Anticipation, Assessment and Continuum of Airway Care

Airway management is of paramount importance in perioperative medicine. The current issue of airway features two studies, one evaluating the use of ultrasound as a preoperative predictor for difficult mask ventilation (DMV) and difficult laryngoscopy (DL), and another was a prospective audit of tracheostomy practice at a tertiary ear, nose and throat centre.[1,2] Read together, they infer something broader: that safe airway practice is not an isolated event but an evolving process, beginning well before induction and extending long after the patient leaves the operating room. Over the last decade, ultrasonography has evolved as a reliable addition to conventional preoperative airway assessment.[3] The study by Rog et al. in this issue contributes to this literature by evaluating ultrasound measurements of anterior neck soft-tissue thickness across five anatomical landmarks in 83 patients undergoing elective surgery under general anaesthesia. Their principal finding was that the Distance from Skin to Hyoid Bone (DSHB) and the Distance from Skin to Anterior Commissure of the Vocal Cord were statistically associated with DMV, whereas no ultrasound parameter predicted DL, adding a useful data point to a field where the evidence has been inconsistent. The receiver operating characteristic analysis for DSHB yielded an area under the curve of 0.94, with a reported sensitivity of 100% and specificity of 90% at a cut-off of 0.72 cm, findings that appear promising when viewed in isolation. However, the authors rightly note that only two patients had DMV (Han Scale Grade 3 or 4). Therefore, these results should be interpreted with caution and considered preliminary. Sensitivity values based on such a small number of positive cases may not be reliable, and the wide confidence interval (0.86–1.0) further highlights this uncertainty. The absence of a significant association between any ultrasound parameter and DL is itself informative. This may be due to the study population being predominantly non-obese (mean body mass index: 24.4 kg/m2). In lean individuals, variations in anterior neck soft tissue may be minimal, limiting its predictive utility. The inference is not that the role of ultrasound is limited, but that its utility for prediction of DL may be population specific, most relevant in patients where excess soft tissue is a possible contributor to difficulty in accessing the laryngeal inlet.[4] Several other methodological limitations, like single-centre design, convenience sampling and a single operator, limit generalisability of the findings. The study supports the evolving role of airway ultrasound in routine pre-operative airway evaluation. The study also reiterates an important principle in airway research that no single parameter reliably predicts a difficult airway. Along with other clinical predictors of difficult airway, ultrasound-based parameters should also be combined to form a composite score, which increases the predictive value of the composite.[5] The emerging role of artificial intelligence would help construct a multimodal prediction model that combines clinical examination, ultrasound measurements and dynamic airway assessment.[6] The second article shifts focus from preoperative assessment clinics to the wards, intensive care units (ICUs) and operating rooms. It is a prospective observational audit conducted by Bhat et al. evaluated 164 patients undergoing tracheostomy documents indications, operative characteristics, complications and outcomes in a tertiary healthcare centre.[2] The principal finding of the study was that almost 57% of tracheostomies were performed for prolonged intubation, mainly in patients with head injuries, central nervous system disorders and respiratory failure. Patients with head-and-neck malignancy were the second most common to undergo tracheostomy in the study cohort, with most of them were done electively in anticipation of airway difficulty during anaesthesia for diagnostic or definitive procedures. The complication rate of 9.1% is notable and is on the lower end of the range reported in the literature. The distribution of complications across immediate, early and late categories, with haemorrhage requiring return to theatre accounting for all immediate events, and tube displacement and subcutaneous emphysema predominating in the early postoperative window. This profile highlights that outcomes depend as much on post-operative monitoring and tube management as on the surgical technique of the procedure itself.[7] The present study’s observation that 87% of its intubation–indication patients underwent late tracheostomy, and that early and late groups did not differ significantly in median ICU length of stay, is consistent with the current evidence.[8] These findings suggest that the decision on when to perform a tracheostomy should be tailored to each patient rather than adhering to a rigid protocol.[9,10] The prospective design and inclusion of both elective and emergency tracheostomies enhance the study’s clinical relevance. However, a single-centre study, the absence of long-term follow-up and relatively small subgroup sizes limit the broader applicability of the findings. In addition, long-term outcomes, including speech rehabilitation, swallowing function, quality of life and late tracheal complications, have not been explored and warrant further investigation. Considered together, these two studies lie at two ends of airway management, one at its beginning and the other at its consequences. The ultrasound study asks: can we know, before anaesthesia begins, who will be difficult to ventilate? The tracheostomy study asks: what happens to patients for whom the airway becomes a sustained clinical problem, requiring a definitive surgical solution? To conclude, managing the airway well is not an event; it is a process. It begins with whatever the clinician assesses before induction of anaesthesia, and it ends with successful decannulation, rehabilitation and the restoration of a patient’s ability to breathe without mechanical assistance. Between those two points lies an enormous amount of clinical work, much of it is critical. Ultrasound and surgical technique are tools within that process. The clinical judgment that decides when and how to use them is something that no tool replaces, and quality clinical research continues to refine. Consent statement Not applicable. Authors contributions Dr Swapnil Parab - Manuscript modification, Final approval,Proof reading; Dr Virinchi Sanapala- Manuscript drafting, Review of Literature. Disclosure of use of artificial intelligence (AI) assistive or generative tools Grammarly AI was used exclusively for language and grammar correction. No AI tools were used for generation of scientific content. Financial support and sponsorship Nil. Conflicts of interest Swapnil Y. Parab is Associate Editor, and Virinchi Sanapala is Assistant Editor of this journal.