The present study reports a 42 years old male patient with modular thyroid cancer. The patient became candidate for direct laryngoscopy (DL) in order to observe the condition of the lesion in the trachea and probable biopsy, and subsequent surgery. After a few moments, it was observed that the patient cannot be ventilated. Immediately, the patient was tried to be intubated but was not successful and thus, quick track was put for the patient rapidly and he was connected to the jet ventilation machine. But after a short time, suddenly the patient got bradycardia and respiratory interruption and drop in saturation that the patient underwent CPR operation which continued for 30 seconds which resulted finally in the patient’s heart rate reaching 100 and spontaneous breathing began. After auscultation of lungs, bilateral pneumothorax was diagnosed that according to previous studies, is probably a complication resulting from trans tracheal jet ventilation (TTJV). This complication was resolved through needle aspiration. After 4 hours, the surgery was over and the patient, with stable vital signs and spontaneous breathing, was sent to the intensive care unit.In some previous studies, the researchers have suggested using open surgical technique in order to reduce the complications resulting from cannot intubate, cannot ventilate (CICV), and the present study also supports this suggestion and recommends it to other anesthesiologists when facing CICV situation, in order to reduce the complications resulting from jet ventilation and its subsequent damages.

As anaesthetists, we may constantly be in the learning curve of the management of difficult airway scenario. It can have a disastrous outcome if one is not adequately prepared with the right equipment. Over time there has been multiple ways to tackle difficult airway scenarios. Needless to say, appropriate airway gadgets are carefully chosen according to the surgery and patient characteristics. But what if these certain techniques fail? Then, what next? The inability to efficiently manage a difficult airway is the major cause of morbidity and mortality in anaesthetic practice. Here, we discuss 4 different case scenarios of difficult airway management. Case reports: Case 1 was a pediatric patient with TMJ ankylosis, with mouth opening 4mm, in whom we used the fibreoptic technique. Case 2-A failed fibreoptic attempt in a case of recurrent Ca oral cavity where we secured the airway using Airtraq video laryngoscope. Case 3-A patient with post burn contracture over front of neck and anterior shoulder where we decided to use intubating laryngeal mask airway (LMA) for securing airway and Case 4-An obese female patient posted for hysterolaparoscopy where we used the laryngeal mask airway supreme. Conclusion: Effective usage of newer drugs, equipment and airway gadgets by technically skilled personnel, with sound clinical judgement are essential factors in reducing airway related adverse scenario and it is of utmost importance to keep these alternate gadgets handy and to be proficient with its usage.

Management of difficult airway is one of the challenges in anesthesia and use of Percutaneous Transtracheal Jet Ventilation (PTJV) and a fiber optic bronchoscope is as a life saving procedure in difficult airway management. An 80-year high risk ASA CLASS IV patient with more than 80% upper airway obstruction due to a large tumor, scheduled for left radical tonsillectomy, was a candidate for tracheostomy before surgery. We performed the procedure by local Anesthesia, PTJV and intubated the patient by fiber optic bronchoscope after general anesthesia (GA). Therefore, tracheostomy obviated while surgery was done successfully.

Intraoperative Airway management of Pan facial fracture is always challenging due to difficult airway resulting from airway trauma and airway sharing between the anesthesiologist and maxillofacial surgeon. Submental intubation is considered a good alternative technique over tracheostomy for providing a clear field intraoperatively for maxillofacial fracture fixation. We want to discuss airway management maneuvers using Awake fiberoptic bronchoscope-assisted intubation and submental intubation technique and the challenges we faced in a patient presented with Pan- facial fracture with difficult airway posted for surgery.

Purpose: The present research was conducted to explain creativity, based on self-management and creative self-efficacy by mediating of educational engagement in elementary school students with learning Difficult. Method: The research method was a descriptive-correlation method with a path analysis design in the form of structural equations. The statistics society was included of students in 4th to 6th grads with learning problems that were engaged to educate in primary schools of Arak city in the academic year of 1400-1401, which were selected 200 boys’ and girls’ students (100 each gender) with learning problems as the research sample by using the purposeful sampling method. Data gathering tools were include Colorado Questionnaire, Shaffer's creativity questionnaire, Karwowski creative self-efficacy, Houghton and Neck's self-management, and Wilborn's educational engagement, which were completed by teachers and parents of students with learning Difficult. The collected data were analyzed by using Pearson's correlation coefficients and path way analysis in SPSS and AMOS software. From structural equations modeling method was used to investigate the research model fitness.  Results: The findings showed that the research model have an agreeable fitness. Also acquired coefficients between variables parameters showed that meaningful direct effect of self-management dimensions and creative self-efficacy on educational engagement and creativity. In this means, by increasing the self -management and creative self-efficacy, there is a positive change in the degree of educational engagement and creativity in students with learning problems. So, the relationships between the variables of the model drawn in this research were confirmed.