Airway Management and Ventilation
Core concepts
Structure airway decisions around prediction, preparation, and rescue. Predict difficulty with history (prior difficult airway, radiation, surgery), examination (mouth opening, thyromental distance, Mallampati, neck mobility), and contextual factors (obesity, obstruction, bleeding).
Prepare a primary plan and at least one backup, plus a rescue plan for "cannot intubate, cannot oxygenate." Understand supraglottic airway use, video laryngoscopy, bougie, and surgical airway indications. Know the ASA difficult airway algorithm logic: optimize oxygenation first, limit attempts, call for help early, and move through devices systematically.
Ventilation concepts: tidal volume based on predicted body weight, lung-protective strategies, peak vs plateau pressures, and causes of high airway pressure (obstruction, bronchospasm, secretions, pneumothorax, decreased compliance). Recognize capnography waveforms: esophageal intubation, obstruction, and bronchospasm patterns.
Traps
- Using actual body weight for tidal volume in obese patients.
- Repeated laryngoscopy without intervening oxygenation.
- Missing that a sudden rise in airway pressure with hypotension may be pneumothorax or anaphylaxis.
- Forgetting preoxygenation and apneic oxygenation before attempts.
Rule of thumb
Oxygenate between attempts; limit attempts; escalate devices and call for help early. If you cannot ventilate or intubate, proceed to surgical airway without delay.
Worked example
After induction, peak pressures rise sharply, breath sounds are absent on one side, and blood pressure falls. Consider pneumothorax; decompress and reassess rather than simply increasing ventilator pressure.