Difficult Airways

Question 1

What is the ASA definition for a difficult intubation?

Answer 1

A situation in which a conventionally trained anesthesiologist has difficulty with mask ventilation of the upper airway, tracheal intubation, or both.

Question 2

According to the ASA, what two components define a difficult airway?

Answer 2

1. Difficulty with mask ventilation
2. Difficulty with tracheal intubation

Question 3

What is an anticipated difficult airway?

Answer 3

An airway known or suspected to be challenging based on preoperative assessment, allowing time to plan and prepare.

Question 4

What is an unanticipated difficult airway?

Answer 4

An airway that becomes difficult during management but was not predicted based on pre-op assessment.

Question 5

What is the safest approach for an anticipated difficult airway?

Answer 5

Awake tracheal intubation under topical anesthesia.

Question 6

What equipment is most useful for anticipated difficult intubation?

Answer 6

A flexible fiberoptic bronchoscope.

Question 7

What medication should you avoid in anticipated difficult airways?

Answer 7

Non-depolarizing NMBA because they prevent spontaneous ventilation if intubation fails.

Question 8

What are backup options for airway management in anticipated difficult intubation?

Answer 8

LMA, facemask, monitored anesthesia care (MAC), or regional anesthesia.

Question 9

Why is preoperative airway assessment crucial?

Answer 9

It helps identify anticipated difficult airways and reduces the chance of unanticipated complications.

Question 10

Can a patient be awakened if the airway proves unexpectedly difficult?

Answer 10

Yes, waking the patient is often a safe and appropriate choice if the airway cannot be secured.

Question 11

What’s the key to safety when an unanticipated difficult airway is encountered?

Answer 11

Early recognition, using the difficult airway cart, and calling for assistance.

Question 12

What is the most useful equipment to have for an anticipated difficult intubation?

Answer 12

Flexible fiberoptic bronchoscope

Question 13

What is the purpose of a difficult airway cart?

Answer 13

To provide immediate access to specialized airway equipment when managing a difficult or failed airway.

Question 14

What type of scope is essential on a difficult airway cart?

Answer 14

A flexible fiberoptic bronchoscope.

Question 15

Name 2 video-based tools commonly found on a difficult airway cart.

Answer 15

1. Video-assisted laryngoscope
2. Flexible fiberoptic bronchoscope

Question 16

What types of supraglottic airway devices should be on a difficult airway cart?

Answer 16

LMAs (including 1st and 2nd generation), intubating LMAs, and other supraglottic devices (King or Combitube)

Question 17

What type of surgical airway tools are found on a difficult airway cart?

Answer 17

Cricothyrotomy kit, large-bore angiocaths, scalpel, and tracheostomy set.

Question 18

Name types of intubation adjuncts stored on the difficult airway cart.

Answer 18

Bougies

Rigid or malleable stylets

Introducers

Lightwand stylet

Question 19

Why should alternative laryngoscope blades be on a difficult airway cart?

Answer 19

They offer different angles and shapes that may improve visualization in challenging anatomies.

Question 20

What oxygen delivery devices might be found on a difficult airway cart?

Answer 20

Nasal cannula (low and high flow), nasopharyngeal catheters, and jet ventilation tools.

Question 21

Should LMAs be available in various sizes on a difficult airway cart?

Answer 21

Yes, to accommodate for a range of patient sizes

Question 22

What tool might be used for retrograde intubation and stored on a difficult airway cart?

Answer 22

A retrograde wire or catheter system.

Question 23

What documentation tools might be found on or near the airway cart?

Answer 23

Airway algorithms and quick-reference guides to assist in high-stress decision-making.

Question 24

What is the first question in the difficult airway decision-making sequence?

Answer 24

Must the airway be managed?

Consider if the case can be done without intubation—e.g., regional or MAC.

Question 25

What is the second question in the airway planning sequence?

Answer 25

Is there potential for difficult laryngoscopy? Think: Mallampati, mouth opening, neck mobility, anatomy, history

Question 26

What is the third question in the difficult airway algorithm?

Answer 26

Can supralaryngeal ventilation be used if needed? LMA, mask ventilation? If these are not options, awake intubation may be safer.

Question 27

What is the fourth question in the airway planning sequence?

Answer 27

Is the stomach empty? This impacts aspiration risk and may require RSI, if not empty may need to be awake intubation

Question 28

What is the fifth (and final) question in airway planning?

Answer 28

Will the patient tolerate an apneic period? Think about OSA, obesity, pediatric or critically ill patients. If no, plan for awake intubation!

Question 29

If you answer “yes” to all 5 airway questions, what approach may be reasonable?

Answer 29

Proceed with induction, and have a SLA present

Question 30

If you answer “yes” to airway needed and difficult laryngoscopy, but “no” to supraglottic ventilation, what’s the safest plan?

Answer 30

Awake intubation—most commonly via fiberoptic technique.

Question 31

How does the answer to “Is the stomach empty?” affect airway management?

Answer 31

If not empty (e.g., trauma, recent meal), use RSI and cricoid pressure to reduce aspiration risk.

Question 32

What does “Will the patient tolerate apnea?” really assess?

Answer 32

Whether a patient is likely to desaturate quickly after induction

Question 33

What factors influence the choice of technique in the difficult airway algorithm?

Answer 33

Provider experience, Available resources, Equipment, Help availability, and Urgency of the case.

Question 34

What is the ideal patient positioning during the difficult airway algorithm?

Answer 34

Head-elevated (ramped) position with low- or high-flow nasal cannula for preoxygenation.

Question 35

What oxygenation strategies are recommended during difficult airway management?

Answer 35

High-flow nasal cannula (HFNC), standard nasal prongs (5–10 L/min), and apneic oxygenation.

Question 36

What are awake intubation options in the difficult airway algorithm?

Answer 36

Flexible bronchoscopy Videolaryngoscopy Direct laryngoscopy Retrograde wire-aided intubation Combined techniques

Question 37

What are invasive airway options in the difficult airway algorithm?

Answer 37

Surgical cricothyrotomy Percutaneous tracheostomy Retrograde wire-guided intubation ECMO (in some cases)

Question 38

What non-invasive backup options should be considered before moving to invasive airway?

Answer 38

Supraglottic airways (1st or 2nd gen LMAs) Face mask ventilation Adjunct devices (stylets, bougies, lighted wands)

Question 39

What are signs that you should consider an awake elective invasive airway?

Answer 39

When a difficult laryngoscopy, Poor supraglottic ventilation, Full stomach, and Poor apnea tolerance are expected

Question 40

What is the role of postponing the case in the algorithm?

Answer 40

If the airway is unsafe and the procedure is not emergent, wake the patient and return with better prep/resources.

Question 41

When can supraglottic ventilation be a final strategy rather than a bridge?

Answer 41

If ventilation is effective and the surgery does not require intubation or high airway pressures.

Question 42

What should always be available when performing a non-awake intubation in a potentially difficult airway?

Answer 42

Preparation for a surgical airway, backup devices, and a clear plan for failure.

Question 43

What does “can’t intubate, can’t ventilate” (CICV) mean?

Answer 43

You’re unable to secure the airway via intubation and also cannot ventilate using a mask or supraglottic device.

Question 44

What is the most dangerous consequence of a CICV situation?

Answer 44

Severe hypoxia leading to brain injury or death.

Question 45

How can repeated intubation attempts contribute to a CICV situation?

Answer 45

They can cause airway trauma, swelling, bleeding, and worsen the obstruction. Dr. Fort said it ends up looking like "ground meat"

Question 46

Why might supraglottic airways fail in a CICV situation?

Answer 46

Distorted airway anatomy, excessive airway secretions, or prior trauma may prevent proper seal or placement.

Question 47

What physiologic change rapidly worsens in a CICV crisis?

Answer 47

Rapid desaturation and rising CO₂ levels, leading to acidosis and cardiac arrest.

Question 48

What factor can impair your performance during a CICV event?

Answer 48

Panic. Do your best to remain calm! This is crucial for executing the emergency plan.

Question 49

Why might gastric insufflation be a problem in CICV?

Answer 49

Attempts at ventilation may force air into the stomach, worsening aspiration risk and reducing lung compliance.

Question 50

What airway complication can arise from trauma during repeated attempts?

Answer 50

Airway bleeding and swelling, which obscure landmarks and worsen visibility.

Question 51

What decision-making delay can worsen outcomes in a CICV event?

Answer 51

Failing to move to an invasive airway early enough TIME IS BRAIN

Question 52

Why is a CICV scenario especially dangerous in obese or OSA patients?

Answer 52

They desaturate much faster due to reduced functional residual capacity (FRC).

Question 53

What role does apneic oxygenation play in CICV prevention?

Answer 53

It can prolong safe apnea time and delay the onset of critical hypoxia.

Question 54

What is the first step after recognizing a CICV situation?

Answer 54

Attempt non-invasive rescue with a supraglottic airway if not already tried.

Question 55

What is the success rate of LMAs in CICV situations?

Answer 55

Not guaranteed LMA insertion has a significant failure rate in CICV scenarios.

Question 56

What is the definitive emergency airway in a CICV event?

Answer 56

Surgical airway, typically cricothyrotomy.

Question 57

What is the percutaneous cricothyrotomy technique using an angiocath?

Answer 57

Puncture cricothyroid membrane with a 14–16G angiocath, confirm air, then connect to circuit via syringe barrel and ETT connector.

Question 58

What is attached to the angiocath during emergency cricothyrotomy?

Answer 58

3 mL syringe barrel (plunger removed) + small end of 7.5 mm ETT connector + anesthesia circuit.

Question 59

What are signs that surgical airway must be performed immediately?

Answer 59

Failure to ventilate with both mask and supraglottic devices, desaturation, and airway obstruction.

Question 60

What type of cricothyrotomy is fastest to perform in an emergency?

Answer 60

Percutaneous cricothyrotomy with a large-bore angiocath.

Question 61

Why is it important to identify the cricothyroid membrane early?

Answer 61

It can be difficult to locate in emergencies, so identify landmarks before induction if possible.