SummaryWe compared the efficacy of the inflatable cuff of the LMA Supreme TM against the non-inflatable i-gel TM cuff in providing an adequate seal for laparoscopic surgery in the Trendelenburg position in 100 female patients. There was no difference in our primary outcome, oropharyngeal leak pressure, between the LMA Supreme and the i-gel (mean (SD) 26.4 (5.1) vs 25.0 (5.7) cmH 2 O, respectively; p = 0.18). Forty-seven (94%) LMA Supremes and 48 (96%) i-gels were successfully inserted on the first attempt, with similar ease, and comparable times to the first capnograph trace (mean (SD) 14.3 (4.7) s for the LMA Supreme vs 15.4 (8.2) s for the i-gel; p = 0.4). Gastric tube insertion was easier and achieved more quickly with the LMA Supreme vs the i-gel (9.0 (2.5) s vs 15.1 (7.3) s, respectively; p < 0.001). After creation of the pneumoperitoneum, there was a smaller difference between expired and inspired tidal volumes with the LMA Supreme (21.5 (15.2) ml) than with the i-gel (31.2 (23.5) ml; p = 0.009). There was blood on removal of two LMA Supremes and one i-gel. Four patients in the LMA Supreme group and one patient in the i-gel group experienced mild postoperative sore throat.

Inability to identify the cricothyroid membrane by inspection and palpation contributes substantially to the high failure rate of cricothyrotomy. This narrative review summarizes the current evidence for application of airway ultrasonography for identification of the cricothyroid membrane compared with the clinical techniques. We identified the best-documented techniques for bedside use, their success rates, and the necessary training for airway-ultrasound-naïve clinicians. After a short but structured training, the cricothyroid membrane can be identified using ultrasound in difficult patients by previously airway-ultrasound naïve anaesthetists with double the success rate of palpation. Based on the literature, we recommend identifying the cricothyroid membrane before induction of anaesthesia in all patients. Although inspection and palpation may suffice in most patients, the remaining patients will need ultrasonographic identification; a service that we should aim at making available in all locations where anaesthesia is undertaken and where patients with difficult airways could be encountered.

ObjectivesTo create a state-of-the-art overview of the new and expanding role of ultrasonography in clinical decision-making, intervention and management of the upper and lower airways, that is clinically relevant, up-to-date and practically useful for clinicians.MethodsThis is a narrative review combined with a structured Medline literature search.ResultsUltrasonography can be utilised to predict airway difficulty during induction of anaesthesia, evaluate if the stomach is empty or possesses gastric content that poses an aspiration risk, localise the essential cricothyroid membrane prior to difficult airway management, perform nerve blocks for awake intubation, confirm tracheal or oesophageal intubation and facilitate localisation of tracheal rings for tracheostomy. Ultrasonography is an excellent diagnostic tool in intraoperative and emergency diagnosis of pneumothorax. It also enables diagnosis and treatment of interstitial syndrome, lung consolidation, atelectasis, pleural effusion and differentiates causes of acute breathlessness during pregnancy. Patient safety can be enhanced by performing procedures under ultrasound guidance, e.g. thoracocentesis, vascular line access and help guide timing of removal of chest tubes by quantification of residual pneumothorax size.ConclusionsUltrasonography used in conjunction with hands-on management of the upper and lower airways has multiple advantages. There is a rapidly growing body of evidence showing its benefits.Teaching Points• Ultrasonography is becoming essential in management of the upper and lower airways.• The tracheal structures can be identified by ultrasonography, even when unidentifiable by palpation.• Ultrasonography is the primary diagnostic approach in suspicion of intraoperative pneumothorax.• Point-of-care ultrasonography of the airways has a steep learning curve.• Lung ultrasonography allows treatment of interstitial syndrome, consolidation, atelectasis and effusion.

Ultrasound-guided transversus abdominis plane block reduced morphine consumption following caesarean section under general anaesthesia, with increased maternal satisfaction.

Airway management is a critical skill in the practice of several medical specialities including anesthesia, emergency medicine, and critical care. Over the years mounting evidence has showed an increasing role of ultrasound (US) in airway management. The objective of this narrative review is to provide an overview of the indications for point-of-care ultrasound (POCUS) of the upper airway. The use of US to guide and assist clinical airway management has potential benefits for both provider and patient. Ultrasound can be utilized to determine airway size and predict the appropriate diameter of single-lumen endotracheal tubes (ETTs), double-lumen ETTs, and tracheostomy tubes. Ultrasonography can differentiate tracheal, esophageal, and endobronchial intubation. Ultrasonography of the neck can accurately localize the cricothyroid membrane for emergency airway access and similarly identify tracheal rings for US-guided tracheostomy. In addition, US can identify vocal cord dysfunction and pathology before induction of anesthesia. A rapidly growing body of evidence showing ultrasonography used in conjunction with hands-on management of the airway may benefit patient care. Increasing awareness and use of POCUS for many indications have resulted in technologic advancements and increased accessibility and portability. Upper airway POCUS has the potential to become the first-line non-invasive adjunct assessment tool in airway management.

The study by Howes and co-workers in a recent issue of the British Journal of Anaesthesia 1 gives us the opportunity to put the 'Cannot Intubate Cannot Ventilate' (CICV) situation and the percutaneous emergency airway access (PEAA) into context: how can we reduce the need for it and prepare for it? Which techniques should we use for it? And how do we teach it?

Ultrasound assessment of gastric volume in the fasted pediatric patient undergoing upper gastrointestinal endoscopy: development of a predictive model using endoscopically suctioned volumes.

A randomised cross-over comparison of the transverse and longitudinal techniques for ultrasound-guided identification of the cricothyroid membrane in morbidly obese subjects SummaryWe compared the transverse and longitudinal approaches to ultrasound-guided identification of the cricothyroid membrane, to determine which was faster and more successful. Forty-two anaesthetists received a one-hour structured training programme consisting of e-learning, a lecture and hands-on training, and then applied both techniques in a randomised, cross-over sequence to obese females with body mass index 39.0 -43.9 kg.m À2. The mean (SD) time to identify the cricothyroid membrane was 24.0 (12.4) s using the transverse technique compared with 37.6 (17.9) s for the longitudinal technique (p = 0.0003). Successful identification of the cricothyroid membrane was achieved by 38 (90%) anaesthetists using either technique. All anaesthetists were successful in identifying the cricothyroid membrane with at least one of the techniques. We advocate the learning and application of these two techniques for identification of the cricothyroid membrane before starting anaesthesia in difficult patients, especially when anatomical landmarks are impalpable. Further use in emergency situations is feasible, if clinicians have experience and the ultrasound machine is readily available.