Emilia Concetta Lo Giudice

Airway management remains one of the few domains of anaesthetic practice still governed by universal, dichotomous screening thresholds applied to profoundly heterogeneous populations. Conventional bedside tests—the modified Mallampati test, thyromental distance and the upper lip bite test—retain modest and inconsistent diagnostic accuracy, leaving the majority of difficult intubations unanticipated while generating false alarms that drive resource-intensive contingency plans. This narrative review reframes preoperative airway evaluation as a problem of individualised risk stratification rather than population screening. We first summarise the performance limits of classical bedside predictors and the reasons for their ceiling effect, including low target prevalence, inter-observer variability, spectrum bias and heterogeneous outcome definitions. We then examine the data streams reshaping the field: point-of-care upper airway ultrasound, whose parameters provide operator-accessible and objective anatomical information; cross-sectional and craniofacial imaging; and machine-learning models based on clinical variables, facial images and voice analysis. For each we discuss accuracy, reproducibility, validation status and barriers to adoption. We then propose a phenotype-oriented framework in which assessment intensity is matched to pre-test probability, with dedicated pathways for obesity and obstructive sleep apnoea, obstetric, head-and-neck oncological and post-radiotherapy, critically ill and emergency, and paediatric populations. We map this framework onto the 2025 European Society of Anaesthesiology and Intensive Care and Difficult Airway Society recommendations and outline the validation, calibration and equity requirements—including algorithmic bias across skin tone, sex and ethnicity—that must be met before precision airway assessment can enter routine practice.

Background: Hyperbaric oxygen therapy (HBOT) is proposed as an adjunct in two sinonasal conditions of high morbidity: acute invasive fungal rhinosinusitis (AIFRS) and post-radiotherapy injury. Methods: We conducted a narrative review and reported it against SANRA; PubMed/MEDLINE was searched (1980–2026; 1414 records screened, 589 retained), with Cochrane, society guidance and reference screening. Results: No randomised trial has tested HBOT against sinonasal endpoints in either indication. In AIFRS the dedicated evidence is four uncontrolled series (n = 27, level 4); none reports how many candidates were unfit to pressurise, the largest synthesis did not identify HBOT as a survival predictor, and the only randomised experiment—murine—was negative. Mycology guidance supports it with marginal strength only (C; quality III), and hyperbaric indication lists omit it. For radiation injury, Cochrane 2023 reports low-certainty benefit in head-and-neck tissue, but HOPON found no reduction in osteoradionecrosis after dentoalveolar surgery (6.4% vs. 5.7%; OR 1.13, 95% CI 0.14–8.92), and pooled DAHANCA-21/NWHHT2009-1 data were non-significant (70% vs. 51% healing); all sinonasal use is extrapolated from the mandible. Middle-ear, not sinus, barotrauma is the commonest ENT complication. Conclusions: HBOT is mechanistically coherent and may be considered case-by-case within a multidisciplinary team, but it is not a standard of care in either indication; the algorithm offered here is unvalidated.

Tracheal intubation in patients at risk of acute hypoxemic respiratory failure (AHRF) carries a high risk of life-threatening desaturation, and the choice of peri-intubation oxygenation strategy critically influences patient safety. This narrative review synthesizes current evidence on non-invasive oxygenation techniques—high-flow nasal oxygen (HFNO), non-invasive ventilation (NIV), and their combination—across the pre-oxygenation, apneic, and awake-intubation phases of airway management. We examine the physiological mechanisms underlying each modality, appraise landmark randomized trials and meta-analyses (including PREOXI, OPTINIV, and OPTIMASK), and address disease-specific considerations in chronic obstructive pulmonary disease, heart failure, interstitial lung disease, severe obesity, obstructive sleep apnea, and obstetric, pediatric, and trauma populations. The evidence supports a phenotype-driven hierarchy rather than a single dominant technique: NIV—optionally combined with HFNO for apneic oxygenation—is preferred in severely hypoxemic critically ill patients, whereas HFNO alone is adequate for many moderately hypoxemic or non-hypoxemic patients. Progressive hypercapnia limits apneic oxygenation, particularly in chronic CO₂ retainers, underscoring the value of continuous CO₂ monitoring. Persistent under-implementation of NIV-based pre-oxygenation reveals a gap between evidence and practice. Individualized, physiology-guided oxygenation—aligned with the goals of personalized peri-procedural medicine—offers the greatest potential to reduce peri-intubation morbidity.

Airway management remains one of the few domains of anaesthetic practice still governed by universal, dichotomous screening thresholds applied to profoundly heterogeneous populations. Conventional bedside tests — the modified Mallampati test, thyromental distance and the upper lip bite test — retain modest and inconsistent diagnostic accuracy, leaving the majority of difficult intubations unanticipated while generating false alarms that drive resource-intensive contingency plans. This narrative review reframes preoperative airway evaluation as a problem of individualized risk stratification rather than population screening. We first summarize the performance limits of classical bedside predictors and the reasons for their ceiling effect, including low target prevalence, inter-observer variability, spectrum bias and heterogeneous outcome definitions. We then examine the data streams reshaping the field: point-of-care upper airway ultrasound, whose parameters provide operator-accessible and objective anatomical information; cross-sectional and craniofacial imaging; and machine-learning models based on clinical variables, facial images and voice analysis. For each we discuss accuracy, reproducibility, validation status and barriers to adoption. We then propose a phenotype-oriented framework in which assessment intensity is matched to pre-test probability, with dedicated pathways for obesity and obstructive sleep apnoea, obstetric, head-and-neck oncological and post-radiotherapy, critically ill and emergency, and paediatric populations. We map this framework onto the 2025 European Society of Anaesthesiology and Intensive Care and Difficult Airway Society recommendations and outline the validation, calibration and equity requirements — including algorithmic bias across skin tone, sex and ethnicity — that must be met before precision airway assessment can enter routine practice.

Background/Objectives: Patients with pre-existing chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF) are a particularly high-risk surgical population in whom postoperative pulmonary complications (PPCs) drive a disproportionate share of morbidity, prolonged stay and mortality. Prehabilitation—the structured optimization of functional reserve during the preoperative interval—has emerged as a proactive, largely non-pharmacological strategy to raise that reserve before the surgical insult. Yet the evidence base is organized predominantly by surgical procedure and enrolled in mixed populations, so the patients with the least physiological reserve—those with established COPD or CHF—remain comparatively understudied. This narrative review takes the comorbidity, rather than the incision, as its organizing axis. Methods: We summarize the pathophysiology that links chronic cardio-respiratory disease to perioperative respiratory failure; appraise the principal non-pharmacological interventions, with the respiratory components (inspiratory muscle training, pulmonary rehabilitation, breathing techniques) as the core and exercise, nutritional, psychological, and smoking-cessation elements as the multimodal context; and re-read the surgical evidence through the lens of the underlying disease. Results: A cross-surgical meta-analysis indicates that preoperative exercise training reduces PPCs (relative risk ≈ 0.52) with no significant difference in effect across surgery type or training modality, supporting a comorbidity-centered rather than procedure-centered framework. We address practical determinants of implementation—timing, patient selection, adherence, home-based and telemonitored delivery, and low-resource applicability—and highlight two cross-cutting problems: heterogeneity of intervention prescription and the lack of standardized PPC definitions. Conclusions: The scarcity of disease-specific evidence is itself the central finding, revealing a mismatch between clinical risk and research investment.

Tracheal intubation in patients at risk of acute hypoxemic respiratory failure (AHRF) carries a high risk of life-threatening desaturation, and the choice of peri-intubation oxygenation strategy critically influences patient safety. This narrative review synthesizes current evidence on non-invasive oxygenation techniques—high-flow nasal oxygen (HFNO), non-invasive ventilation (NIV), and their combination—across the pre-oxygenation, apneic, and awake-intubation phases of airway management. We examine the physiological mechanisms underlying each modality, appraise landmark randomized trials and meta-analyses (including PREOXI, OPTINIV, and OPTIMASK), and address disease-specific considerations in chronic obstructive pulmonary disease, heart failure, interstitial lung disease, severe obesity, obstructive sleep apnea, and obstetric, pediatric, and trauma populations. The evidence supports a phenotype-driven hierarchy rather than a single dominant technique: NIV—optionally combined with HFNO for apneic oxygenation—is preferred in severely hypoxemic critically ill patients, whereas HFNO alone is adequate for many moderately hypoxemic or non-hypoxemic patients. Progressive hypercapnia limits apneic oxygenation, particularly in chronic CO₂ retainers, underscoring the value of continuous CO₂ monitoring. Persistent under-implementation of NIV-based pre-oxygenation reveals a gap between evidence and practice. Individualized, physiology-guided oxygenation—aligned with the goals of personalized peri-procedural medicine—offers the greatest potential to reduce peri-intubation morbidity.

Patients with pre-existing chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF) are a particularly high-risk surgical population in whom postoperative pulmonary complications (PPCs) drive a disproportionate share of morbidity, prolonged stay and mortality. Prehabilitation—the structured optimization of functional reserve during the preoperative interval—has emerged as a proactive, largely non-pharmacological strategy to raise that reserve before the surgical insult. Yet the evidence base is organized predominantly by surgical procedure and enrolled in mixed populations, so the patients with the least physiological reserve—those with established COPD or CHF—remain comparatively understudied. This narrative review takes the comorbidity, rather than the incision, as its organizing axis. We summarize the pathophysiology that links chronic cardio-respiratory disease to perioperative respiratory failure; appraise the principal non-pharmacological interventions, with the respiratory components (inspiratory muscle training, pulmonary rehabilitation, breathing techniques) as the core and exercise, nutritional, psychological and smoking-cessation elements as the multimodal context; and re-read the surgical evidence through the lens of the underlying disease. A cross-surgical meta-analysis indicates that preoperative exercise training reduces PPCs (relative risk ≈ 0.52) with no significant difference of effect across surgery type or training modality, supporting a comorbidity-centred rather than procedure-centred framework. We address practical determinants of implementation—timing, patient selection, adherence, home-based and telemonitored delivery, and low-resource applicability—and highlight two cross-cutting problems: heterogeneity of intervention prescription and the lack of standardized PPC definitions. The scarcity of disease-specific evidence is itself the central finding, revealing a mismatch between clinical risk and research investment.

The work of anesthesiologists–intensivists, critical care specialists, and medical emergency teams is multifaceted and complex, with airway management representing a cornerstone and a common denominator of many procedures and interventions. Tracheal intubation has represented and still represents today the gold standard for airway control. This narrative review, conducted through a comprehensive search of PubMed/MEDLINE, EMBASE, and the Cochrane Library from database inception to December 2025 and supplemented by manual reference searches and retrieval of key historical sources, aims to trace the evolution of laryngoscopy for airway management and tracheal intubation—from its nineteenth-century origins to the current state of the art—while simultaneously addressing the clinical, educational, and safety implications of this evolution. Laryngoscopy evolution progressed in parallel with technological development and innovation, resulting in the expansion of clinical possibilities and in the improvement of patient safety. The evolution of laryngoscopy essentially took place between the late 1800s and the first half of the 1900s, culminating in the widespread adoption of the Macintosh laryngoscope. Almost 50 years later, a pivotal turning point occurred around the 2000s with the introduction of videolaryngoscopes. Along this path, the devices that succeeded one another introduced new problems, driving the search for new solutions. At present, tracheal intubation with videolaryngoscopy has achieved success and safety standards substantially superior to those of the early days of the technique. In this review we retrace the historical milestones of laryngoscopy, analyze the problems that emerged over time with various devices and the solutions adopted, examine the evolution of videolaryngoscopes and the impact of these devices on both technical and non-technical skills, discuss the ongoing debate surrounding their routine use (universal videolaryngoscopy) and the selection of optimal adjunct devices, and outline the emerging role of artificial intelligence in improving success rates and facilitating the learning curve. This journey, after 150 years of evolution, has reached a high level of maturity in terms of safety and efficacy.

Cardiac arrhythmias complicate 20–50% of surgical procedures and contribute substantially to perioperative morbidity, mortality, and healthcare costs, with postoperative atrial fibrillation (POAF) being the most frequent form. Their genesis reflects the convergence of surgical stress, anaesthetic agents, autonomic imbalance, systemic inflammation, and electrolyte disturbances, explaining the limited efficacy of single-mechanism interventions. This narrative review synthesises contemporary evidence on pathophysiology, risk stratification, prevention, acute management, and emerging technologies, emphasising individualised, patient-tailored approaches. MEDLINE, Embase, and Cochrane CENTRAL were searched (January 2010–January 2026), prioritising randomised trials, meta-analyses, and guidelines. Contemporary risk stratification integrates clinical scores, biomarkers, and electrocardiographic parameters; machine-learning models show moderate discrimination (pooled AUC 0.84) and may enable more personalised prediction pending external validation. Evidence-based prophylaxis—beta-blockade, magnesium, selective amiodarone, and emerging anti-inflammatory strategies such as colchicine—reduces POAF in high-risk populations, while acute management is guided by haemodynamic status and individual risk. Anticoagulation follows CHA₂DS₂-VASc stratification, although optimal timing and duration remain undefined. Wearable monitoring, AI-based detection, and atrial-selective agents show clinical promise. Systematic, personalised integration of risk assessment, prophylaxis, monitoring, and management offers the clearest path to reducing arrhythmia-associated morbidity.

Background. Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen at supra-atmospheric pressure, producing tissue hyperoxygenation, enhanced phagocytic killing, neoangiogenesis, and immunomodulation. Although HBOT is well established in head-and-neck practice, its specific role in sinonasal disease remains poorly systematised. Objective. To reappraise the rationale, evidence, and practical implementation of HBOT in two cardinal sinonasal indications—acute invasive fungal rhinosinusitis (AIFRS) and post-radiotherapy sinonasal damage—through a rhinology-centred, multidisciplinary lens. Methods. Narrative review of articles published in PubMed/MEDLINE, Scopus, Embase, and the Cochrane Library between 1 January 1980 and 31 March 2026, conducted following the SANRA framework and combining MeSH terms for HBOT with sinonasal, mucormycosis, osteoradionecrosis, and skull-base keywords. Results. In AIFRS, HBOT addresses the angioinvasive ischaemic core, restores oxidative neutrophil killing, and potentiates amphotericin B; observational data—including the recent COVID-19-associated mucormycosis (CAM) experience—suggest a survival benefit when HBOT is added early to surgical and antifungal therapy. In post-radiotherapy injury, HBOT reverses Marx's hypoxic–hypocellular–hypovascular triad, supporting healing of osteoradionecrosis (maxillary and skull-base), soft-tissue radionecrosis, and reconstructive procedures in the irradiated bed. Sinus barotrauma, the most frequent rhinological complication, is largely preventable with structured pre-treatment ENT assessment. Conclusions. HBOT is a mechanistically well-founded, well-tolerated adjunct with a favourable safety profile when delivered by a multidisciplinary team. Sinonasal-specific prospective registries and pragmatic randomised trials are urgently needed.