Airway Management and Difficult Airway
Oxygenate first; intubate second
Airway management begins with prediction, preparation, positioning, and preoxygenation. Assess mouth opening, Mallampati, thyromental distance, neck mobility, dentition, obesity, and prior difficulty, but remember that individual tests have poor predictive value. Prepare suction, oxygen, bag-mask, supraglottic airway, video laryngoscope, and front-of-neck access. Use apneic oxygenation and high-flow or standard nasal oxygen when appropriate. Confirm tube placement with sustained waveform capnography.
Traps: a difficult airway is not the same as a difficult mask or difficult rescue. Do not persist with repeated direct laryngoscopy when oxygen saturation is falling. An awake technique is preferred when aspiration risk, airway obstruction, or previous failure makes asleep induction dangerous. Extubation is a high-risk phase: assess edema, secretions, position, and readiness.
Worked example: cannot intubate, cannot oxygenate after induction. Call for help, declare CICO, attempt supraglottic rescue only if it does not delay, and proceed to emergency front-of-neck airway with scalpel-bougie-tube technique. Oxygenation, not intubation, is the endpoint.
Rule of thumb: limit laryngoscopy attempts and change something each time-operator, device, position, or technique.