The evidence on the pathophysiology of the novel coronavirus SARS-CoV-2 infection is rapidly growing. Elucidating why some patients suffering from COVID-19 are getting so sick, while others are not, has become an informal imperative for researchers and clinicians around the globe. The answer to this question would allow rationalizing the fear surrounding this pandemic. Understanding of the pathophysiology of COVID-19 relies on unraveling of interplaying mechanisms, including SARS-CoV-2 virulence, human immune response, and complex inflammatory reactions with coagulation playing a major role. An interplay with bacterial co-infections, as well as the vascular system and microcirculation affected throughout the body should also be examined. More importantly, a comprehensive understanding of pathological mechanisms of COVID-19 will increase the efficacy of therapy and decrease mortality. Herewith, the authors present a combined viewpoint based on the current state of knowledge on COVID-19: beginning from the virus, its transmission, and mechanisms of entry into the human body, through the pathological effects on the cellular level, up to immunological reaction, systemic and organ presentation. Last but not least, currently available and possible future therapeutic and diagnostic options are briefly commented on. (Cardiol J 2020; 27, 2: 99-114)

We describe a case of total spinal anaesthesia, which occurred after a 3-ml lignocaine (20 mg ml(-1)) test dose was administered through an epidural catheter in a 79-year-old patient scheduled for gastrectomy under combined general and epidural anaesthesia. The surgery was postponed, and the patient required admission to the intensive therapy unit. Spinal MRI from the total spinal cord did not reveal any pathology. During the next 24 h the patient recovered and after 11 days was successfully operated on under general anaesthesia. No late complications followed. We presume that during placement, the epidural catheter had migrated to the spinal canal as a result of technical difficulties. Although controversial, we consider that administering a standard test dose of local anaesthetic via an epidural catheter is recommended, especially in high-risk patients and when epidural space identification or catheter placement poses technical difficulties. A test dose of local anaesthetic does not fully prevent complications.

It is possible to misdiagnose postpartum cardiomyopathy for PE. An error in diagnosis is life-threatening for the patient. Echocardiography is a valuable tool in the differential diagnosis. As a noninvasive procedure, it should be performed at the bedside as soon as possible to institute proper treatment and to avoid potentially fatal errors.

Although standard management of an expected difficult intubation is based on fibre-optic techniques, the application of optical laryngoscopes such as Airtraq is gaining widespread acceptance. We here describe a case where an intubation attempt with the Airtraq laryngoscope was not only unsuccessful, but negatively influenced subsequent use of a flexible fibroscopic approach. caSe RepoRtA 52 year-old female patient (ASA 3) was scheduled for cervical laminectomy in a prone position. She had a long history of rheumatoid arthritis that had led to compression of the spinal cord and progressive neurological deterioration. She had symptoms of imminent tetraparesis: decreased muscle strength, especially in the lower limbs, and paresthesiae in the upper extremities. She had been treated with steroids and methotrexate without improvement. A distinct retrosternal thyroid goitre precluded an anterior approach to the cervical spine, and a posterior approach was chosen.The patient's medical history included a failed tracheal intubation six years before. A minor gynaecological procedure was then completed with bag and mask ventilation. Physical examination revealed multiple predictors of difficult tracheal intubation. The cervical spine was almost completely immobilised in flexion (Fig. 1). The chin was withdrawn and the mouth opening was limited to 2.2 cm. Upper incisors were protruding and the left one was missing. The thyromental distance was 7 cm and visibility of the posterior pharyngeal wall was recognised as the fourth Mallampati class. The hyoid bone and the larynx were not immobilised, however slight clicks within the soft tissues of the neck were felt during palpation. The trachea was not deviated. Chest X-ray did not reveal deviation or tracheal stenosis.The patient had agreed to an intubation attempt with an Airtraq (Prodol Meditec S.A., Vizcaya, Spain) laryngoscope under topical airway anaesthesia and sedation. As a 'Plan B' , according to Difficult Airway Society guidelines [1] we chose oral fibre-optic intubation under sedation.After premedication with 15 mg of midazolam orally, the patient was brought to the operating suite and standard monitoring was begun. The tongue and throat were topi-

Thank you for your comments to the paper "Complications after using the Airtraq laryngoscope for a predicted difficult intubation" published in Anaesthesiology Intensive Therapy, volume 45, no.1, 2013 (pp. 35-37) and for valuable remarks regarding planning and management in cases of predicted difficulties in securing the airway. Moreover, I am grateful for providing me with the newest papers focused on this issue.I reckon that it is easy to write about our successes but only thanks to the revealed failures and matter-of fact discussions, further failures can be avoided.Safe anaesthesia planning comprises not only securing the airway for the surgery but also prediction of difficult situations during the immediate postoperative period. In the case described by us, one of the key aspects was the fact that the surgical procedure involved the high cervical spine, which poses a serious risk of acute respiratory failure at any time during the postoperative 24 hours (or even several subsequent days). It is known that fibreoptic intubation is not the management of choice in emergencies; for the reason you have mentioned, it requires good preparation and patient's cooperation. Considering this, we decided to check whether the intubation is feasible with the equipment that can also be used in rescue cases. We were aware that the attempt could end in failure. We should probably discontinue our attempts when, despite earlier preparation and administration of local anaesthesia, it became clear that the patient was not going to cooperate during intubation and required deeper sedation.I do share your opinion (vide the discussion) that scheduled fibreoptic intubation under local anaesthesia is the prime method of securing the difficult airway. It is true that this procedure is included amongst the practical skills in the curriculum of anaesthesiology and intensive therapy specialisation. Unfortunately, in many centres this requirement is neglected. Most likely, this results from the fact that many specialization supervisors trained when intubation fibrescopes were practically unavailable in our country cannot supervise proper performance of fibrescopic intubation. The case we were faced with happened several years ago. Unfortunately, the changes take place very slowly. The list of specialization courses supervised by the Medical Centre for Postgraduate Education of 2012 and 2013 there does not contain any courses in difficult airway, which would enable the residents specializing in anaesthesiology to learn at least simulated fibreoptic intubations. Such courses are available only as training courses for specialists; moreover, many of them are payable. The recruitment for this year has already been completed.I believe that the trainings in your centres are worthy popularisation. It is high time fibrescopic intubation became the practical and not on-paper skill of Polish anaesthesiologists. To achieve this goal, better availability of equipment, simulators and trainings, not to mention the changes in mentality are required.I do ...