These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

Summary Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

This study sought to compare and contrast the beliefs and expectations of two groups--the one choosing to visit an orthodox medical general practitioner and the other a complementary medicine homeopath. Eighty patients from each group were compared and were found not to be significantly different in sex, level of education, marital status, religious or political affiliation. They completed a fairly lengthy questionnaire which examined health consciousness, perceived health risks, illness prevention, general health beliefs, treatment preference, medical history, mental health and health locus of control. Compared to patients of orthodox medicine, homeopathic patients claimed to (a) take less notice of popular health care recommendations; (b) believe in numerous 'healthy life-style' methods of preventing illness; (c) trust more in their chosen primary health professional (and to try other complementary medical practices); and (d) be dissatisfied with orthodox medicine and believe in potential self-control over health. Results were not dissimilar to previous studies (Furnham & Smith, 1988) but limitations of this particular study were considered.

We read with much interest the special article by Frerk and colleagues 1 about recent updated guidelines on the management of unanticipated difficult intubation in adults. The article appears to be very informative and assists in decision making. The authors described use of the scalpel-finger-bougie technique in case of impalpable cricothyroid membrane and suggested a midline vertical skin incision of 8-10 cm directed caudad to cephalad. We found an 8-10 cm length of incision over the trachea to be quite debatable, as it can lead to higher risk of bleeding/oozing from the local tissues making poor visualization of landmarks and risk of infection postoperatively. However, it can help in better palpation of the cricothyroid membrane. 2 We suggest the authors should acknowledge the use of techniques such as infiltration of local anaesthetic along with epinephrine, or the standby measures such as application of cautery (monopolar/bipolar), to stop bleeding at the local site while performing the procedure in an emergency.

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This is why we have always advocated this technique, but acknowledged that occasionally you may be somewhere with no immediate access to a size 6.0 tracheal tube, but a 6.0 ETT can be found in the intubation drawer. The rest of the guidelines and principles I think are excellent, but I am concerned that the DAS has specified the bougie technique as the UK standard rather than the simpler (and arguably, safer) four step technique described 20 yr ago and used successfully many times since.

The conventional treatment for patients with acute upper airway obstruction is tracheostomy, which is a safe, definitive procedure in most hands. Alternatively, a debulking procedure can be considered but this requires both surgical and anaesthetic skill and expertise. However, where possible, it provides a good alternative with the advantages of removing the cause of obstruction and yielding tissue for histopathological analysis, and avoiding the need for a tracheostomy, with its associated morbidity. We evaluated all patients who presented with acute upper airway obstruction and underwent endoscopic laser debulking surgery performed by the senior author, over a three and a half year period. We recorded patient demographic data, their underlying pathologies, complication rates associated with laser debulking surgery and the conversion to tracheostomy. Thirty patients were identified, including 19 males and 11 females, with a mean age of 57.10 ± 17.20 years (19-93 years). All patients underwent debulking procedures with carbon dioxide laser under general anaesthetic. All patients had their underlying diagnosis confirmed from their debulking surgery. Twelve patients were found to have benign pathology and 18 had malignant airway obstruction. There were no laser-associated complications. One patient required conversion to emergency tracheostomy, during their debulking surgery. Endoscopic laser assisted debulking surgery has successfully been used to establish a safe airway. It allows obtaining tissue specimens, to confirm the underlying diagnosis, thus avoiding the need for further biopsies under anaesthetic. For all malignant cases, patients were subsequently able to proceed to definitive treatment. It has obviated the need for emergency tracheostomy in almost all of the cases in our patient cohort.

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