Airway Management and Ventilation
Airway plans and ventilation
The Airway Management and Ventilation domain tests prediction, preparation, bag-mask ventilation, supraglottic devices, tracheal intubation, rapid-sequence induction and rescue. The exam favors a stepwise plan and confirmation with waveform capnography.
- Preoxygenation: 3–5 minutes of tidal-volume breathing or 8 vital-capacity breaths with a tight mask; aim for end-tidal O2 above 90% when feasible.
- Sniffing position aligns oral, pharyngeal and laryngeal axes; ramping helps obese patients.
- Laryngoscopy grade: Cormack-Lehane I–IV. BURP (backward, upward, rightward pressure) can improve view but should be brief and light.
- ETT confirmation: continuous waveform capnography plus chest rise and auscultation. Cuff pressure 20–30 cm H2O; depth about 21 cm in women and 23 cm in men at the incisors, then confirm.
- Rapid-sequence induction: preoxygenate, induce, give neuromuscular blocker, intubate; cricoid pressure is no longer routine and should be released if it impedes intubation.
- Cannot intubate, cannot oxygenate (CICO): call for help, 100% oxygen, supraglottic rescue, then front-of-neck access without delay.
Worked example
After induction, the capnogram is absent, SpO2 falls to 70%, and no chest rise occurs. The reasoning: assume esophageal intubation or failed ventilation. Remove the tube, mask-ventilate with 100% O2, insert a supraglottic device, and if oxygenation still fails, proceed to front-of-neck access. Do not repeatedly attempt intubation while the patient desaturates.
Traps that cost marks
A colorimetric CO2 detector can false-negative in low flow. Do not rely on auscultation alone. Do not confuse tube depth with cuff seal; an endobronchial tube causes unilateral breath sounds and rising airway pressure.