Article of the Month


Dear colleagues and airway enthusiast 
The European Airway Management Society is introducing a new feature – Article of the Month. 
This is designed to provide an opportunity to our members to highlight and share airway related topics and to open discussion forums in order to share clinical experience for the benefit of all EAMS members. 
The Article of the Month will be made available via the EAMS website and is going to be accompanied by a short text (up to 200 words) explaining why is this article being selected. 
EAMS members with login to will have access to the articles as full-text PDF's.
We would like to encourage our members to propose articles of the month. The short text accompanying the article will also be made available on line with full acknowledgement of the author who proposed the article. 
The final decision to go on-line will be taken by the EAMS Board of Directors. 

Best regards 
R. Tino Greif 
President of the European Airway Management Society


Dear EAMS members,

The article of the month of December 2021 is an unmissable opportunity: we are talking about the 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway (1).

This is a cornerstone paper in airway Management, the fourth update of a series firstly published in 1993 which this year, for the first time ever, includes a panel of international experts within the Authors and exhibits the endorsement of International scientific Societies, including EAMS.

Our Society is also represented through the co-authorship by Prof Robert Greif and Dr Massimiliano Sorbello, which are part of the distinguished panel of airway management experts publishing this guideline.

Apart from an impressive literature body selection and analysis, the document includes new insights in airway management, from Human Factors to flexible algorithms, representing a unique opportunity to revise, reconsider and improve our daily practice in airway management.

A must-read document for any airway enthusiast!

Massimiliano Sorbello

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Dear collegues,

A recent study showed how communication failure in anaesthesia contributed to injuries of patients. Often full-scale simulation is enthusiastically recommended as a tool to teach human factors, which include communication, leadership, team performance and task management. Now we have a well done systematic review on the “Effect of simulation-based team training in airway management” published in Anaesthesia.

We have to congratulate the authors that they found a substantial number of studies about that topic and that they grouped the studies according to Kirkpatrick’s model for evaluation of training, which rarely happened in the past.
Unfortunately, the heterogeneity was too large to summarize the date in a meta-analysis. Despite that, the reader gets a nice summary of the current evidence for simulation in airway management education.

Robert Greif

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Dear airway management enthusiasts,

This month’s article of the month is Awake Tracheal Intubation Guidelines from the UK's Difficult Airway Society, published in Anaesthesia.

The authors collected all the available evidence related to awake intubation, consulted large number of the most experienced airway management enthusiasts around the world, critically appraised all of it and produced a concise and clear guidance to the best practice for conducting awake intubation. The set of flow charts and tables summarise the most clinically relevant parts of the guidelines, making the use of the guidelines easy.

The guidelines contain something for every clinician irrespective of the level of experience. The very experienced in airway management can use the guidelines to review what they do and adopt the bits that are relevant to their practice. And I can tell you that I learned a lot from the guidelines despite being an airway enthusiast for the last 30 yrs.

For the clinicians that are new to awake intubation, there is ample of useful practical advice on how to perform awake intubation with high success rate and what to do if it isn't successful.

I include my email for those who would like to discuss any aspect of the guidelines or who would like additional information –

Enjoy the read.

Iljaz Hodzovic 

Dear EAMS Members and Airway enthusiast,

It is my highest pleasure to recommend the outstanding article “Management of the difficult airway” published in the New England Journal of Medicine by our honorary EAMS member Thomas Heidegger.

In a well written, straight to the point way, Dr. Heidegger provides an excellent overview about the most important issues in the management of the difficult airway: the relevant data regarding the incidence of complications and critical events, an overview of the definition, incidence, and prediction of a difficult airway; the management of unanticipated and anticipated difficult airways as well as the management of tracheal extubation of a difficult airway in the operating room, the ICU, and the emergency department and human factors in airway management.

Apart from the well-structured overview, the article is full of interesting new data or concepts: for example, you will discover a scoring system of describing the view with video laryngoscopes, the importance of the upper lip bite test, a categorization of difficult airway predictors and an interesting difficult airway algorithm. The article will draw you attention why video laryngoscopy is not a panacea, particularly in intensive care patients and why appropriately training is mandatory. You learn about the challenges of airway management in obese patients, encounter the risk factors for unsuccessful extubation and highlights the value of using airway exchange catheters. Finally, the cited literature reads like “the best article in airway management”, with many authors being members of our society.

Are you curious? Enjoy reading!

Arnd Timmermann, EAMS Executive director
Red Cross Clinics Berlin, Germany

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Dear EAMS members and  airway enthusiasts,

Historically, obesity has been considered to be a risk factor for increased difficulty in airway management. Obese patients present with varying degrees of fat deposition at key locations of the airway. Consequently, morbidly obese patients are thought to be at increased risk for difficult airway management but the outcomes of various studies are conflicting. Some authors concluded that obesity is not a risk factor for difficult intubation whereas others found that obesity is an independent risk factor for intubation.

In article by Moon et al, the primary aim as to determine to what degree morbid obesity affected the incidence of difficult intubation and difficult mask ventilation. In the second, Saasouh et al evaluate the relationship between BMI and difficult tracheal intubation.

Enjoy reading and looking forward to the webinar!

Pedro Charco Mora

Dear EAMS members and airway friends,

IntubateCOVID is an observational study on how the clinicians managed the intubation procedure in COVID -19 infected patients. Data was collected from 32 countries (607 institutions, 4,476 intubations) with different economical level, most of the procedures being from ICUs.

The authors found differences on first-attempt success depending on the equipment that clinicians used, the operator’s previous intubating experience and the economical level of the country.

It offers some clues on how to manage the intubation procedure in future airway related pandemics.

Hope you find it interesting!

Xavier Onrubia

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Dear airway enthousiast:

This month's EAMS article of the month and webinar focus on critically ill patient's airway management, since the most commonly performed procedures in these patients are related with airway management, including tracheal intubation and tracheostomy. [1]

Firstly,  the “DAS Guidelines for the management of tracheal intubation in critically ill patients” [2] provide strategies to optimize oxygenation, airway management, and tracheal intubation in these patients, in all hospital locations. These guidelines stress the importance of human factors for improved outcomes of emergency airway management: the role of the airway team, a shared mental model, planning, and communication throughout airway management.

Secondly, the recently published observational multicenter:  “Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries” [3] concluded that major adverse events occur frequently. The reported adverse events in patients undergoing emergency intubation are: cardiovascular instability, severe hypoxemia, and cardiac arrest. 

Furthermore, to  deepen our understanding of these adverse events, previous studies where Janz et al [4] and Russel et al [5] explore possible measures to prevent cardiovascular collapse secondary to intubation are included.

Finally, with the aim of preventing hypoxemia Casey et al [6] focus on the advantages and disadvantages of  face mask ventilation and, Jaber et al [7], discuss the preferred intubation devices in this setting.

Enjoy reading and looking forward to the webinar!

Paula Chiesa

Dear EAMS members and  airway enthusiasts,

We are still fighting this pandemic  COVID-19 and  the last year has shown us the  importance of obesity as an independent risk factor for the severity of COVID-19.

The articles of this month focus on implications for mechanisms,  comorbidities,  prognosis and some key points to optimise airway management and ventilation for obese patients  in such challenging times! 

Recent studies have shown that obesity is associated with the severity of coronavirus disease. Hospitalization, intensive care unit admission, mechanical ventilation, and even mortality in obese patients were higher than normal-weight patients. Obesity could alter the direction of severe COVID-19 symptoms to younger individuals. (articles 1&2)

Some key points to optimize airway management, noninvasive  and invasive mechanical ventilation in ICU patients with obesity are suggested in articles 3 & 4.

Enjoy the reading and keep safe!

Kind regards,

Daniela Godoroja- Diarto

Dear airway enthusiastics,

We are still fighting this pandemic and the number of patients keep increasing also in pediatric patient group even if they are not symptomatic but still contagious.

Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease.

Hope this article will help all of us in airway management in pediatric group of patients during this, somehow, unending pandemia.

Best regards,

Prof. Dr. Özgür Canbay

Dear EAMS members and fellow airway enthusiasts,

These last twelve months have shown us the importance of resilience and great teamwork in making the difference in such challenging and unique times! 

Crisis occurs while taking care of patients and managing their airways in time pressured and highly risky procedures. Both technical skills and human factors are the safe ground for a successful teamwork.

The articles of this month focus on the basal pillars of human factors, resilience and teamwork and how they can improve airway management safety.

Enjoy the reading and keep safe & well!

Ana Isabel Pereira

Dear airway enthusiasts,

This month’s article is a recently published paper in Lancet about video laryngoscopy in small infants.
In this multicenter, randomised controlled trial, the primary outcome was the proportion of patients with successful orotracheal intubation on the first attempt. Secondary outcomes were number of intubation attempts; time to successful orotracheal intubation; proportion of unsuccessful intubations with the randomly assigned device; and proportion of non-severe and severe complications.
A nice comparison of video laryngoscopy and direct laryngoscopy in routine, non-emergency intubations under ideal conditions.

Have fun reading the full text in:

With best wishes

Kemal Tolga Saracoglu, Prof MD DESA FEAMS


Dear colleagues,

We lovingly greet you in this really difficult period for our work, in which we must increasingly think not only about the health of our patients, but also about our safety.

“Unfortunately” we work in a regional reference hospital for Covid-19 and we are particularly attentive to the safety of us doctors and our collaborators, risking to make us consider ourselves too apprehensive, at times...

We use the aerosol box, video laryngoscope and the most valid individual protection devices. Thanks to this approach, at the moment we have not registered any cases of infection in healthcare personnel.
Here are two recent articles that validate our clinical practices are good quality mannequin-based simulation studies.

The first highlights strengths and weaknesses of the “aerosol box”, an economic and optimizable device to be used not only in the intubation phase but also in nursing management.

The second compares two protective equipments on difficult airway management through the use of different instruments for intubation.

Looking forward to meeting you at the next congress, when all this is over.

Rosa Gallo
Francesco Maiarota
-Cosenza Hospital  Italy-

Dear airway management enthusiasts,

I hope you are all healthy during these difficult times.
As articles of the month, you will find two recently published studies that deal with High Flow Nasal Oxygenation:

1. Z.M. Piosik, et al look into the safe limits of  apneic oxygenation as before the onset of respiratory alkalosis. 
2. T.Riva, et al, explore the importance of positive airway pressure in the maintenance of oxygenation in a randomized controlled trial.

Enjoy reading!

Paula Chiesa

Dear colleagues,

I hope you are healthy and happy in this odd, new and unusual world.

In my department, I work as a pediatric anesthetist at Hacettepe University Hospital, we keep taking urgent and of course emergency cases during this period by taking safety measures. Video laryngoscopes as a most significant step of these safety measures, gained very much importance .

Videolaryngoscopes are useful in tracheal intubation in adults and in children, but it is not clear whether or not there are differences in efficacies between the different types of video laryngoscopes in children.

I have read the following two articles, one is editorial, interestedly. Although derived from retrospective analysis, these findings of Peyton and colleagues'make a useful contribution to our understanding of device performance across paediatric patients.

1. Peyton J, Park R, Staffa SJ, et al; PeDI Collaborative Investigators. A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry. 

2. Norris A, Armstrong J. Comparative videolaryngoscope performance in children: data from the Pediatric Difficult Intubation Registry. 

Wish you healthy days,

Özgür Canbay

Dear airway management enthusiasts,

After the summer break, EAMS started again with webinars.

The first was last week on 24 September about the “Usefulness of aerosol boxes and barrier enclosures for airway Management to prevent infection during the COVID-19 pandemic”. The speakers Prof. Dr. William Rosenblatt (Yale Medicine Anesthesiology. New Haven. USA) and Prof. Dr. Felipe Urdaneta (University of Florida. Gainesville. USA) discussed with Professor Dr. Robert Greif, (Bern University Hospital, Bern. Switzerland) and Dr. Massimiliano Sorbello (Policlinico San Marco University Hospital, Catania, Italy) about the lack of evidence for the effectiveness of these barriers and the additional risk these methods might bring for the patient and the personnel in the OR during airway management. As no scientific evidence exist that these methods prevent infection they are by no measn a substitute for proper PPE.

The Discussion was based on a recent publication in the BJA entitled: “Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: a scoping review and narrative synthesis. M Sorbello, W Rosenblatt, R Hofmeyr, R Greif, F Urdaneta."

For those who are interested in more details about the  webinar and the article please use your member log-in.

Become a member.

Robert Greif

Dear airway enthusiastic friends,
Although there are many articles related to airway management in this time of COVID -19 era, my interested turned to a bit different choice to share with you- of course related to what I know best: Obese Airway management. It refers to not one but to two correspondences in BJA, related to airway trauma in critically ill obese patients due to COVID-19 .

1.Tracheal trauma after difficult airway management in morbidly obese patients with COVID-19

2.Tracheal introducers and airway trauma COVID-19.

As we face the new worldwide pandemic of COVID-19, it was clearly suggested that a serious potential risk factor for infection development with severe disease progression is obesity. Simonnet et al mentioned that approximately 85% of patients with obesity required mechanical ventilation and   other preliminary data from New York City showed that obesity (BMI>40 kg/m2) is the second strongest independent predictor of hospitalization, after old age (preprint by Petrilli et al.)

The first paper  exemplified  that patients with severe obesity with a typical presentation of SARS-CoV-2 infection, requiring invasive ventilationafter failing noninvasive oxygen therapy presented difficult tracheal intubation and the use of a bougie probably induced tracheal trauma thereby worsening the respiratory condition and leading to urgent ECMO.

The second paper has come on behalf of  the airway experts as a response to the first paper and give advice about the optimising oxygen delivery before intubation to allow more controlled airway management  especially in hypoxaemic obese patients. The likelihood of successful tracheal bougie placement with a Grade IV laryngeal view is quite low, whereas the risk of airway trauma as a result of blind bougie insertion is significant, so that use of a bougie in such a scenario is considered contraindicated.

The appropriate use  of this simple device remains a precious adjunct for airway management  in conjunction with direct or video-laryngoscopy, especially in difficult airway management patients such as obese patients.

Please enjoy!

Dani Godoroja

Hi, my dear airway enthusiastic friends.

A lot of papers run into my head to be selected for “article of the month”. 

I finally decided to present you this one:

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance 

Three reasons directed me to this choice

- The interest of the topic in this COVID-19 pandemic. There have been published a lot of papers on tracheostomy in the COVID-19 patient by several scientific societies and working groups coming from different medical disciplines, mainly Head and Neck surgery, Critical Care, and Anaesthesiology. This paper tries to summarize all opinions.

- The multidiscipline and international composition of the group of authors (30), most of them known experts on the topic, coming from (in alphabetical order) Australia, China, France, Germany, Italy, Spain, Switzerland, UK and USA

-The accurate update of the paper (24 references from a total of 45 were published in 2020 and 2 more papers were “in press”)

There is an excellent summary of recommendations about patient selection, timing of tracheostomy, performance and management after procedure

I hope you enjoy this paper.

Xavi Onrubia

Dear EAMS members and airway enthusiasts,

July’s article of the month consists of a narrative review of the Front of Neck Access (FONA) from well renowned airway experts.

The management of a Cannot Intubate-Cannot Oxygenate (CI-CO) scenario is extremely challenging and one of the anaesthesiologist's fields of expertise. The authors mention that “the concept of FONA covers a large amount of techniques, principles, problems and debates”. The review discusses the epidemiological and technical aspects about CI-CO. 

Although only a few will ever perform a cricothyrotomy during their careers, always remember the 7 Ps: Proper Planning, Preparation and Practise Prevents Poor Performance!

Enjoy this Summer reading in the EAMS Journal Trends in Anaesthesia and Critical Care!

Keep safe and well!

Ana Isabel Pereira

Dear colleagues,
I hope you manage to stay well and healthy and are still able to  get to some reading done in this crazy year. Flexible endoscopic intubation has been praised as the standard technique for expected difficult intubations by numerous international guidelines. Current literature suggests that this is an easy technique with a high success rate and low complication rate. However, having taught flexible endoscopic intubations at workshop skill stations throughout the world, I found that anesthesiologists' skills in this technique are often inadequate. There seems a significant disconnect between published literature and clinical reality. 

In this month's manuscript, Dr. Grange et al. examined the experience with flexible intubation in the UK. They show what others already knew: one of the critical skills in anesthesiology is not as frequently used as it should be, the complication rate does not seem to match the published data.

Enjoy the read in the EAMS journal TACC!


Best wishes,
Rudy Noppens

Consensus guidelines for managing the airway in patients with COVID-19

Iljaz Hodzovic 


Robert Greif


March moth’s articles comes as a pair: Two 2020-papers (epub ahead of print 2019) that have to be read in conjunction: Ahmad and co-workers review on multiple aspects and practical guidance for AWAKE INTUBATION – The cornerstone technique in managing the predicted difficult airway, plus our accompanying editorial that reminds us that if an awake intubation is indicated then we shouldn’t abandon it easily – but remember that a spontaneous-ventilating intubation may be a close second best.


Michael Seltz Kristensen

Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults [published online ahead of print, 2019.

Aziz MF, Kristensen MS. From variance to guidance for awake tracheal intubation [published online ahead of print, 2019.


The most stressful situation for an anaesthesiologist may be a No intubate/No oxigenate (NINO) patient. A recent study (NAP 4) says that in spite of the fact that all algorithms have a strategy for this situation- in all of them cricotirotomy is the final solution-, the resolution is not good in most of them. Why is this? How could we correct the mistakes that arise?. Simulation has proven to be an effective tool to improve how crisis resources are managed, such as NINO patient and CPR. It allows mistakes to be analyzed and solutions found, thus improving our performance. But, what if we have a NINO patient on whom we are performing cardiopulmonary resuscitation? This study by Ott et al (BMJ 2019) tries to address this question by establishing a possible airway management situation that, however infrequent, must not be forgotten. We hope you enjoy reading it.

Pedro Charco Mora

Ott T, Stracke J, Sellin S, et al. Impact of cardiopulmonary resuscitation on a cannot intubate, cannot oxygenate condition: a randomised crossover simulation research study of the interaction between two algorithms. BMJ Open 2019;9:e030430. doi:10.1136/bmjopen-2019-030430

Open acces link (january 23th, 2020):


Dear airway enthusiasts,

This month’s article is a from Fiadjoe et al. about pediatric normal and difficult airway management. If you are curious about the following questions you have to read the full text:

  • • What are cognitive biases observed in pediatric difficult airway management?
  • • What are the strengths and weaknesses of videolaryngoscopes and flexible bronchoscopes for tracheal intubation?
  • • What is the current evidence for spontaneous versus controlled ventilation techniques when managing the anticipated difficult airway?
  • • What is the role of passive oxygenation in difficult airway management in the OR and pediatric ICU?
  • • What is the current evidence regarding the use of neuromuscular blockade in neonatal tracheal intubation and difficult airway in children?

Have fun at

Kemal Tolga Saracoglu

Dear EAMS community,

For a decade a manuscript looking at the impact of using a parachute for jumping out of a plane has been used to show the limitations of evidence-based medicine (Smith, G, Pell, J (2003) BMJ 327, 7429). Recently, a group of researches took this topic to the next level and performed a randomized, controlled trial to examine the impact of using a parachute vs. a backpack when jumping from aircraft. What has this to do with airway management? Please read this manuscript carefully! It draws some critical conclusions on how randomized trials need to be performed in order to address the clinical question or problem that counts. After reading this manuscript, you will never be reading an airway related article in the same way.

Enjoy this month's manuscript.

Robert W Yeh, Linda R Valsdottir, Michael W Yeh, Changyu Shen, Daniel B Kramer, Jordan B Strom, Eric A Secemsky, Joanne L Healy, Robert M Domeier, Dhruv S Kazi, Brahmajee K Nallamothu4 On behalf of the PARACHUTE Investigators: Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trialBMJ 2018;363:k5094

Best regards,

Rudy Noppens

Difficult airway adverse events are frequent in the hospital setting is associated with a worse outcome for patients. Patients with difficult airways present unique challenges in emergencies, especially when airway management is required outside the operating room. Current data indicate that the lack of a systematic approach for responding to difficult airway patients in an emergency is a significant factor for morbidity and mortality. The Johns Hopkins Hospital Difficult Airway Response Team (DART) program was created as a multidisciplinary effort to prevent airway related morbidity and mortality. The present manuscript by Mark et al. describes the structure, equipment and cases of the DART at Johns Hopkins. This information can be beneficial in creating a similar system in other hospitals. 
Ruediger Noppens

Emergency front-of-neck access (eFONA) is one of the most feared clinical interventions any of us is likely to face. Unfortunately, current evidence does not seem to provide enough guidance as to what is the most effective way of dealing with the dreaded can’t intubate can’t oxygenate scenario.

In this study, Rees et al have compared cannula and scalpel-bougie  eFONA techniques using time to oxygen delivery as their primary outcome. The value of this study is, perhaps, not as much in the main findings as it is in the analysis of failures and repeated attempts. Rees et al. found that the participants had lower odds of failure using cannula (one failure) than using scalpel – bougie technique (15 failures).

Knowing how and why failures happen can be invaluable and is likely to help individual anaesthetist make a more informed decision about what eFONA technique is likely to suit better their clinical environment and skill mix. Well worth reading.

Rees KA, O’Halloran LJ, Wawryk JB, Gotmaker R, Cameron EK, Woonton HDJ: Time to oxygenate for cannula- and scalpel-based techniques for emergency front-of-neck access: a wet lab simulation using an ovine modelAnaesthesia 2019; Early View.

As the summer is underway, we may find time to contemplate and reflect on the issues related to anaesthesia and airway management. 

To illustrate the unexpected nature of difficult airways, Pandit and Heidegger (Anaesthesia 2017; 72: 283-95) paraphrased the opening line of Tolstoy’s Ana Karenina stating that ‘all easy airways are alike, each difficult airway is difficult in its own way’. 

That unexpected nature of the airway management difficulty is perhaps a good reason to read this month’s article of the month while sitting in your garden on a lazy Sunday afternoon with a glass of your favourite refreshment.

This month’s article of the month is a narrative review of the strategies for the prevention of airway complications. The article provides an excellent overview of the current evidence pointing towards potential surprises and how to avoid them. I am still working on making some of these strategies part of my routine when managing the airway. I am picking one strategy at a time and making it become a habit so I can implement it without actively thinking about whether or how.

Enjoy it.

Cook TM, Strategies for the prevention of airway complications – a narrative review, Anaesthesia 2018; 73: 93-111.

Dear all

This is a recent study from the Danish Anaesthesia Register and they looked at predictors for difficulties with facemask ventilation.

Interestingly if their score is between 6–10 points these patients need special attention as it could turn out difficult mask ventilation compared to those with lower score. Higher the risks are obvious. A clear cut off value was not to establish and their proposed score needs prospective validation in clinical practice. All in all a new attempt  to solve a nearly impossible task - predicting what happens in the future but still a needed task - pre-anaesthesia evaluation to focus attention to possible problems of the patients, the process or the anaesthesia personnel which includes all of us.

Have fun in reading the article

Best regards

(Robert Greif)

Lundstrøm LH, Rosenstock CV, Wetterslev J, Nørskov AK: The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patientsAnaesthesia. 2019 May 20. doi: 10.1111/anae.14701. [Epub ahead of print]

Dear co-airway-afficionados!

In patients with pathology of the neck ultrasonography is highly accurate in localizing the cricothyroid membrane and is comparable to CT-scan as the accepted standard. And in this population the cricothyroid membrane was only identified successfully in 8% of the patients whereas ultrasonography resulted in 81% success. These are the findings of our colleagues Siddiqui, You-Ten and co-workers from Toronto who authored the first of the two EAMS-articles-of-the –Month for May 2019. It thus seems beneficial to identify the cricothyroid membrane before initiating airway management in this notoriously difficult group of patients, and we should consider to use bedside-ultrasound for this purpose.

This leads to the second of the articles where we look at the useful information for managing the airway of the difficult patients that we gain from identifying both the cricothyroid membrane and other important structures of the front-of-the-neck.

Enjoy your reading!

And remember that it is possible to comment on all articles-of-the-month via our EAMS-webpage.

Best from Copenhagen!


Michael Seltz Kristensen

Siddiqui N, Yu E, Boulis S, You-Ten KE: Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical TrialAnesthesiology. 2018 Dec;129(6):1132-1139

Dear airway enthusiasts,

This month's article is from Arnd Timmermann. In this very large multicentre, prospective observational cohort study including almost 250000 patients from more than 200 hospitals from 28 European countries the authors could demonstrate that the use of neuromuscular blocking agents (NMBA) in general anaesthesia was associated with an increased risk of postoperative pulmonary complications. Interestingly, this was more evident in patients with ASA status I or II. Nor the use of qualitative or quantitative neuromuscular monitoring or the use of reversal agents could reduce the risk of postoperative pulmonary complications.

They concluded that Anaesthetists must balance the potential benefits of NMBA´s against the increased risk of postoperative pulmonary complications.

The reader must know that it is not clear if these increased pulmonary complication rate are due the use of NMBA´s or the use of the endotracheal tube, since the airway of the group who has received no NMBA were almost all managed by the use of supraglottic airway devices. 

The article adds to the knowledge that the use of SGA in general anesthesia should be considered as the first line airway management strategy whenever feasible.


Kirmeier E, Eriksson LI, Lewald H, Jonsson Fagerlund M, Hoeft A, Hollmann M, Meistelman C, Hunter JM, Ulm K, Blobner M; POPULAR Contributors:  Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational studyLancet Respir Med. 2019 Feb;7(2):129-140

Dear EAMS members,

The February’s Article of Month is ready for your attention on A recently published review article by Ahmad I et al: Airway management research: a systematic review. The authors mention the lack of investigation for the examination of the methodology of airway research. The data they report provide a benchmark on methodology and end‐points used and demonstrate the geographical distribution of airway management research.

The authors retrieved 1505 relevant studies published between 2006 and 2017, together recruiting 359.648 subjects.A nice way to inform strategy on the future directions of airway management research. For more information we invite you to login the web page and read the full text of the article.


Dear airway enthusiasts,
This month's article has just been published in Journal of Clinical Anesthesia: Videolaryngoscopy versus direct laryngoscopy for nasotracheal intubation: A systematic review and meta-analysis of randomised controlled trials and recommended by Kemal Tolga Saracoglu. A nice opportunity to have the results from fourteen randomised controlled trials with 20 comparisons (n = 1052). If you want to learn whether the use of VL could improve the nasotracheal intubation outcomes, please visit: and login.
Have fun!

Dear Airway Enthusiasts

This month's article is a Cohrane review and coming from the president: Prof. Greif. The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear.
The objective of this review is to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway abnormalities.

Have fun!

Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H.Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H: Airway physical examination tests for detection of difficult airway management in apparently normal adult patient. Cochrane Database of Systematic Reviews 2018, Issue 5.


Dear EAMS Members;

This month's article was recently published by Massimiliano Sorbello et al. in European Journal of Anaesthesiology. Looks like we need to take lessons from their experience.

Dear Collogues and Airway Enthusiasts,

This month's article, chosen by Dr. Michael Seltz Kristensen, is a reminder that: if difficult/failed direct laryngoscopy is expected we must: 1) at least consider awake intubation... and 2) if we decide to induce anaesthesia we must not soleley rely on the success of an angulated videolaryngoscope, but we must have other rescue options avalable, including alternative techniques for intubation and a plan that is predicted to be successfull for ventilation/front of neck access. 

Arslan Zİ: The Channelled Airtraq® as a Rescue Device Following Failed Expected Difficult Intubation withArslan Zİ. The Channelled Airtraq® as a Rescue Device Following Failed Expected Difficult Intubation withan Angulated Video Laryngoscope. Turk J Anaesthesiol Reanim 2018; 46(5): 399-401.

Dear EAMS-Members,

Article of the Month September is recommended by Michael Seltz Kristensen from Denmark:
"This is THE SINGLE AIRWAY PAPER TO READ IF YOU ONLY WANT TO READ ONE PAPER IN ALL YOUR CAREER: The Canadian guidelines - so much covered in such a stringent manner in ONE paper!"

Dear EAMS-Members,

After a short summer holiday season, we are back with the article of month. This month’s contribution came from Prof. Arnd Timmermann. His article of the month is a German study done by the anesthesiologist and A&E physician Michael Bernhard and Coworkers from Leipzig, Germany. He took a closer look to the raising concerns around the usage of supraglottic airway devices (SAD) for out-of-hospital airway management. The dominate SAD device in Germany is the laryngeal tube (LT). The LT was critized for the unrecognized malposition’s leading in massive stomach inflation (≈10%) and severe tongue swelling (≈40%). It is unclear, if the usage of the LT and the specific malposition’s had any influence in the outcome of patients ventilated by the LT. Therefore the authors retrospectively analyzed data from the German Resuscitation Registry for a study period of 6½ years, including approximately 43.000 patients after out of-hospital cardiac arrest treated with manual chest compression and automated chest compression devices and who were ventilated by a laryngeal tube or an endotracheal tube. Nearly 27.500 patients fulfilled study criteria and were including for further analysis. This study demonstrated that patients treated with SAD only suffered from the lowest hospital admission rate with ROSC, lowest survival rate to hospital, discharge, and lowest survival rate to hospital discharge with good neurological outcome in comparison to all other airway and compression methods. The result were better if the LT was immediately was replaced with an ET by a supporting emergency physician at the out of hospital scene. The authors concluded that SAD only should be avoided or SAD should be changed into ETI, independent of whether chest compression method was used.

This months article comes from Dr. Rüdiger Noppens and focuses on a back-up strategy for potential difficult re-intubation in the ICU setting. The authors examined the impact of the guide wire of the staged extubation set on correct positioning and patient tolerance. This is one of the first manuscripts looking on the feasibility of this strategy over a prolonged time period. Have fun!

S. McManus, L. Jones, C. Anstey and S. Senthuran: An assessment of the tolerability of the Cook staged extubation wire in patients with known or suspected difficult airways extubated in intensive careAnaesthesia 2018, 73, 587–593

Dear readers of EAMS’ article of the month section. 

For this this month’s article, we present you a recent narrative review by Tim Cook, titled "Strategies for the prevention of airway complications – a narrative Review”. The article is not featuring classic research results, but you will find a nice overview of many important points that apply to airway management, up–to-date.


Lorenz Theiler

T. M. Cook: Strategies for the prevention of airway complications – a narrative review. Anaesthesia 2018, 73, 93–111

Dear EAMS members,

This month’s article is from Lorenz Theiler, you will actually find 2 articles attached.

Both articles should be enlightening as they reflect this year’s European Airway Congress: From the past to the future of airway management

The first article is the classic paper by Cormack and Lehane. When you read the 1984 article carefully, you will realize that, yes, the authors do mention the four grades of the best view obtained in direct laryngoscopy. But in its core, the article is about teaching airway management. Because difficulties in airway management are rarely encountered, we have to make up for it by actively teaching it all the time. Cormack and Lehane are doing a great job in transferring this message.

The second article is another classic. Magill’s paper about airway management, dated 1930. When I read his thoughts, I was not surprised how much has changed in the last ninety years, but instead I was awed by the fact that much stayed the same. I realized many believes we have about airway management are in fact just that: believes. They come from another time, driven by circumstances very different from today. It might be worth thinking about this, and constantly keep reflecting whether our actions are still adequate. 


Magill 1930 Techniques in Anaesthesia

Cormack Lehane 1984 Difficult tracheal intubation in obstetrics

Dear airway enthusiasts, This month we suggest you to read the latest guideline for the management of tracheal intubation in critically ill adults. The article is coming from Massimiliano Sorbello who is one of the Italian reviewers of this guideline with Flavia Petrini. Here you will find the tracheal intubation algorithm and the can’t intubate can’t oxygenate algorithm. Please log in and read the full text! Have fun..

A. Higgs, B. A. McGrath, C. Goddard, J. Rangasami, G. Suntharalingam R. Gale, T. M. Cook and on behalf of Difficult Airway Society, Intensive Care Society, Faculty of Intensive Care Medicine, Royal College of Anaesthetists: Guidelines for the management of tracheal intubation in critically ill adultsBritish Journal of Anaesthesia, Volume 120, Issue 2, 323 - 352

Dear airway enthusiasts;

This month’s article is about a 5-year retrospective analysis of Extraglottic airway devices. A choice from our Board member Massimiliano Sorbello. The authors point out the incidence of perioperative extraglottic airway device failure and identify modifiable factors associated with this complication that may be the target of preventative or mitigating interventions. Please login to reach the full text and enjoy the article!

For December article of the month, we have selected an article from the December issue of Anaesthesia:
Although this article appears to suggest what many of us think we already know, this is one of the first articles to use the power of the systematic review and meta-analysis to state that anaesthetists are better of using videolaryngoscopes when managing difficult airways. This article has confirmed that VLSs have higher success rate, shorter intubation time, are associated with fewer intubation attempts and are less likely to cause airway injury when compared to Macintosh laryngoscope. All extremely relevant factors for difficult airway management.

Please be aware that the full texts will be provided to EAMS members with login to

With best wishes
Iljas Hodzovic, MD, FRCA

Dear Colleagues;

This month, the articles are related with tracheal extubation. The first paper is a guideline on ‘’Intubation and extubation of the ICU patient’’. You will find recommendations from experts of the SFAR and SRLF.

Quintard H, l'Her E, Pottecher J, Adnet F, Constantin JM, De Jong A, Diemunsch P, Fesseau R, Freynet A, Girault C, Guitton C, Hamonic Y, Maury E, Mekontso-Dessap A, Michel F, Nolent P, Perbet S, Prat G, Roquilly A, Tazarourte K, Terzi N, Thille AW, Alves M, Gayat E, Donetti L. Intubation and extubation of the ICU patient. Anaesth Crit Care Pain Med 2017 Oct;36(5):327-341.

No abstract available

The second paper is again from France: a randomised controlled trial  which compares suction with positive pressure before extubation in adult patients.

L'Hermite J, Wira O, Castelli C, de La Coussaye JE, Ripart J, Cuvillon P. Tracheal extubation with suction vs. positive pressure during emergence from general anaesthesia in adults: A randomised controlled trial. Anaesth Crit Care Pain Med 2017 Sep 4. pii: S2352-5568(17)30001-2. doi: 10.1016/j.accpm.2017.07.005. 

After general anaesthesia (GA) in adults, the optimal tracheal extubation technique (positiveBackground: After general anaesthesia (GA) in adults, the optimal tracheal extubation technique (positivepressure or suctioning) remains debated. The primary endpoint of this study was to assess the effects ofthese techniques on onset time of desaturation (SpO2 < 92%).Methods: Sixty-nine patients with a body mass index < 30 scheduled for elective orthopaedic surgerywere allocated to positive pressure (PP) or suctioning (SUC) group. GA was standardised with propofoland remifentanil via target-controlled infusion. A morphine bolus of 0.15 mg/kg was administered 20–30 mins before the end of surgery. The effect of extubation technique on onset time of desaturation (T92)was assessed during the first 10 mins after extubation during the spontaneous air breathing. Secondaryendpoints included: frequency of desaturation, respiratory complications, need to use oxygen therapyand SpO2 at the end of the first hour while breathing in air ( identifier: NCT01323049).Results: Baseline patient characteristics and intraoperative management data for the 68 patientsincluded had no relevant clinical difference between groups. T92 (sec) after tracheal extubation was 214(168) vs. 248 (148) in the PP and SUC groups, respectively (P = 0.44). In the PP and SUC groups, 50 and43% reached a SpO2 < 92% within the first 10 mins after extubation respectively (P = 0.73). There were nostatistically significant differences between groups for any secondary endpoints.Conclusions: Positive pressure extubation as compared with suctioning extubation did not seem to delayonset time of desaturation after GA in standard weight adult patients.

Please be aware that the full texts will be provided to EAMS members with login to

With best wishes
Kemal Tolga Saracoglu
Co-secretary of the European Airway Management Society

In order to start the Article of the Month process, I have selected two articles, both related to the importance of pre-oxygenation. One of the articles discusses the physiological basis, benefits and potential risks of pre-oxygenation:

Anesth Analg. 2017 Feb;124(2):507-517. doi: 10.1213/ANE.0000000000001589. Preoxygenation: Physiologic Basis, Benefits, and Potential Risks. Nimmagadda U, Salem MR, Crystal GJ.

I have also included two meta-analyses from the emergency medicine journals related to the pre-oxyganation in the emergency room. What works in the emergency room is likely to be relevant under more controlled conditions in the operating room:

Am J Emerg Med. 2017 Aug;35(8):1184-1189. doi: 10.1016/j.ajem.2017.06.029. Epub 2017 Jun 15. Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Pavlov I, Medrano S, Weingart S.

Am J Emerg Med. 2017 Oct;35(10):1542-1546. doi: 10.1016/j.ajem.2017.06.046. Epub 2017 Jun 24. Apneic oxygenation during intubation in the emergency department and during retrieval: A systematic review and meta-analysis. Binks MJ, Holyoak RS, Melhuish TM, Vlok R, Bond E, White LD.

With that you should have enough arguments for any discussion about this topic.

Have fun in reading the articles that will be provided to EAMS members with login to as full-text PDF's.

Best regards
Tino Greif
President of the European Airway Management Society



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