[Ultrasound supported identification of the ligamentum conicum in teaching head and neck sonography]. / Sonographisch gestützte Identifikation des Ligamentum conicum in der Kopf-Hals-Ultraschalllehre.

OBJECTIVE: Upper airway obstructions are usually acute emergencies. Coniotomy is the last option to secure the airway and can be supported by sonography. The aim of this study was to establish a training program to teach these skills. MATERIAL AND METHODS: The training consisted of theoretical training with an additional video presentation (10 minutes each) and practical training (45 minutes). Evaluations were completed before (T1) and after (T2) the training to measure prior experience and satisfaction with the training as well as subjective and objective competence levels. At T2, a practical test was also completed by n=113 participants. A standardized evaluation form was used to document the results of the practical test. RESULTS: A large proportion of the participants had neither seen a coniotomy (64.6%) nor performed one independently (79.6%). Significant improvement (T1 to T2) was measured with regard to the subjective assessment of competence (p<0.001). The training received positive ratings for all items tested (scale ranges 1-2). During practical tests, the participants achieved an average of 89.2% of the possible points and needed a mean of 101 ±23 seconds to identify the conic ligament. CONCLUSION: Structured training for sonographic identification of the conic ligament leads to significant improvement in the subjective assessment of competence and a high objective competence level in a short period of time. This type of training should be standardized in head and neck ultrasound training in the future.

Awake tracheal intubation in routine airway management: A retrospective analysis in a tertiary centre.

INTRODUCTION: While awake tracheal intubation (ATI) is regarded as the gold standard for difficult airway management according to current guidelines, there seems to be a reluctance in its application. This retrospective cohort study, conducted at a German tertiary hospital over a 2-year period, aimed to demonstrate that integrating awake tracheal intubation using flexible bronchoscopy (ATI:FB) into routine airway management makes it a successful and safe approach. MATERIALS AND METHODS: In 2019 and 2020, records from the data acquisition system (DAQ) and archived anesthesia records were screened to evaluate the specifics of ATI:FB procedures, focusing on overall success and safety. Analysis included complications, time required for ATI:FB, and potential influencing factors such as patient characteristics, indication, medical/operative specialty, sedation technique, route and experience of anesthesiologist. Logistic regression assessed the impact of various variables on occurrence of complications and linear regression, with log(time) as the dependent variable, evaluated median time required to perform ATI:FB. RESULTS: ATI:FB constituted 4.3 % (n = 1,911) of all airway management procedures, predominantly observed in dental, oral, and maxillofacial surgery (46.5 %) and otorhinolaryngology (38.4 %). The success rate for ATI:FB was notably high at 99.6 %, with only 5.4 % of cases experiencing complications, including technical issues, agitation, and visibility obstruction due to mucous secretion. Complication risk was influenced by the medical specialty and the experience of the anesthesiologist. A strong effect was observed in otorhinolaryngology (OR = 4.54, 95 % CI [1.64; 14.06]). The median time required for ATI:FB was 16 minutes (IQR: 11 to 23), with factors such as indication (p < 0.0001), experience of anesthesiologist (p < 0.0001), sedation technique (p = 0.0408), priority of the procedure (p = 0.0134), and medical/operative specialty (p < 0.0001) affecting the duration. The median time required for ATI:FB differed significantly based on the experience of the anesthesiologist (p < 0.0001). CONCLUSION: ATI:FB proves successful and safe, with low complications and manageable procedural time. Experience of the anesthesiologist is a modifiable factor enhancing safety, emphasizing the need for ATI:FB integration into routine airway management.

Early warning for SpO2 decrease by the oxygen reserve index in neonates and small infants.

INTRODUCTION: Continuously assessing the oxygenation levels of patients to detect and prevent hypoxemia can be advantageous for safe anesthesia, especially in neonates and small infants. The oxygen reserve index (ORI) is a new parameter that can assess oxygenation through a relationship with arterial oxygen partial pressure (PaO2 ). The aim of this study was to examine whether the ORI provides a clinically relevant warning time for an impending SpO2 (pulse oximetry hemoglobin saturation) reduction in neonates and small infants. METHODS: ORI and SpO2 were measured continuously in infants aged <2 years during general anesthesia. The warning time and sensitivity of different ORI alarms for detecting impending SpO2 decrease were calculated. Subsequently, the agreement of the ORI and PaO2 with blood gas analyses was assessed. RESULTS: The ORI of 100 small infants and neonates with a median age of 9 months (min-max, 0-21 months) and weight of 8.35 kg (min-max, 2-13 kg) were measured. For the ORI/PaO2 correlation, 54 blood gas analyses were performed. The warning time and sensitivity of the preset ORI alarm during the entire duration of anesthesia were 84 s (25th-75th percentile, 56-102 s) and 55% (95% CI 52%-58%), and those during anesthesia induction were 63 s (40-82 s) and 56% (44%-68%), respectively. The positive predictive value of the preset ORI alarm were 18% (95% CI 17%-20%; entire duration of anesthesia) and 27% (95% CI 21%-35%; during anesthesia induction). The agreement of PaO2 intervals with the ORI intervals was poor, with a kappa of 0.00 (95% CI = [-0.18; 0.18]). The weight (p = .0129) and height (p = .0376) of the infants and neonates were correlated to the correct classification of the PaO2 interval with the ORI interval. CONCLUSIONS: The ORI provided an early warning time for detecting an impending SpO2 decrease in small infants and neonates in the defined interval in this study. However, the sensitivity of ORI to forewarn a SpO2 decrease and the agreement of the ORI with PaO2 intervals in this real-life scenario were too poor to recommend the ORI as a useful early warning indicator for this age group.

Video Laryngoscopy Using King Vision™ aBlade™ and Direct Laryngoscopy in Paediatric Airway Management: A Randomized Controlled Study about Device Learning by Anaesthesia Residents.

Background: Airway management in children is challenging due to anatomical and physiological differences. This randomized trial investigates whether anaesthesia residents can intubate the paediatric trachea more quickly and with a higher success rate using the King Vision™ Paediatric aBlade™ video laryngoscope (KVL) compared to conventional direct laryngoscopy (DL). Methods: Eleven anaesthesia residents (mean age: 31 years, mean training status 47 months) were each asked to perform intubations with the KVL and DL in paediatric patients. The primary outcome was the first-attempt success rate. Secondary outcomes were the time to best view (TTBV), time to placement of the tracheal tube (TTP), time to ventilation (TTV), and participant-reported ease of use on a Likert scale. Results: 105 intubations with the KVL and 106 DL were performed by the residents. The success rate on the first attempt with the KVL was 81%, and the success rate on the first attempt within a given time limit of 30 s was 45%, which was lower than with DL (93% and 77% with time limit, p < 0.01). The median TTBV [IQR] on the first attempt with KVL was 7 [5−10] s, the median TTP was 28 [19−44] s, and the median TTV was 51 [39−66] s. DL-mediated intubation was significantly faster (TTP: 17 [13−23] s; p < 0.0001 and TTV: 34 [28−44] s; p < 0.001). Application of the KVL was rated as difficult or very difficult by 60% of the residents (DL: 5%). Conclusion: In contrast to promising data on the paediatric training manikin, residents took longer to intubate the airway in children with the KVL and were less successful compared to the DL. Therefore, the KVL should not be recommended for learning paediatric intubation by residents.

Big data: Airway management at a university hospital over 16 years; a retrospective analysis.

PURPOSE: Little is known about the current practice of airway management in Germany and its development over the last decades. The present study was, therefore, designed to answer the following questions. Which airway management procedures have been performed over the last 16 years and how has the frequency of these procedures changed over time? Is there a relationship between patient characteristics or surgical specialisation and the type of airway management performed? METHODS: In the present study, we used our in-house data acquisition and accounting system to retrospectively analyse airway management data for all patients who underwent a surgical or medical procedure with anaesthesiological care at our tertiary care facility over the past 16 years. 340,748 airway management procedures were analysed by type of procedure, medical/surgical specialty, and type of device used. Logistic regression was used to identify trends over time. RESULTS: Oral intubation was the most common technique over 16 years (65.7%), followed by supraglottic airway devices (18.1%), nasal intubation (7.5%), mask ventilation (1.6%), tracheal cannula (1.3%), double lumen tube (0.7%), and jet ventilation (0.6%). On average, the odds ratio of using supraglottic airway devices increased by 17.0% per year (OR per year = 1.072, 95% CI = 1.071-1.088) while oral intubation rates decreased. In 2005, supraglottic airway devices were used in about 10% of all airway management procedures. Until 2020, this proportion steadily increased by 27%. Frequency of oral intubation on the other hand decreased and was about 75% in 2005 and 53% in 2020. Over time, second-generation supraglottic airway devices were used more frequently than first-generation supraglottic airway devices. While second-generation devices made up about 9% of all supraglottic airway devices in 2010, in 2020 they represented a proportion of 82%. The use of fibreoptic intubation increased over time in otorhinolaryngology and dental, oral, and maxillofacial surgery, but showed no significant trends over the entire 16-year period. CONCLUSION: Our data represent the first large-scale evaluation of airway management procedures over a long time. There was a significant upward trend in the use of supraglottic airway devices, with an increase in the use of second-generation masks while a decrease in oral intubations was observed.

Intraocular Pressure Measurement in Childhood Glaucoma under Standardized General Anaesthesia: The Prospective EyeBIS Study.

Objective: We aimed to compare intraocular pressure (IOP) measurements using iCare® PRO rebound tonometry (iCare) and Perkins applanation tonometry (Perkins) in childhood glaucoma subjects and healthy children and the influence of anaesthesia depth, age and corneal thickness. Material: Prospective clinical, case-control study of children who underwent an ophthalmologic examination under general anaesthesia according to our protocol. Children were 45.45 ± 29.76 months old (mean ± SD (standard deviation)). Of all children, 54.05% were female. IOP was taken three times (T1−T3), according to duration and the depth of anaesthesia. The order of measurement alternated, starting with iCare. Agreement between the device measurements was evaluated using Bland−Altman analysis. Results: 53 glaucoma subjects and 22 healthy controls. Glaucoma subjects: IOP measured with iCare was at T1: 27.2 (18.1−33.8), T2: 21.6 (14.8−30.6), T3: 20.4 mmHg (14.5−27.0) and Perkins 17.5 (12.0−23.0), 15.5 (10.5−20.5), 15.0 mmHg (10.5−21.0) (median ± IQR (interquartile range)). Healthy controls: IOP with iCare: T1: 13.3 (11.1−17.0), T2: 10.6 (8.1−12.4), T3: 9.6 mmHg (7.7−11.7) and Perkins 10.3 (8.0−12.0), 7.0 (5.5−10.5), 7.0 mmHg (5.5−8.5) (median ± IQR). The median IOP was statistically significantly higher with iCare than with Perkins (p < 0.001) in both groups. The mean difference (iCare and Perkins) was 6.0 ± 6.1 mmHg for T1−T3, 7.3 at T1, 6.0 at T2, 4.9 mmHg at T3. Conclusion: The IOP was the highest in glaucoma subjects and healthy children at T1 (under sedation), independently of the measurement method. iCare always leads to higher IOP compared to Perkins in glaucoma and healthy subjects, regardless of the duration of anesthesia.

Evaluation of gender differences in postoperative sore throat and hoarseness following the use of Ambu AuraGain laryngeal mask: the randomised controlled LadyLAMA trial study protocol.

INTRODUCTION: Postoperative sore throat (POST) is a comparatively minor but very common side effect of general anaesthesia with a supraglottic airway device. The patient considers these side effects a mirror of the quality of anaesthesia. The aims of this study are to evaluate gender-specific differences in the incidence of POST and to assess whether the effects of known risk factors vary between genders. METHODS AND ANALYSIS: The LadyLAMA trial is a single-centre, patient-blinded, randomised controlled trial. Consecutive patients requiring ophthalmological surgery under general anaesthesia with a second generation Ambu AuraGain laryngeal mask are randomly allocated to either cuff pressure of 45 cmH2O or cuff pressure of 60 cmH2O. We estimate the difference in POST between the genders at 20% and we hypothesised that a reduction of cuff pressure would reduce POST by 10%. A total of 800 patients will be recruited, with each subgroup including 200 patients to achieve 80% power for detecting a difference at the 5% significance level. Primary endpoints are gender differences in the incidence of POST within 24 hours postoperatively, as well as comparison of cuff pressure 45 cmH2O to 60 cmH2O with respect to POST. The main secondary objective is the effect of cuff pressure on POST stratified by gender. Further secondary endpoints are gender-specific differences in POST and hoarseness in postanaesthesia care unit (PACU) at 48 and 72 hours (or until freedom of discomfort). The parameter cuff pressure serves as key-secondary endpoint. ETHICS AND DISSEMINATION: The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (Nr. 2021-15835). The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION NUMBER: NCT04915534.

Childhood glaucoma registry in Germany: initial database, clinical care and research (pilot study).

OBJECTIVE: The aim of this prospective pilot study is to establish an initial database to register patients diagnosed with different types of childhood glaucoma and the set-up of a national registry for childhood glaucoma (ReCG) in Germany. 28 children with different types of diagnosed childhood glaucoma, who were admitted and treated at the Childhood Glaucoma Center of the University Medical Center Mainz, Germany were included. Main outcome measures were the type of childhood glaucoma, mean intraocular pressure (IOP) and genetic data of the patients. RESULTS: The documents and questionnaires for each individual included: informed consent form of the parents, medical history form of the child, patient's gestational history questionnaire and general anesthesia examination form. Primary congenital and secondary childhood glaucoma were revealed in 11 (39%) and 17 (61%) patients, respectively. The mean IOP measured with Perkins tonometer in all patients under general anesthesia at the time of inclusion was 17.5 ± 11.8 mmHg in the right and 17 ± 8.9 mmHg in the left eyes. In 33% of children with glaucoma mutations in the CYP1B1, FOXC1, LTBP2 and TEK genes were found. The development of specific questionnaires for childhood glaucoma provides detailed baseline data to establish a ReCG in Germany for the first time.

Results of childhood glaucoma surgery over a long-term period.

PURPOSE: To evaluate long-term results of glaucoma surgery in newborn and infants with glaucoma. METHODS: Seventy-nine eyes of 52 children (age: 3 weeks-15.3 years) with primary congenital or secondary glaucoma treated between 2015 and 2017 were included. The median follow-up time was 3.9 years. Conventional probe trabeculotomy, 360° catheter-assisted trabeculotomy, filtering and cyclodestructive surgery were compared. Strict criteria for surgical success were applied: Complete surgical success (IOP below target IOP, no further surgery) and incomplete surgical success (additional surgery allowed) were analyzed, and IOP at baseline and last follow-up was compared. RESULTS: Intraocular pressure (IOP) was significantly reduced in primary congenital (preoperative IOP: 27.8 ± 7.5 mmHg vs. postoperative IOP: 14.2 ± 4.5 mmHg) and secondary glaucoma (preoperative IOP: 29.2 ± 9.1 mmHg vs. postoperative IOP: 16.6 ± 4.7 mmHg). 90% of all eyes reached target IOP with or without medication allowing for additional surgeries. As first surgery, 360° catheter-assisted trabeculotomy had a tendency to higher surgical success than other surgical approaches, while cyclodestructive procedures had lowest. CONCLUSIONS: We found very promising surgical results in our childhood glaucoma patient group. Surgical success in both congenital and secondary glaucoma was high.

Current practice of German anesthesiologists in airway management : Results of a national online survey.

BACKGROUND: There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners. OBJECTIVE: To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps. METHODS: A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices. RESULTS: A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a "cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques. CONCLUSION: Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.

Anaesthesia protocol evaluation of the videolaryngoscopy with the McGrath MAC and direct laryngoscopy for tracheal intubation in 1000 patients undergoing rapid sequence induction: the randomised multicentre LARA trial study protocol.

INTRODUCTION: Rapid sequence induction of anaesthesia is indicated in patients with an increased risk of pulmonary aspiration. The main objective of the technique is to reduce the critical time period between loss of airway protective reflexes and rapid inflation of the cuff of the endotracheal tube to minimise the chance of aspiration of gastric contents. The COVID-19 pandemic has reinforced the importance of first-pass intubation success to ensure patient and healthcare worker safety. The aim of this study is to compare the first-pass intubation success rate (FPS) using the videolaryngoscopy compared with conventional direct laryngoscopy in surgical patients with a high risk of pulmonary aspiration. METHODS AND ANALYSIS: The LARA trial is a multicentre, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath MAC videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of FPS is 92% in the McGrath group and 82% in the Macintosh group. Each group must include a total of 500 patients to achieve 90% power for detecting a difference at the 5% significance level. Successful intubation with the FPS is the primary endpoint. The secondary endpoints are the time to intubation, the number of intubation attempts, the necessity of airway management alternatives, the visualisation of the glottis using the Cormack and Lehane Score and the Percentage Of Glottic Opening Score and definite adverse events. ETHICS AND DISSEMINATION: The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (registration number: 2020-15502) and medical ethics committee of the University of Freiburg (registration number: 21-1303). The results of this study will be made available in form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION: NCT04794764.

Anaesthetic protocol for paediatric glaucoma examinations: the prospective EyeBIS Study protocol.

INTRODUCTION: Neonates and young infants with diagnosed or highly suspected glaucoma require an examination under anaesthesia to achieve accurate intraocular pressure (IOP) measurements, since crying or squinting of the eyes may increase IOP and lead to falsely high values. IOP considerably depends on perioperative variables such as haemodynamic factors, anaesthetics, depth of anaesthesia and airway management. The aim of this paper is to report the design and baseline characteristics of EyeBIS, which is a study to develop a standardised anaesthetic protocol for the measurement of IOP under anaesthesia in childhood glaucoma, by investigating the link between the magnitude of IOP and depth of anaesthesia. METHODS AND ANALYSIS: This is a single-centre, prospective cohort study in 100 children with diagnosed or highly suspected glaucoma all undergoing ophthalmological examination under general anaesthesia. 20 children, who undergo general anaesthesia for other reasons, are included as controls. The primary outcome measure is the establishment of a standardised anaesthetic protocol for IOP measurement in childhood glaucoma by assessing the relationship between IOP and depth of anaesthesia (calculated as an electroencephalography variable, the bispectral index), with special emphasis on airway management and haemodynamic parameters. The dependence of IOP under anaesthesia on airway management and haemodynamic parameters will be described, using a mixed linear model. Restricting the model to patients with healthy eyes will allow to determine a 95% reference region, in which 95% of the measurement values of patients with healthy eyes can be expected. ETHICS AND DISSEMINATION: The study has been approved by the local ethics committee of the Medical Association of Rhineland-Palatine (Ethik-Kommisssion der Landesaerztekammer Rheinland-Pfalz), Germany (approval number: 2019-14207). This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at national and international scientific meetings and data sharing with other investigators. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03972852).

A comparison of two hyperangulated video laryngoscope blades to direct laryngoscopy in a simulated infant airway: a bicentric, comparative, randomized manikin study.

BACKGROUND: In infants, securing the airway is time-critical because of anatomical and physiological differences related to airway management in children less than 1 year old. The aim of this study was to compare the time to ventilation using two different hyperangulated video laryngoscope blades with the time to ventilation via conventional direct laryngoscopy in a normal airway [NA] and in a simulated difficult airway [DA]. METHODS: This study was a comparative, bicentric, open-label, randomized controlled evaluation. An infant high-fidelity simulator (SimBaby™; Laerdal® Medical, Stavanger, Norway) was used, and two scenarios were proposed, as follows: NA and DA evoked with tongue edema and cervical collar. After theoretical and practical briefing, each participant compared in the two airway scenarios the novel King Vision™ Pediatric aBlade (KV) (Ambu® A/S, Bad Nauheim, Germany) video laryngoscope and the C-MAC™ D-blade Ped (DB) (Karl Storz® SE & Co. KG, Tuttlingen, Germany) video laryngoscope to conventional laryngoscopy using the Miller Blade (MiB) and the Macintosh Blade (MaB) in a random sequence. RESULTS: Eighty physicians (65 AN and 15 PCCM staff) were included. In the NA scenario, the median [IQR] time to successful time to ventilation (TTV) was significantly shorter for the KV at 13 s [12-15 s] than for the MaB at 14.5 s [13-16 s], DB at 14.5 s [13-16] and MiB at 16 s [14-19] (p < 0.001). In DA, the KV also shortened TTV to 14 s [13-16], whereas TTV was 23 s with the MaB [20-26], 19 s with the DB [16-21], and 27 s with the MiB [22-31] (p < 0.001). There were no differences in first-pass intubation success rates (FPAs) between hyperangulated blades and direct laryngoscopes in NA. In DA, the hyperangulated blades enabled 92 (DB) to 100% (KV) FPAs compared with 65 (MiB) to 76% (MaB) for conventional laryngoscopy (p < 0.001). CONCLUSION: Video laryngoscopes with hyperangulated blades were associated with shorter TTV in normal and difficult infant airway situations. The higher FPAs of hyperangulated blades in DA may avoid desaturations and decrease adverse events in pediatric airway management.

Red blood cell transfusion in perioperative pediatric anesthesia: a survey of current practice in Germany.

BACKGROUND: Little is known about the current practice of the perioperative transfusion of red blood cells (RBCs) in pediatric patients. This study was performed to evaluate the practice of RBC transfusion in German pediatric anesthesia. STUDY DESIGN AND METHODS: An online survey was conducted among members of the German Society of Anesthesiology and Intensive Care. Participants were asked to indicate the hemoglobin (Hb) thresholds for starting RBC transfusion in six cases of different bleeding situations in pediatric anesthesia. Demographics of participants, general knowledge, and application of transfusion rules and guidelines were assessed. RESULTS: We included 1207 of 1396 returned questionnaires. Of the respondents, 89% were qualified specialists and 68% had experience in anesthesia in children aged less than 6 months. The lowest median Hb transfusion threshold was 6 g/dL in a 16-year-old and the highest was 10 g/dL in a premature neonate. Intraoperative Hb thresholds increased for clinically unstable (median difference to clinically stable children, +1 g/dL; p < 0.001) or neonate and premature children (median difference to older children, +1 and +2 g/dL; p < 0.001). The stated Hb threshold ranges were broad, especially in neonates or premature children (interquartile range, neonates 3, premature children 4 g/dL). Of the participants, only 16% had knowledge of a guideline that includes blood transfusion in children. CONCLUSION: Striking variability exists in practice of perioperative pediatric RBC transfusion. A specialized guideline for perioperative blood transfusion in children could be helpful to define and promote optimal pediatric RBC transfusion strategies.

Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow.

A patient's willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can jeopardize their spontaneous breathing, topical anesthesia of the airway is a popular technique. The spray-as-you-go technique represents one of the simplest opportunities to anesthetize the airway mucosa. The application of local anesthetic through the working channel of the flexible endoscope is a widespread practice for anesthetists as well as pulmonologists. There is neither need for additional devices nor special training as a pre-requisite to perform this technique. However, a known clinical problem is the coughing and gagging reflex that may occur when the liquid anesthetic strikes the airway mucosa and other sensitive structures like the vocal cords. This can be avoided by the use of oxygen applied through the working channel with the aim of fogging the local anesthetic into finer particles. Furthermore, the oxygen flow provides a higher oxygen supply and contributes to a better view, dispersing mucus secretions and blood away from the lens. Using an atomizer with a high oxygen flow of 10 L/min we maximized these benefits, caused less coughing and had more satisfied and therefore cooperative patients. Possible, but very rare complications of using oxygen flow including gastric insufflation, organ rupture or barotrauma did not arise. We attribute the complication-free use of high oxygen flow to the design of the set, which permits flow and pressure release.