Endotracheal Intubation Complication

Study Objective This observational study aims to prospectively investigate to what extent tracheostomy-related complications in children are asymptomatic or associated with symptoms when detected through surveillance airway endoscopy. We also aim at investigating how reliable caregiver reports and investigations by pediatriscians are in identifying symptoms associated with severe tracheostomy-related airway complications. Background Children with airway obstruction due to congenital malformations, trauma, or chronic respiratory or neuromuscular conditions may require a tracheostomy. The Long-Term Intensive Care Unit (LIVA), part of the Pediatric Perioperative Medicine and Intensive Care (BPMI) at Karolinska University Hospital, has been providing specialized care for children with tracheostomies across Sweden since 1998. The care at LIVA involves assessements by a multidisciplinary team, including pediatricians, ENT specialists, pediatric anesthesiologists, nurses, physiotherapists, dietitians, speech therapists, counselors, and play therapists. Follow-up at LIVA includes regular multidisciplinary assessments and one to two surveillance airway endoscopies under anesthesia annually, aimed at early detection of airway complications related to the tracheostomy tube. Complications such as granulomas, infections, or bleeding are often asymptomatic but can be potentially life-threatening. There is currently no national or international consensus on the optimal frequency of surveillance endoscopies, and the potential for individualizing surveillance based on risk factors, including the presentation of symptoms, remains unexplored. Given the risks associated with anesthesia, minimizing unnecessary procedures is critical. Currently, a retrospective study is underway to examine the incidence of tracheostomy-related complications, their correlation with risk and demographic factors, and preoperative symptoms. Preliminary results indicate that 72% of patients experienced at least one tracheostomy-related complication, while only 19% exhibited symptoms prior to surveillance endoscopy according to patient records. Suprastomal granuloma was the most frequent complication observed. Interventions were required for all symptomatic patients and 71% of asymptomatic patients with identified complications. Patients using ventilators and/or cuffed cannulas had a higher incidence of complications compared to those without (88% vs. 61%, p\<0.05). Study Population The study population comprises children under 18 years of age undergoing follow-up at the Long-Term Intensive Care Unit (LIVA) at Karolinska University Hospital in Stockholm, Sweden. Research Questions 1. To what extent are tracheostomy-related complications in children asymptomatic when detected through surveillance airway endoscopy? 2. How reliable are caregiver reports in identifying symptoms associated with tracheostomy-related airway complications? Methods Children scheduled for surveillance airway endoscopy are admitted to LIVA. Upon admission, the caregiver is asked to complete a short questionnaire regarding symptoms that may indicate a tracheostomy-related complication. After the questionnaire has been completed, the child will be examined by the responsible paediatrician, with the aim of identifying any signs or symptoms that could indicate an airway complication. The examination includes physical examination and medical history conducted according to a predefined protocol. The airway endoscopy is performed by an ENT surgeon who has not examined the patient beforehand and is not informed of the caregiver's responses nor the result of the examination by the pediatrician. However, there is no strict protocol in place to blind the surgeon to any visibly apparent symptoms or to information that may be spontaneously reported by the caregiver or paediatrician. Ethical Approval Ethical approval for the study has been obtained (Ref. No: 2023-07493-01).

Background: Liberation from mechanical ventilation (MV) involves a three-step process; weaning, readiness testing, and extubation. Readiness testing uses objective clinical criteria to determine whether a patient is ready to begin weaning from MV. These criteria include improvement of the underlying indication for MV, hemodynamic stability, and the ability to initiate and sustain both adequate inspiration and expiration. Successfully extubation from invasive MV is a critical milestone in the recovery from severe respiratory failure and and is a clinical challenge for clinicians. Spontaneous breathing trials (SBT) are conducted to evaluate a patient's readiness for ventilator liberation in the intensive care unit (ICU). Extubation is considered successful if invasive mechanical support is not required within 48 hours after the removal of the endotracheal tube. As the final step of the weaning process, the decision to extubate is typically guided by objective criteria demonstrating the patient's ability to sustain respiratory function without mechanical assistance. Considering the complex pathologies of intensive care patients, besides SBT many clinical parameters have been used as predictors of weaning and extubation. For this reason, different multi-component scales and scores have been developed. The study protocol is designed and will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. The aim of this study is to develop a multi-component Readiness for EXtubation score (REXs) that can predict extubation readiness and to analyze this score that can be applied to patients under invasive MV in the ICU. Sample Size: The sample size was calculated as 427 using the Area Under ROC Curve in the ExPreS study. The total targeted sample size was accepted 470 patients with estimating that there would be a 10% dropout. Screening and Admission: The daily screen will be performed between 8:00 and 10:00 a.m. by the clinician assigned to the unit each morning that the patient was on invasive mechanical ventilation. Patients meeting the criteria will be included in the study. Data Collection and Anonymization: The data collected are part of routine clinical care, and the data will be anonymized. Clinicians will add anonymously the data they obtain to a created electronic case report form (e-CRF). Clinicians will be allowed to assign numbers to patients so that they can be distinguished by the clinicians who add them. The dataset that constitute the e-CRF for each patient are; demographics (country, age, sex, BMI), ICU type, cause of ICU admission, number of comorbidities, weaning/extubation type, SBT duration, arterial blood gases (ABG: pH, PaCO2, PaO2), ventilation parameters (brand/model, FiO2, PEEP, ventilation index, RSBI, MVspont/MVtotal, PCF, P0.1, vital capacity, NIF, Cdyn), secretion type, agitation and sedation score (RASS), heart rate, hemoglobin, nutrition target percentage, ventilatory support after extubation, extubation failure (24,48 and 72 hrs), duration of invasive MV, ICU and hospital length of stay and mortality. pH: It measures the acidity or alkalinity of blood and is crucial for assessing acid-base balance. Normal arterial pH is 7.35-7.45. A pH lower than 7.35 indicates acidosis, while a pH higher than 7.45 indicates alkalosis. Abnormal pH can indicate metabolic or respiratory disorders. The pH of the blood is crucial when assessing the success of weaning. The pH outside the normal range can indicate an imbalance in acid-base homeostasis, which may suggest inadequate respiratory function or metabolic disturbances that would make weaning unsafe. Maintaining a normal pH ensures that the patient's respiratory and metabolic systems can function without requiring excessive ventilatory support. PaCO2: PaCO2 is a direct measure of ventilation. During weaning, a PaCO2 level within normal limits is needed for extubation success. Persistent hypercapnia during weaning suggests that the patient may be unable to sustain adequate ventilation on their own, leading to potential failure. PaO2/FiO2: This ratio is a measure of the severity of hypoxemia. During weaning, a higher PaO2/FiO2 ratio suggests that the lungs are functioning well enough to support breathing without mechanical assistance. A low ratio suggests the need for continued mechanical ventilation. PEEP: PEEP is used to prevent alveolar collapse and improve oxygenation. When weaning, reducing PEEP gradually helps assess whether the patient can maintain oxygenation without it. High levels of PEEP might be detrimental when reducing ventilatory support, as it can affect weaning success. Ventilation Index (VI): The ventilation index (VI) combines respiratory rate and tidal volume, giving an overall assessment of ventilation efficiency. A low VI is favorable during weaning because it indicates that the patient is able to achieve adequate ventilation with minimal support. VI is calculated as VI="(PIP\* PaCO2\*RR)/1000". Rapid Shallow Breathing Index (RSBI): The rapid shallow breathing index (RSBI), also known as the ratio of respiratory rate to tidal volume (RR/VT), is the most commonly used predictor of weaning success due to its simplicity and ease of interpretation. The clinical utility of the RSBI is emphasized in the 2007 international consensus guidelines for weaning from mechanical ventilation, the 2007 Brazilian consensus guidelines, and the 2013 Brazilian guidelines for mechanical ventilation, all of which recommend its use. MVspont/MVtotal: This ratio reflects the proportion of ventilation that is spontaneous versus mechanical in one minute. A higher spontaneous ventilation (MVspont) relative to total ventilation (MVtotal) indicates that the patient is relying less on mechanical support, which may be reflect favorable for weaning. Peak Cough Flow (PCF): PCF is an indicator of a patient's ability to clear secretions. Secretion retention is a key factor in weaning failure, as it increases respiratory load and is often linked to an ineffective cough. Evaluating cough strength in ICU patients can help predict weaning outcomes, as insufficient cough strength appears to be associated with higher in-hospital mortality. Consequently, assessing cough strength in intubated patients is increasingly being integrated into ICU extubation protocols. The subject is instructed to take a deep breath and cough as forcefully as possible. The clinician then freezes the ventilator screen and measures the maximal expiratory flow (L/min) from the flow curve. Clinicians can use the mechanical ventilator's algorithm if available. The average of three successful measurements will be taken. P0.1: In a study on healthy subjects, Whitelaw et al. conducted random, brief end-expiratory occlusions using a specialized circuit during both resting and CO2 rebreathing. They observed that the decrease in airway pressure (Paw) within the first 100 milliseconds (0.1 s) of an occluded breath remained relatively constant, was consistent for each subject under different conditions, and correlated more strongly with end-tidal CO2 than with minute ventilation. They introduced this parameter as airway occlusion pressure Pocc, or P0.1. P0.1 reflects the inspiratory effort of the patient. It is used to assess the respiratory drive. Normal P0.1 suggests that the patient has adequate respiratory drive to maintain spontaneous breathing. Clinicians can use the mechanical ventilator's algorithm if available. The average of three successful measurements will be taken. Vital Capacity (VC): Vital capacity (VC) reflects the total volume of air a person can exhale after a maximal inhalation. During weaning, a VC of at least 10-15 mL/kg is generally considered adequate for successful extubation. Vital capacity is measured by instructing patients to inhale deeply to their maximum capacity, followed by a forceful exhalation. The clinician then freezes the ventilator screen and measures maximal volume (mL) from the volume curve. Clinicians can use the mechanical ventilator's algorithm if available. The maximum of three successful measurements will be taken. Negative Inspiratory Force (NIF): Negative inspiratory force (NIF), also referred to as maximum inspiratory pressure, reflects the maximal effort of the inspiratory muscles during inhalation against an obstructed airway. This index is used to evaluate respiratory muscle strength, with a value greater than - 30 cm H2O serving as a criterion for initiating the mechanical ventilator weaning process. After exhaling, the patient is given the command to take a deep breath. The clinician freezes the screen when the patient perform the fastest inhalation during expiratory hold maneuver. The clinician measures the minimum pressure from the pressure curve. Clinicians can use the mechanical ventilator's algorithm if available. The minimum of three successful measurements will be taken. Cdyn: Dynamic compliance is a measure of lung and chest wall compliance during mechanical ventilation. High compliance typically indicates less stiff lungs, which is favorable during weaning. It is obtained by dividing the VT by the difference between PIP and PEEP. Secretion: In mechanically ventilated patients, the primary mechanisms of secretion clearance-mucociliary transport and cough-are impaired. Major contributing factors to pulmonary secretion retention include the presence of an artificial airway, insufficient humidification of inspired gases, and limited mobility. Ineffective secretion clearance increases the risk of ventilator dependency and reintubation due to airway obstruction, aspiration, or infection. Agitation/Sedation: Effective management of agitation and sedation is essential for successful weaning in mechanically ventilated patients, as both excessive sedation and agitation can impede the process. Over-sedation reduces respiratory drive, weakens respiratory muscles, prolongs ventilation, and increases the risk of ventilator-associated pneumonia. In contrast, agitation can heighten the work of breathing, increase the risk of self-extubation, and cause cardiovascular strain. The Richmond Agitation-Sedation Scale (RASS) is a 10-point tool that categorizes patient states, ranging from severe agitation (+4, combative) to deep sedation and unresponsiveness (-5), with 0 indicating a calm and alert state. Heart rate: Heart rate is an important indicator of cardiovascular stability during weaning. A significant increase in heart rate during mechanical ventilation or SBTs can signal distress, leading to the suspension of the weaning attempt. Hemoglobin: The impact of hemoglobin levels on weaning outcomes in mechanically ventilated patients remains controversial, with limited data, particularly for those experiencing difficult weaning. Patients with weaning difficulties may benefit more from higher hemoglobin levels than those in the early stages of respiratory failure, as sufficient hemoglobin is essential for adequate oxygen delivery during the weaning process. Lower hemoglobin levels reduce arterial oxygen content, impair oxygen delivery, and increase respiratory muscle workload, potentially hindering successful weaning. %Nutrition Target: Adequate nutrition is essential for survival and reducing hospital stay in critically ill patients, as it supports muscle strength, including respiratory muscles, which is crucial for successful weaning from mechanical ventilation. Malnutrition can impair weaning by weakening respiratory function. To guide evidence-based nutritional therapy, several global guidelines have been published. The American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM) recommend energy intake of 25-30 kcal/kg/day and protein intake of 1.2-2.0 g/kg/day, while the European Society for Parenteral and Enteral Nutrition (ESPEN) suggests 20-25 kcal/kg/day with 1.3 g/kg of protein equivalents per day. Statistical Analysis: Statistical analysis will be performed using IBM SPSS Statistics 26 (IBM Corp., Armonk, NY, USA). Categorical variables will be summarized as numbers (n) and frequencies (%). The Fisher's exact test will be applied for 2×2 contingency tables, and the Chi-square test will be used for all other contingencies to evaluate associations between clinical/demographic characteristics and extubation success or failure. For continuous variables, the Shapiro-Wilk test will be used to assess normality of distribution. Normally distributed variables will be summarized as means (± standard deviation), while non-normally distributed variables will be expressed as medians (with interquartile range). The independent samples Student's t-test will be employed to compare groups for normally distributed variables, and the Mann-Whitney U test will be used for non-normally distributed variables. All parameters with a p-value \< 0.4 in group comparisons (extubation success vs. failure) will be further investigated using univariable logistic regression analysis to assess their association with extubation outcome; odds ratios (OR) and 95% confidence intervals (CI) will be calculated. Receiver operating characteristic (ROC) analysis will be performed to evaluate the predictive value of each parameter. The cutoff values optimizing sensitivity and specificity will be determined using the Youden Index. The REXs cutoffs used in comparisons will be established based on the Youden Index. Finally, REXs cutoff values indicating low, moderate, and high probability of extubation risk will be determined.

INTRODUCTION Many newborn infants have difficulty breathing after birth. Some of these babies have a tube inserted into their "windpipe" (trachea) - an endotracheal tube (ETT) - through which they are given breathing support (ventilation). When clinicians attempt to intubate (insert an ETT), they use an instrument called a laryngoscope to view the airway in order to identify the entrance to the trachea (larynx). Standard laryngoscopes have a "blade" (which, despite its name, is not sharp) with a light at the tip. Doctors insert the blade into the baby's mouth to view the larynx. Traditionally, clinicians used a standard laryngoscope to look directly into the baby's mouth to view the larynx (direct laryngoscopy, DL). When clinicians attempt to intubate newborns with DL, less than half of first attempts are successful. Also adverse effects - such as falls in the blood oxygen levels (fall in oxygen saturation (SpO2), or "desaturation"), slowing down of the heart rate (bradycardia), oral trauma - are relatively common. In recent years, video laryngoscopes (VL) have been developed. In addition to a light, VL have a video camera at the tip of the blade. This camera acquires a view of the larynx and displays it on a screen that the clinician views when attempting intubation (indirect laryngoscopy). In a randomised study performed at the National Maternity Hospital, Dublin, Ireland, more infants were successfully intubated at the first attempt when clinicians used VL compared to DL \[79/107 (74%) versus 48/107 (45%), P\<0.001\]. While this study was large enough to show that VL resulted infants being successfully intubated at the first attempt in one hospital, it couldn't give information about how it might work in a range of hospitals, and it wasn't large enough to see what effect VL had on adverse events. There is a large difference in cost between a standard laryngoscope (approx. €300) and a video laryngoscope (approx. €21,000). This is a matter of concern for all hospitals, particularly in settings where resources are more limited. The investigators aim to assess whether VL compared to DL results in more infants being intubated at the first attempt without physiological instability. STUDY DESIGN A recent single centre study reported that that more newborn infants were successfully intubated at the first attempt when VL was used to indirectly view the airway compared to DL. This study was not large enough to determine the effect of VL on adverse effects that are seen commonly (e.g. desaturation) or more rarely (e.g. bradycardia, receipt of chest compressions or adrenaline, oral trauma) during intubation attempts. For the current study, the investigators chose a stepped-wedge cluster randomised controlled design, where the participating centre, rather than the individual infant, will be the unit of randomisation. This design has been found appropriate to test the effects of an intervention that encompasses a behavioural aspect and to implement interventions while studying them at the same time. In this study, all centres will begin in the "control group"; where clinicians will routinely attempt intubation with DL, as is their usual practice. At specified intervals, centres will be randomly assigned to cross over to the "intervention group", where clinicians will routinely attempt intubation with VL. All participating centers will have included patients in both arms by the end of the study. SAMPLE SIZE ESTIMATION To determine the intra-cluster correlation (that means the correlation between two observations from the same centre), the investigators used the dataset of the MONITOR trial that included infants from 7 delivery rooms worldwide. In this trial, the intra-cluster correlation for intubation in the delivery room was reported as 0.1. This complete stepped-wedge cluster-randomized design includes 21 time periods (including the baseline) and 20 centres that will be including patients, with each randomised to a unique sequence. Each time period lasts a fortnight. Each time period, 1 centre will switch their treatment from DL to VL. With all centres including 2 patients each time period, 42 patients will be included per centre which will provide a total sample size of 840 patients. Assuming a control proportion of 0.4, this sample will achieve 90% power (0.9091) to detect a treatment proportion of 0.55, assuming a conservative ICC of 0.05. The power is not very sensitive to ICC values up to 0.1 (power of \>90% to detect difference 40% versus 56%). The test statistic used is the two-sided Wald Z-Test. TREATMENT OF SUBJECTS DIRECT LARYNGOSCOPY (DL, control period) At the start of the study, clinicians at participating centres will attempt intubation using a standard laryngoscope to perform DL as is their normal practice. VIDEO LARYNGOSCOPY (VL, intervention period) For each centre, a lot will be drawn which indicates the month in which endotracheal intubation will be routinely attempted with VL rather than DL. In the month before the switch, centres will be provided with a C-MAC VL by the manufacturers, Karl Storz-Endoskop (Tuttlingen, Germany). The system will be provided on loan for the duration of the study and will consist of an 8" high-definition monitor with connecting cable and reusable straight Miller type blades size 0 and size 1. The equipment will be demonstrated by representatives from Karl Storz, and clinicians who intubate babies at participating hospitals will be encouraged to practice with the equipment on mannequins. We will have an virtual meeting with each centre in the week before they are due to switch to review the protocol, data collection and to answer any queries that they may have. All other procedures in the delivery room and NICU will be performed according to international and local guidelines. All other aspects of the approach to intubation at the participating centre are at the discretion of the local clinicians and should remain the same for the duration of the study; e.g.: * The drugs used before intubation attempts (e.g. opiate, atropine, curare-like drug) * The route by which intubation is usually attempted (i.e. oral or nasal) * Whether they use a stylet is routinely used * Whether supplemental oxygen is given during attempts

GlideScope-assisted flexible fiberoptic intubation has been successfully used in cases of anticipated and unexpected difficult airways. This technique depends on two operators where the second operator assists in holding the GlideScope while intubation is being attempted by the first operator. However, it is not yet established whether this two-operator technique has any effect on the success rate of first-attempt intubation by the GlideScope video laryngoscope. The primary objective of this study is to compare the first attempt success rate of endotracheal intubation using the GlideScope video laryngoscope when performed by two operators versus a single operator. Secondary objectives include assessing the time to intubate, the need for optimization maneuvers, the effect of the presence of predictors of difficult intubation, the occurrence of adverse events during intubation such as oxyhemoglobin desaturation to less than 90% measured by pulse oximetry, the incidence of airway trauma, and the incidence and severity of post-operative sore throat. In this prospective randomized controlled trial, 428 patients (214 in each group) adult patients will be enrolled in one of two groups over 9 months of work. They will be further stratified into blocks according to the presence of at least one predictor of difficult intubation. Patients allocated to the control group will be intubated using the GlideScope by a single operator (the resident on the study). Those allocated to the experimental group will be intubated using the GlideScope with the assistance of a second operator (the resident and the attending physician). In both groups, the time to intubate will be measured by the attendings on the study, along with other parameters collected by the resident on the study. If intubation fails, the airway will be subsequently managed using any technique deemed appropriate by the attending anesthesiologist. Data comparing the success rate of endotracheal intubation when a second operator assists in holding the GlideScope is missing. This two-operator technique is essential in the new multimodal airway management involving video-assisted flexible fiberoptic intubation. Our study will determine whether the assistance in using the GlideScope provides similar first attempt success rate of endotracheal intubation and thus guarantees securing a difficult airway.

This study is conducting after permission from institutional ethical committee. Participants came for elective OMF surgery under general anesthesia are enrolled in this study who fulfilled the inclusion criteria. Informed consent is taken from the participants. Brief history about demographic data was taken from each participant. All participants are examined for airway assessment, cardiovascular and respiratory examination before undergoing anesthesia. Participants are divided into 2 groups by simple lottery method in group xylometazoline and group adrenaline. Group Xylometazoline: receive 3 to 5 drops of 0.1% xylometazoline nasal drops in selected nostril 15 mins before transfer to OT. Group Adrenaline: receive intranasal packing with adrenaline soaked gauze piece in selected nostril. Packing is done 15 mins before transfer to OT and removed after 7 to 10 minutes. Proper monitoring of vital signs will be done in preoperative area. Anesthesia machine and accessories are checked, and drugs including emergency drugs are kept ready. Baseline BP, heart rate, ECG, and peripheral oxygen saturation is obtained and recorded from multipara monitor. All participants are preoxygenated by 100% oxygen for 5 mins. Induction is done with propofol (1%) 2mg/kg and atracurium 0.5 mg/kg by senior anesthesiologist present. The anesthetist present in OT is blind to both groups. Laryngoscopy is done by an experienced anesthesiologist using a MAC 3 or 4 blade based on participants' anatomy. Nasotracheal intubation is done by a cuffed lubricated (with lidocaine 2%) nasal tube of appropriate size. Anesthesia is maintained with atracurium 0.1 mg/kg and isoflurane in 60% O2 at 3L flow. The anesthesiologist will record incidence and severity of bleeding at the time of intubation and extubation. Data will be analyzed on SPSS version 20. Chi square test will be used to compare the incidence of nasal bleeding in both groups. Effect modifiers are controlled through stratification of age, gender, diabetes mellitus, hypertension to see the effect of these on the outcome variables. Post stratification chi square test will be applied taking P-value of \<0.05 as statistically significant.

Videolaryngoscopy is widely used for tracheal intubation in anaesthesia and critical care; however, variability in patient anatomy, operator experience, and institutional practice may influence videolaryngoscopy performance and strategy selection. Conventional bedside airway assessments provide limited guidance for videolaryngoscopy-specific decision-making, particularly in diverse clinical environments. This multicentre observational study will collect clinical parameters, demographic data, and point-of-care airway ultrasound measurements from adult patients undergoing videolaryngoscopy across participating centres. The collected data will be analysed using artificial intelligence-based analytical approaches, including statistical and machine-learning techniques, to examine their association with predefined videolaryngoscopy-related outcomes. The primary objective is to evaluate the performance and generalisability of multimodal predictive models developed using multicentre data. The study is designed to support the development and validation of data-driven decision-support tools for videolaryngoscopy planning. These tools are intended for research purposes and do not replace clinical judgement.

Tracheal intubation is a routine procedure in anaesthesia and critical care; however, difficulties during videolaryngoscopy may still occur despite advances in airway devices. Conventional bedside airway assessments provide limited guidance for videolaryngoscopy-specific decisions, such as blade selection or anticipation of adjunct use. This unicentric observational study collects clinical characteristics, demographic data, and point-of-care airway ultrasound measurements in patients undergoing videolaryngoscopy. These variables are analysed using machine-learning techniques to examine their association with predefined videolaryngoscopy-related outcomes, including blade performance and adjunct requirement. The primary objective is to develop and internally evaluate a predictive model integrating multimodal data to support videolaryngoscopy strategy planning. The model is intended solely as a research and decision-support tool and does not replace clinician judgement. External validation in independent cohorts is planned.

The incidence of intraoperative hypoxaemia in children is high and age-dependent. An incidence of over 10 % is reported in8- to 16-year-old children and over50 % in newborns. Severe respiratory critical events occur in paediatric anaesthesia with an incidence of 3.1 %. After the onset of apnoea, hypoxaemia develops more rapidly in children than in adults, which is due to increased oxygen consumption, a lower functional residual capacity and an increased closing capacity. These events can lead to permanent neurological damage or death. One approach to preventing adverse respiratory events due to hypoxaemia during paediatric anaesthesia is the use of apnoeic oxygenation. The principle is to supply oxygen to the airways of anaesthetised patients via a conventional nasal cannula. As less carbon dioxide is produced than oxygen is consumed during apnoea, the supply of oxygen to the upper airways leads to an 'inward diffusion' of oxygen, which prolongs the time until desaturation and hypoxaemia occur. This also extends the 'safe apnoea time' and the anaesthetist has more time to secure the airway. As the incidence and severity of arterial oxygen desaturation is higher in critically ill children compared to healthy children, this vulnerable group in particular could benefit from apnoeic oxygenation. Apnoeic oxygenation is increasingly becoming a standard technique in paediatric anaesthesia, with applications ranging from induction of anaesthesia in the operating theatre and standard airway management to the management of difficult airways. In its current guidelines, the European Society of Anaesthesiology and Intensive Care recommends the use of apnoeic oxygenation in the airway management of newborns and infants. The main aim of this study is to evaluate the effectiveness of apnoeic oxygenation in terms of time to desaturation and hypoxaemia, as well as the impact of apnoeic oxygenation on intubation success in anaesthetised children.

Painless endoscopy is a popular method of endoscopic diagnosis and treatment.General intravenous anesthesia with propofol and fentanyl has been widely used in painless endoscopic diagnosis and treatment.However, the combined application of the two has an obvious respiratory central inhibitory effect, resulting in a decrease in blood oxygen saturation in patients, especially in obese and elderly patients, who are more prone to a sudden decrease in blood oxygen, and even life-threatening.Due to the potential risk of upper airway obstruction in some obese patients, intraoperative hypopnea may occur during painless colonoscopy due to sedative and analgesic drugs.Causing the patient to be starved of oxygen.At present, there is no special oropharyngeal ventilation device for gastroenteroscopy.In recent years, a new type of oropharyngeal ventilation channel has been developed and applied in clinic.Compared with the traditional nasal catheter, the new oropharyngeal airway nasal mask can better fit the patient's face, ensure the internal air tightness of the nose mask, and maximize the oxygen supply efficiency.Connecting the carbon dioxide outlet of the oral pharyngeal airway body can not only collect the exhaled gas of the patient, but also reduce the backflow of carbon dioxide gas.It can also be connected to a carbon dioxide detection device to monitor the partial pressure of carbon dioxide at the end of a patient's breath in real time.To evaluate whether a new type of oropharyngeal airway can reduce the incidence of hypoxia during painless gastroenteroscopy in general patients, the investigators present this study and investigate the safety and efficacy of the new type of oropharyngeal airway.

This prospective observational study aims to evaluate whether upper airway ultrasound measurements can improve the prediction of difficult airway compared with conventional anthropometric assessments. Adult patients undergoing elective procedures requiring airway management will be included. Ultrasound parameters such as tongue thickness, anterior neck soft tissue thickness, and hyomental distance will be measured before airway intervention. Standard clinical predictors (Mallampati score, thyromental distance, neck circumference, etc.) will also be recorded. The primary objective is to determine the diagnostic accuracy of ultrasound-based measurements in predicting difficult laryngoscopy and intubation. The study seeks to provide evidence supporting the integration of upper airway ultrasound into routine pre-anesthetic airway evaluation.