Airway Management and Difficult Airway Preparedness
What the exam tests
Airway Management and Difficult Airway Preparedness tests prediction, preoxygenation, device selection, confirmation, and rescue plans.
Core rules and concepts
- Predict difficulty with Mallampati, 3-3-2 rule, mouth opening, thyromental distance, cervical motion, and prior records. No single test is reliable.
- Preoxygenate for about 3 minutes or with vital-capacity breaths; add apneic oxygenation when prolonged attempts are expected.
- The ASA difficult airway approach uses plans A–D: mask or supraglottic, supraglottic rescue, intubation or video laryngoscopy, then emergency front-of-neck access.
- Confirm every tracheal tube with continuous capnography and bilateral breath sounds; capnography is the standard.
- Limit attempts, call for help early, and change something each attempt: operator, device, position, or adjunct.
Worked example
After one direct laryngoscopy, a patient has no capnogram, oxygen saturation is 85%, and the view was grade 4. Reasoning: stop repeated attempts, call for help, oxygenate with a mask or supraglottic device, and use video laryngoscopy with a bougie. If oxygenation cannot be maintained despite these measures, declare cannot intubate cannot oxygenate and perform emergency front-of-neck access.
Traps
Do not make multiple traumatic attempts without oxygenating. Do not rely on auscultation alone. Do not forget suction, a working bougie, and a preformed rescue plan. Do not delay front-of-neck access in a true CICO emergency. Do not confuse a difficult mask with a difficult intubation; both need a plan.