This Week in Anesthesiology — Aug 31, 2026

Welcome to This Week in Anesthesiology. This week we're covering 10 notable papers spanning airway management and the new universal airway guidelines, perioperative lung protection and ventilation, and risk stratification and analgesia in the older and higher-risk surgical patient. Let's dive in.

We start with airway management, where Anaesthesia has published two major consensus documents from the Project for Universal Management of Airways, along with a systematic review that exposes how poorly we still describe what we see through a videolaryngoscope. The first PUMA guideline, from Chrimes and colleagues, deliberately steps back from the individual patient and addresses what they call the foundation for airway care: the physical environment, the equipment and monitoring, the education of practitioners in both procedural and behavioural skills, and the culture of the department [1]. An international multidisciplinary working group reviewed existing guidelines and literature, generated consensus statements, cross-checked them against an advisory group that included airway assistants and human factors experts, and graded recommendations using the American Heart Association system. The practical message is that organisations, not just individuals, should be audited: is your difficult airway trolley standardised across sites, is capnography universally available, is your culture genuinely no-blame when an airway goes badly. The companion guideline, led by Ellard, turns to the most under-planned moment in anaesthesia, which is taking the tube out [2]. Its framework asks you to evaluate three risks at extubation, the risk of hypoxaemia, of pulmonary aspiration, and of harm from airway stimulation, and to reassess whether anything has changed since intubation. Two ideas deserve to change practice. First, planned extubation is always elective, so if deferring it meaningfully reduces risk, defer it. Second, when swapping between airway lifelines, the guideline prefers conversion procedures, meaning those that keep a continuous guide in place to allow rapid restoration of ventilation, over replacement procedures where you simply remove one device and insert another, particularly when the airway is judged at risk. Alongside these, Grün and colleagues reviewed 13 studies covering seven classification tools for videolaryngoscopy, from Cormack-Lehane through the percentage of glottic opening score to the VIDIAC and paediatric PeDiAC scores [10]. Most studies reported only inter-rater reliability, accuracy or performance data existed for just three tools, Cormack-Lehane itself performed only modestly, and risk of bias was high throughout. So when you document a videolaryngoscopic view for the next anaesthetist, do it in descriptive words as well as a grade, because the grade alone carries less information than we assume.

The second theme is perioperative lung protection, and three papers this week converge on it from different angles. In the British Journal of Anaesthesia, Zorrilla-Vaca and colleagues performed a secondary analysis of the two iPROVE trials, nearly 2,000 adults having major abdominal or thoracic surgery, asking whether the dexamethasone we give routinely for nausea also protects the lungs [5]. The unadjusted numbers looked encouraging, but after inverse probability weighting for confounders, intraoperative corticosteroids at antiemetic doses were not associated with any significant reduction in postoperative pulmonary complications. There was a modest improvement in the oxygenation ratio in recovery, around 20 millimetres of mercury, but that is a physiological signal, not an outcome. The honest reading is that antiemetic-dose steroid is an antiemetic, and you should not count it as lung protection. Also in the British Journal of Anaesthesia, Mariotti and colleagues screened 105 randomised trials of ventilation strategies in cardiac surgery with cardiopulmonary bypass and pooled 39 of them [9]. The clearest finding is that maintaining ventilation during bypass, rather than leaving the lungs collapsed and apnoeic, reduced postoperative pulmonary complications by roughly 13 percent relative to no ventilation, with no heterogeneity across 15 trials. Postoperative non-invasive respiratory support showed a trend toward lower mortality, but this did not reach statistical significance and the authors are explicit that it remains hypothesis-generating. Pressure-controlled versus volume-controlled ventilation intraoperatively, and adaptive support ventilation afterwards, made no difference to any outcome. And from the Canadian Journal of Anesthesia comes a pragmatic trial from Oh and colleagues on hypoxaemia during one-lung ventilation in patients with chronic obstructive pulmonary disease [6]. Ninety patients undergoing lung resection were randomised to selective salbutamol nebulisation into the ventilated lung thirty minutes after one-lung ventilation began, or placebo, with 82 analysed. Salbutamol improved the oxygenation ratio by an average of 26 and reduced alveolar dead space, with a small drop in serum potassium and a transient rise in heart rate but no arrhythmia. Notably, in patients already on preoperative inhaler therapy there was no between-group difference, suggesting the benefit lies in delivering the drug selectively to the dependent lung intraoperatively rather than to both lungs beforehand.

The third theme concerns risk stratification and recovery, and it opens with the right heart. In Anesthesia and Analgesia, Alavi and colleagues looked at over 5,500 adults having coronary bypass or valve surgery and asked whether quantitative preoperative measures of right ventricular function predict outcome [7]. The striking background finding is how rarely these numbers are reported at all: tricuspid annular plane systolic excursion appeared in about a third of studies and fractional area change in fewer than one in five. Where they were reported, they mattered. A tricuspid annular excursion below 17 millimetres roughly doubled the odds of in-hospital death, and a fractional area change below 35 percent was associated with more than triple the odds, with both also predicting longer hospital stay, though neither predicted acute kidney injury. The actionable point is not a new test, it is insisting that your echo reports actually quantify the right ventricle. Turning to the ageing brain, the European Journal of Anaesthesia published a prospective cohort from Pan and Wang following 420 patients aged 60 and over through elective gastrointestinal cancer surgery, measuring bed-level nocturnal noise, light and care interruptions alongside multidomain physiological resilience [3]. Delirium occurred in just over one in five patients. A higher hospital environmental burden was associated with substantially increased odds of delirium and complications, while greater physiological resilience was associated with roughly a 40 percent reduction in the odds of delirium. This is single-centre, observational and explicitly hypothesis-generating, so treat it as support for the ward-level sleep hygiene interventions many of us already advocate rather than as proof. Finally, in the Journal of Clinical Anesthesia, Huang and colleagues pooled 21 randomised trials and 1,271 patients on intravenous magnesium sulfate for spinal surgery [4]. Magnesium produced a small reduction in 24-hour pain scores, well under one point on a ten-point scale, and cut opioid consumption by about five milligrams of morphine equivalent, with the effect strongest when a loading dose was followed by an infusion. Nausea and vomiting fell, but hypotension rose and emergence was slower, with longer times to follow commands and to regain orientation. That is a modest analgesic gain for a real trade-off in haemodynamics and wake-up time.

If you only have time for one paper this week, make it the PUMA tracheal extubation guideline in Anaesthesia [2]. Extubation is where a disproportionate share of airway catastrophes still happen, and this is the first broadly applicable, structured framework for deciding whether your extubation is at risk and what to do about it.

Here are the key takeaways from this week in Anesthesiology. Airway safety is now framed as an organisational property, not just an individual skill, and extubation deserves the same explicit planning we give to intubation. When you must swap airway devices in an at-risk patient, keep a continuous guide in place rather than removing and replacing. Antiemetic-dose dexamethasone does not protect the lungs, so do not let it substitute for genuine lung-protective ventilation. In cardiac surgery, keeping the lungs ventilated during bypass reduces pulmonary complications, and that is one of the few ventilation strategies with consistent supporting evidence. Selective salbutamol into the ventilated lung is a reasonable adjunct for hypoxaemia during one-lung ventilation in patients with chronic obstructive pulmonary disease. And press for quantitative right ventricular measures in your preoperative echocardiogram reports, because when they are reported, low values carry substantial mortality risk. Finally, lung ultrasound for acute respiratory distress syndrome, reviewed in the Canadian Journal of Anesthesia across nearly 2,000 patients, is good at ruling the diagnosis in with a specificity around 95 percent but only moderately sensitive at around 69 percent, so a negative scan does not exclude it [8].

That's your roundup for This Week in Anesthesiology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.