associated with a difficult intubation in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass at an integrated multispecialty health system with a 325-bed community teaching hospital serving 19 counties.MethodsThe anesthetic records of patients undergoing LRYGB from 2001 to 2010 were reviewed. Difficult intubations were defined as direct laryngoscopy graded ≥1 on a 0–2 difficulty scale and unplanned fiberoptic intubations. Statistical analysis included chi-square, univariate, and multivariate logistic regression.ResultsA total of 915 consecutive patients underwent LRYGB during the study period. Of these, 3 patients were excluded because of incomplete data. Of the 912 included patients, 25 (2.7%) underwent planned fiberoptic intubation, 830 (91%) had an uneventful intubation, and 57 (6.3%) had a difficult intubation. Difficult intubations were more common in men than in women (11% versus 6%, P = .027). Difficult intubations were not associated with an increasing preoperative body mass index (P = .073), the presence of obstructive sleep apnea (P = .784), or the presence of gastroesophageal reflux disease (P = .335). Multivariate predictors of a difficult intubation were Mallampati class 4 (odds ratio [OR] 2.76, P = .035), abnormal thyromental distance (OR 4.39, P = .001), restricted jaw mobility (OR 3.26, P = .018), and a history of a difficult intubation (OR 4.17, P = .002).ConclusionsAn increased Mallampati class, abnormal thyromental distance, restricted jaw mobility, and a history of difficult intubations were independent predictors of a difficult intubation. An increasing body mass index did not predict for a difficult intubation.     

Evaluation of the learning curve of a new intubation technique: intubating laryngeal mask

OBJECTIVE: Assessment of the learning curve of a new device for blind orotracheal intubation: Intubating laryngeal mask. STUDY DESIGN: Prospective clinical study. METHODS: Ten persons practicing anaesthesia (specialist, fellow, nurse) underwent videotape learning and manikin training required with the device. Each person had to carry out a tracheal intubation in ten consecutive patients undergoing scheduled surgery. No patient presented history or clinical sign of difficult airway management. Results were expressed as mean +/- SD. Main percentages were provided with their 95% confidence interval; the percentage comparison were performed using Chi 2 test. The significance level for overall analysis was p < 0.05. RESULTS: One hundred patients were included. The overall success rate of tracheal intubation with the intubating laryngeal mask was 88%. An easy learning curve was obtained according to the low failure rate that was observed. No failure was noticed after eight procedures. Significant diminution of the delay for tube insertion was observed during the practice (3 +/- 1.30 min for the first procedure and 1.16 +/- 0.60 min for the tenth procedure). Circumstances of the oral intubation were improved with muscle relaxation. Finally, all failure with the intubating laryngeal mask were followed by successful intubation using direct laryngoscopy. CONCLUSION: The intubating laryngeal mask is a new device for blind orotracheal intubation with an easy learning curve in patients without difficulty in airway management, even for non-selected operators.     

Incidence,causes, and management of failed awake fibreoptic intubation—A retrospective study of 833 procedures

Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty-nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies.     

Failed intubation in a parturient with spina bifida

We describe a case of unexpected difficult intubation and ventilation during induction of general anaesthesia for caesarean section. This case was particularly challenging as the parturient suffered with particularly severe cord tethering following surgery for spina bifida as a child. The observed change in anticipated intubation difficulty during pregnancy, and the use of the laryngeal mask airway as a life-saving device in obstetrics are described. Consideration of the difficulties of anaesthetising the patient with spina bifida for caesarean section in general, and the issues relevant in deciding whether to continue with surgery or to wake the patient up in particular are discussed. Suggestions are made for the management of this emergency situation in those not skilled in fibreoptic intubation.     

Using a nasopharyngeal airway during fiberoptic intubation in small children with a difficult airway

BACKGROUND: Induction of anesthesia and tracheal intubation in small children with a difficult airway is a challenging task. We report the experience with a procedure based on sevoflurane inhalation via a nasopharyngeal airway inserted early during induction before airway obstruction occurs. A pediatric fiberscope is used to perform a nasotracheal intubation via the opposite nostril. METHODS: All small children with suspected or known difficult airway needing tracheal intubation were scheduled for a fiberoptic intubation following the described protocol. RESULTS: In 3 years, we performed 27 successful fiberoptic guided tracheal intubations in 19 children, median age 8.2 months (1.0-39.1 months) and median weight 7.6 kg (3.0-15.0 kg). The optimal depth for placement of the nasopharyngeal airway was found to be 8.0 cm (7.0-8.5 cm) from the nostril in the first year of life and 8.5 cm (8.0-10 cm) in the second year. Oxygenation was sufficient during the entire procedure in all cases except one child who had short-lasting laryngeal spasm caused by instillation of lidocaine during light anesthesia. The duration of fiberoptic intubation was significantly shorter when performed by an experienced anesthesiologist (55 s vs. 120 s), but there was no significant correlation between the duration of fiberoscopy and oxygen saturation during fiberoscopy or endtidal CO(2) after intubation. CONCLUSION: The combination of nasopharyngeal airway and fiberoptic guided tracheal intubation seems to be a reliable and safe procedure for managing the difficult airway in small children.