Airway management is a cornerstone of safe anaesthetic practice, particularly in paediatric patients, where anatomical and physiological variations present significant challenges. Children have a proportionally larger head and tongue, a more anterior and cephalad larynx, and a narrow subglottic region. These features contribute to increased difficulty in visualization and intubation compared to adults. Furthermore, children have a higher oxygen consumption rate and lower functional residual capacity, which predisposes them to rapid desaturation during apnoea. Traditionally, direct laryngoscopy has been the gold standard for tracheal intubation. However, in paediatric populations, achieving an optimal laryngoscopic view can be difficult, especially in unanticipated difficult airways. This has led to the increased use of supraglottic airway devices (SGADs) as both primary airway devices and rescue tools. SGADs offer several advantages, including ease of insertion, minimal haemodynamic response, and the ability to maintain airway patency without the need for laryngoscopy. Importantly, newer SGADs are designed to serve as conduits for tracheal intubation, either blindly or under fibreoptic guidance. Among these devices, the AIR-Q Intubating Laryngeal Airway (ILA) is specifically designed to facilitate tracheal intubation. It features a short, wide airway tube and a removable connector, allowing easy passage of standard endotracheal tubes. The Ambu AuraGain, on the other hand, is a second-generation SGAD with an anatomically curved design and a gastric drainage channel, offering improved airway seal and protection against aspiration. While both devices are widely used, there is limited comparative data evaluating their effectiveness as conduits for blind tracheal intubation in paediatric patients. Blind intubation remains particularly relevant in settings where fibreoptic equipment is unavailable or in emergency situations. This study aims to compare the performance of AIR-Q and AuraGain in terms of intubation success rate, time efficiency, ease of use, and complications, thereby providing evidence-based guidance for clinical practice.

Study Design and Setting This was a prospective, randomized, comparative study conducted in the Department of Anaesthesiology at a tertiary care teaching hospital. Institutional ethics committee approval was obtained prior to commencement of the study, and informed consent was secured from the parents or guardians of all participants. Study Population A total of 100 paediatric patients aged between 1 and 18 years, scheduled for elective surgical procedures under general anaesthesia, were enrolled in the study. Patients were classified as American Society of Anesthesiologists (ASA) physical status I or II. Inclusion Criteria • Age between 1 and 18 years • ASA physical status I and II • Elective surgical procedures requiring general anaesthesia Exclusion Criteria • Anticipated difficult airway • Upper respiratory tract infection • Gastroesophageal reflux disease • Risk of aspiration • Craniofacial abnormalities • Limited mouth opening Randomization and Group Allocation Patients were randomly allocated into two groups using a computer-generated randomization sequence: • Group A: AIR-Q ILA (n = 50) • Group B: Ambu AuraGain (n = 50) Anaesthetic Technique All patients were fasted according to standard guidelines. In the operating room, standard monitoring was established, including electrocardiography, non-invasive blood pressure, pulse oximetry, and capnography. Anaesthesia was induced using intravenous agents, and muscle relaxation was achieved with an appropriate neuromuscular blocking agent. After achieving adequate depth of anaesthesia, the assigned supraglottic airway device was inserted. Device Insertion and Intubation Procedure The appropriate size of AIR-Q or AuraGain was selected based on patient weight. After insertion and confirmation of adequate ventilation, blind tracheal intubation was attempted using a microcuff endotracheal tube. The following parameters were recorded: • Time taken for device insertion • Ease of insertion (graded as easy, moderate, or difficult) • Number of attempts required for successful intubation • Time taken for successful intubation • First-attempt success rate Outcome Measures Primary Outcomes: • First-attempt success rate • Total intubation time • Number of attempts Secondary Outcomes: • Ease of insertion • Complications (trauma, desaturation, laryngospasm) Statistical Analysis Data were analysed using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation, and categorical variables as percentages. Student’s t-test and chi- square test were used for comparison. A p-value < 0.05 was considered statistically significant.

Demographic Characteristics The two groups were comparable with respect to age, weight, and gender distribution. No statistically significant differences were observed. Parameter AIR-Q Group AuraGain Group Age (years) 7.2 ± 3.1 7.5 ± 3.4 Weight (kg) 22.4 ± 6.5 23.1 ± 7.2 Male/Female 28/22 26/24 First Attempt Success Rate The AIR-Q group demonstrated a significantly higher first-attempt success rate compared to the AuraGain group. Device Success Rate AIR-Q 88% AuraGain 64% Intubation Time Mean intubation time was significantly shorter in the AIR-Q group. Parameter AIR-Q AuraGain Time (seconds) 18.5 ± 6.2 29.8 ± 9.4 Number of Attempts Attempts AIR-Q AuraGain First 44 32 Second 5 12 Third 1 6 Ease of Insertion Ease Level AIR-Q AuraGain Easy 84% 70% Moderate 14% 22% Difficult 2% 8% Complications The incidence of complications was low and comparable between the groups. Complication AIR-Q AuraGain Trauma 2% 6% Laryngospasm 2% 4% Desaturation 0% 2%

The present study demonstrates that the AIR-Q ILA is a more effective conduit for blind tracheal intubation compared to the Ambu AuraGain in paediatric patients. The findings are clinically significant, particularly in resource-limited settings where fibreoptic bronchoscopy may not be readily available. The higher first-attempt success rate observed with AIR-Q can be attributed to its design features, including a wider airway tube and a more direct alignment with the glottic opening. These features facilitate smoother passage of the endotracheal tube. In contrast, the AuraGain, although anatomically curved and equipped with a gastric channel, may not provide optimal alignment for blind intubation. This could explain the lower success rate and increased intubation time observed in this group. The shorter intubation time associated with AIR-Q is another important finding. Rapid airway securement is crucial in paediatric patients due to their limited oxygen reserves and higher susceptibility to hypoxia. The number of attempts required for successful intubation was also significantly lower in the AIR-Q group. Multiple attempts can increase the risk of airway trauma and complications, making this an important clinical consideration. The incidence of complications was low in both groups, indicating that both devices are relatively safe. However, the slightly higher incidence of trauma in the AuraGain group may be related to repeated intubation attempts. These findings are consistent with previous studies. Jagannathan et al. reported higher success rates with AIR-Q in paediatric patients. Similarly, Sethi et al. demonstrated improved intubation characteristics with AIR-Q compared to other SGADs. Despite its advantages, the AIR-Q is not without limitations. It lacks a gastric drainage channel, which may increase the risk of aspiration in certain patients. Therefore, patient selection remains important.

The AIR-Q Intubating Laryngeal Airway is superior to the Ambu AuraGain as a conduit for blind tracheal intubation in paediatric patients. It offers higher first-attempt success rates, reduced intubation time, and fewer attempts, making it a valuable tool in clinical practice. The Ambu AuraGain, while effective as a supraglottic airway device, may be less suitable for blind intubation. However, it remains a useful device, particularly when gastric drainage is required. LIMITATIONS • Single-centre study • Limited sample size • Operator-dependent variability • Lack of fibreoptic confirmation in all cases FUTURE DIRECTIONS Future studies should focus on multicentre trials with larger sample sizes. Comparative studies involving fibreoptic-guided intubation and video laryngoscopy would further enhance understanding of device performance.

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