İHolaḷ Your concern for the patients is indeed very much appreciated. However, performing FI is everything but strait forward thing. There are many conditions that have to be met, like the performance of the anaesthesiologist, patient cooperation, perfect local anaesthesia and just wright sedation. Admit it or not, due to so many demands, most of the awake FI end up with a bolus of propofol. CVCI very rarely happens in patients who have both, difficult mask ventilation and difficult intubation after induction of general anaesthesia. This situation is usually resolved with a rescue airway placement  (LMA) or an intubation through a Fastraq. CVCI usually happens after many unsuccessful attempts at intubation due to the swollen or even damaged airway.     Since I work in the pediatric setting too, I see the problem of difficult mask ventilation in children far more frequent and challenging compared to adults. They are more prone to upper airway obstruction under sedation and general anesthesia than adults.  DMV very often develop during the light anesthesia (excitement) stage when using an inhaled induction. Children are also more prone to pharyngeal collapse, enlarged adenoids/ tonsils, laryngeal spasm, recurrent upper respiratory tract infection and so forth. Recuerdos de Ljubljana

I will rather talk about the clinical predictors of unsuccessful mask ventilation which correlate well with a difficult intubation. These are a history of snoring, obstructive sleep apnea, obese neck anatomy, limited mandibular protrusion, and BMI of 30 kg/m2 or more. In these patients an awake FI is recommended. 

Endotracheal intubation in the case of expected difficult airway does not necessarily need to be performed in a patient awake. If I assume (history, clinical signs) that the mask ventilation should not be a problem after induction of general anesthesia I perform ETI in a patient asleep following the same quidelines that were suggested by Difficult airaway society to be used for unexpected difficult airway (first bougie, than Airtraq plus/minus bougie or FB and finaly ILMA plus/minus FB). The usefulness of that algorhitm had been tested in more that 12000 patients by french researches and recently published in Anesthesiology. In our department we use FI routinely in patients asleep for teaching purposes (a PPP will shortly be posted), in awake patients with difficult airway and problematic mask ventilation and in awake patients after big operations in the upper airway to be guided to the glottis (by patients' phonation) in the case of changed anatomy.    

Recently we have got a few samples of AirQ to be used in children (No. 1,5-3).  My expectations were high since it shares some structural features with the Fastraq currently not available for children < 30 kg. AirQ has in fact been advertised as an intubating laryngeal mask airway designed primarily to allow for the passage of conventional cuffed tracheal tubes used for blind tracheal intubation. Accordingly, in comparison to the classical LMA, its’ airway tube is wider, shorter, more rigid and curved and it has the possibility to remove the proximal connector, in order to increase the internal diameter of the tube. However, in spite of these features similar to the Fastraq, the blind intubation we performed through the ILMA No. 1,5-2 did not succeed, not even by coincidence. We therefore proceeded with the fiberoptic guidance and succeeded, which has already been demonstrated in the two previous studies in children with normal and difficult airways. Air-Q, therefore, is not a Fastraq for children since the latter’s foremost feature is its applicability in blind intubation, one which Air-Q is incapable of.

Nice presentation of an awake ILMA insertion. I also find ILMA very useful for intubation and/or ventilation in difficult airway cases. I personally use it as a second choice tool, after Airtraq, in an unexpected difficult airway scenarios. I usually start the intubation through an ILMA blindely and if it does not work that way I switch to a fiberoptical guidance. In the expected difficult airway I use the ILMA after induction of anaesthesia and estimation that the mask ventilation should not be a problem. However, I do not recommend its usage in pharyngeal and laryngeal malignancies, after their operative removal and radiotherapy because the ILMA seal is usually very bad and intubation impossible due to the changed anatomy. In these cases I go for an awake FI.    Best regards Tatjana