Acute epiglottitis is uncommon in adults but can obstruct the airway within hours. Although few patients require airway intervention, those who do present one of the highest-risk intubation scenarios in clinical practice. Obesity further complicates physiological or technical challenges of airway management. It shortens safe apnea time, weakens the seal of a facemask or supraglottic device, hides the neck landmarks needed for a surgical airway, and can make imaging of the neck uninterpretable. A 39-year-old man presented with two days of sore throat, dysphagia, and a muffled voice. He had asthma, hypertension, and severe obstructive sleep apnea treated with home continuous positive airway pressure. His body mass index was 66.5 kg/m[2], with a weight of more than 200 kg. Urgent care had treated him for pharyngitis after a negative rapid streptococcal test. In the emergency department, the working diagnosis was angioedema. Intravenous dexamethasone and intramuscular epinephrine initially improved his symptoms over three hours, and then he deteriorated again. A lateral neck radiograph was reported as markedly limited by body habitus, and he declined a computed tomography scan because he could not tolerate supine positioning. After induction with intravenous ketamine, intubation with video laryngoscopy failed because the epiglottis was too swollen to admit an endotracheal tube, and oxygen saturation fell to 62%. Fiberoptic laryngoscopy was also unable to pass the swollen epiglottis, with a second desaturation to 69%. Laryngeal mask airway placement, only with an extensive two-handed jaw thrust maneuver, restored saturation to 99%, and a general surgeon performed a bedside cricothyroidotomy, placing a 6.0 mm endotracheal tube 40 minutes after the decision to intubate. Tracheostomy was attempted in the operating room but aborted because the trachea lay too deep. On hospital day 4, an otolaryngologist drained an epiglottic abscess and exchanged the cricothyroidotomy tube for an oral endotracheal tube through direct laryngoscopy with rigid and fiberoptic bronchoscopies, and cultures grew group G beta-hemolytic Streptococcus. Severe acute respiratory distress syndrome, biventricular systolic dysfunction, bilateral deep vein thromboses despite prophylaxis, and a peroneal compressive neuropathy followed. He went home on hospital day 46 with the cricothyroidotomy stoma still open. Three lessons follow. First, an improved response to steroids and epinephrine in supraglottic obstruction can still be temporary and should not be read as a trend. Second, in a patient of this size, one failed intubation attempt can be all that separates a stable airway from a "cannot intubate, cannot oxygenate" emergency. And, third, a cricothyroidotomy tube in a deep neck is not a definitive airway and may not hold its position, so the plan for converting it should be established before placement.

Background and Objectives: Hypoxia is the most common adverse event in patients undergoing procedural sedation. Burn-related pain is severe and often requires high doses of opioids and anxiolytics, increasing the risk of respiratory depression. This study aimed to compare the effectiveness of high-flow nasal oxygen (HFNO) and standard nasal oxygen (SNO) in preventing hypoxia during deep sedation in patients with minor and moderate burns. Materials and Methods: This single-center prospective observational study enrolled 76 adult patients (ASA I-III) with minor to moderate burns undergoing supine-position procedures under sedation. Patients were allocated to HFNO (n = 38) or SNO (n = 38) groups according to a pre-specified, non-randomized allocation rule based on an alternating/sequential assignment by admission order. Peripheral oxygen saturation (SpO2), Bispectral Index (BIS), and Near-Infrared Spectroscopy (NIRS) were monitored throughout. Desaturation was defined as SpO2 ≤ 90%; severe hypoxia as SpO2 < 75%. Sedation depth was standardized using BIS (target: 60-80). Propofol-ketamine-based induction was used in all patients. Results: Groups were comparable in demographics, comorbidities, burn characteristics, and procedural duration. SpO2 ≤ 90% occurred in 79% of SNO patients vs. 11% in the HFNO group (p < 0.001). SpO2 between 75 and 90% was observed in 68% of SNO vs. 0% of HFNO patients (p < 0.001), and SpO2 < 75% in 26% vs. 0% (p < 0.001). Airway interventions-jaw thrust, flow increase, and FiO2 increase-were significantly more frequent in the SNO group (84% vs. 2.6%, 84% vs. 11%, and 84% vs. 5.3%, respectively; all p < 0.001). No significant between-group differences were noted in procedure interruptions, laryngospasm, BIS, NIRS, or hemodynamic parameters. Conclusions: HFNO significantly reduced the incidence of hypoxia and the need for airway interventions compared with SNO during deep sedation in minor and moderate burn patients. These findings suggest that HFNO may represent a preferable oxygenation strategy in this population; given the observational design of this study, confirmation in randomized controlled trials is warranted before this can inform routine practice recommendations.

Voluntary upper eyelid opening stretches mechanoreceptors in the superior tarsal muscle (STM), serving as an analog to a serial muscle spindle, inducing reflex contractions of slow-twitch fibers in the levator palpebrae superioris and facial expression muscles via the mesencephalic trigeminal nucleus and rostral locus coeruleus (LC). Because the LC projects widely to the brainstem and spinal cord, we hypothesized that excessive STM mechanoreceptor stretching could induce dystonic contractions across broader muscle groups. This observational case report describes two unique patients presenting with multifocal and limb dystonia. Diagnostic mechanical testing (eyebrow elevation and cheek depression via taping) and sensory masking (high-frequency focal vibration) were utilized to evaluate the immediate modulation of proprioceptive inputs. Therapeutic interventions included oculoplastic surgical reconstruction with longitudinal follow-up intervals ranging from 1 week to 18 months. Case 1 involved a 29-year-old man with severe levator aponeurosis disinsertion presenting with task-specific limb flexion dystonia. Mechanical reduction of the STM stretch, initially via taped eyebrow elevation and subsequently through corrective surgery, completely resolved the dystonic movements. Case 2 involved a 38-year-old man who developed left-predominant craniocervical and limb dystonia following lower eyelid surgery, driven by increased reflex contractions of the palpebral orbicularis oculi muscle opposing eyelid opening. Symptoms were significantly alleviated either by facial taping to reduce STM stretching or by applying high-frequency focal vibration to trigeminal nerve branches to mask the abnormal proprioceptive input. Secondary metabolic, drug-induced, and primary genetic etiologies were formally ruled out in both cases. These cases suggest a novel, hypothesis-generating model wherein excessive proprioceptive stimulation from STM mechanoreceptors hyperactivates the rostral LC, potentially exerting downstream tonic influences on spinal and brainstem motor pathways. While these striking clinical outcomes highlight a plausible ocular-proprioceptive trigger for craniocervical and peripheral dystonias, prospective controlled studies are required to validate this pathophysiological mechanism.

Airway management failure remains one of the most consequential adverse events in clinical practice, with the potential for severe hypoxemia, cardiac arrest, and death. While traditional airway adjuncts, such as oropharyngeal airways (OPAs) and nasopharyngeal airways (NPAs), serve as foundational rescue tools, their limitations, including the inability to access distal pharyngeal obstructions, risk of laryngospasm, and incompatibility with positive pressure ventilation, underscore the need for innovative solutions. The distal pharyngeal airway (DPA) is a relatively novel device designed to extend beyond the tongue base to the level of the epiglottis, addressing the most common anatomic site of upper airway obstruction. We present two cases that demonstrate the lifesaving utility of the DPA in high-acuity airway emergencies. The first case describes a 47-year-old male with a BMI of 46, a history of obstructive sleep apnea and multiple comorbidities, who experienced rapid oxygen desaturation to 60% during procedural sedation for esophagogastroduodenoscopy (EGD). The jaw thrust maneuver proved ineffective; insertion of the DPA device through the endoscopic bite block aperture with bag-valve-mask ventilation restored oxygen saturation within 30 seconds, and the procedure was completed successfully. The second case involves a 69-year-old female who presented in acute respiratory distress following thyroid lobectomy, with a postoperative hematoma causing tracheal displacement and complete obliteration of anterior neck landmarks. Sequential failed attempts with two video laryngoscopes and a supraglottic airway resulted in oxygen saturation declining to 60%. DPA placement with two-person assisted mask ventilation successfully restored ventilation and oxygenation, bridging the patient to definitive airway management and subsequent video laryngoscopy-assisted intubation with a bougie. These cases highlight the DPA as an effective rescue device in both procedural and emergency airway settings, particularly when conventional adjuncts fail. Early recognition of high-risk scenarios, systematic decision-making, team coordination, and access to innovative devices such as the DPA are essential to optimizing patient safety and outcomes across diverse clinical environments.

Background and Objectives: Remimazolam and remifentanil are ultra-short-acting agents that are used for sedation and analgesia, respectively. Their combined effect on respiratory function is unclear. We evaluated whether co-administration produced dose-dependent respiratory depression and loss of consciousness (LOC) preceded oxygen desaturation. Materials and Methods: A randomized, double-blind trial was conducted from May to July 2024. Female patients (20-65 years; n = 108; American Society of Anesthesiologists physical status I-II) undergoing elective gynecological surgery were selected. Patients received remifentanil via target-controlled infusion (TCI) at effect-site concentrations (Ce) of 1.0, 1.5, or 2.0 ng/mL (Groups 1.0, 1.5, and 2.0) combined with a fixed Ce of 500 ng/mL remimazolam. Respiratory variables, timing of LOC, bispectral index, and adverse events were recorded. Results: Respiratory depression increased in a dose-dependent manner. Jaw thrust was required in 52.8% of Group 1.0 and 91.7% of Group 2.0 (p < 0.001). The need for 100% oxygen increased from 30.6% to 69.4% (p = 0.001). Minute ventilation decreased only in Group 2.0 (p = 0.008). Involuntary movements were frequent in Group 1.0 (p = 0.005). Conclusions: Remimazolam-remifentanil co-administration via TCI induced dose-dependent respiratory depression and pre-LOC desaturation. Therefore, continuous monitoring and careful titration are essential.

BACKGROUND Procedural sedation and analgesia (PSA) can relieve pain and anxiety during invasive procedures. Carbon dioxide (CO2) monitoring or integrated pulmonary index (IPI) can reduce respiratory depression in adults with PSA, but the effect of the combination of these 2 methods on intraoperative hypoxemia in pediatric urologic surgery is unclear. This study was conducted to determine whether capnography combined with IPI could lessen intraoperative hypoxemia during pediatric urinary procedures with PSA. MATERIAL AND METHODS We conducted a randomized controlled trial (ChiCTR 2300073943). Children referred for urinary procedures with PSA were randomly assigned to either a control group with standard monitoring or an intervention group with standard monitoring combined with capnography and IPI monitoring. The primary outcome was intraoperative hypoxemia. Secondary outcomes were severe intraoperative hypoxemia, airway management, and perioperative complications. RESULTS A total of 133 patients completed the analysis (67 in the intervention group and 66 in the control group). Compared with the control group, the incidence of intraoperative oxygen saturation decline was significantly lower in the intervention group (34.33% vs 56.06%, odds ratio=0.410, 95% confidence interval: 0.203-0.825, P=0.012). Simultaneously, the incidence of severe oxygen desaturation (SpO2 <90%) was also significantly reduced in the intervention group (19.40% vs 36.40%, odds ratio=0.421, 95% confidence interval: 0.192-0.925, P=0.034). Regarding airway management interventions, the intervention group exhibited a higher frequency of jaw thrust maneuvers (1.84±1.31 vs 1.17±1.12 times, P=0.004) and a significantly reduced need for invasive positive-pressure ventilation (1.64±1.31 vs 2.39±1.48, P=0.002). No differences in other airway management techniques or perioperative complications were observed between the 2 groups. CONCLUSIONS The addition of capnography and IPI monitoring to standard monitoring reduces the risk of intraoperative hypoxemia in pediatric urologic surgery and reduces the need for aggressive ventilation through early intervention.

The mnemonic "MR SOPA" (Mask adjustment, Repositioning head/airway, Suctioning, Open mouth, Pressure increase and Alternative airway) facilitates remembering corrective steps when ventilation during neonatal resuscitation is inadequate. Here, we critically evaluate the scientific evidence for each step and appraise the usefulness of the mnemonic as a sequential guidance in airway management of newborn infants: Mask: Size and placement are crucial to minimize mask leak and airway obstruction. Firm top and flexible edges may help form a better seal, while mask shape seems to be less important. Two-person holding technique may optimize applied tidal volumes. Repositioning: A neutral head position in newborns may improve airway patency. Suctioning: Suctioning should be reserved for infants with perceived airway obstruction to reduce vagal stimulation or tissue damage. Open the mouth/airway: There is no data on opening the mouth per se. Airway maneuvers like chin lift and jaw thrust may improve airway patency. Pressure increase: Despite weak evidence, increased PIP of ≥25 cmH2O may be necessary to overcome closed glottis and fluid-filled lungs in non-breathing infants but must be titrated carefully to preclude lung injury. Alternative airway: Nasopharyngeal tubes and laryngeal masks are valid options when face mask ventilation fails. Endotracheal intubation remains the gold standard but should be reserved for experienced staff. These statements are based on scarce and limited evidence, largely from preclinical or smaller clinical studies. There is no evidence for performing the MRSOPA steps in its original sequence. Thus, more rigorous studies are needed to substantiate nature, timing and order of the interventions.