Week 13 Handout: Altered Airway

Question 1

What is a cornerstone of safe anesthesia?

Answer 1

Airway management is a cornerstone of safe anesthesia.

Question 2

What percentage of patients with distorted anatomy experience difficult intubation?

Answer 2

28% of patients with distorted anatomy experience difficult intubation.

Question 3

What percentage of patients with distorted anatomy experience impossible intubation?

Answer 3

2.8% of patients with distorted anatomy experience impossible intubation.

Question 4

What aspects can altered anatomy compromise?

Answer 4

Altered anatomy can compromise mask ventilation, laryngoscopy and intubation, ventilation strategy, and airway rescue.

Question 5

What are congenital causes of altered airway anatomy?

Answer 5

Congenital causes include Pierre Robin sequence, Treacher Collins syndrome, Down syndrome, and Goldenhar syndrome.

Question 6

What are acquired causes of altered airway anatomy?

Answer 6

Acquired causes include tumors, burns or radiation fibrosis, trauma, obesity and OSA, and cervical spine disease or previous surgery.

Question 7

What is the impact of poor mask seal?

Answer 7

Anomalies such as micrognathia or facial asymmetry impair seal and ventilation.

Question 8

What makes laryngoscopy difficult?

Answer 8

Tumors, edema, or distorted landmarks make glottic visualization difficult.

Question 9

What is suboptimal positioning in airway management?

Answer 9

Limited neck mobility (e.g., cervical fusion) impairs alignment of airway axes, complicating both mask ventilation and direct laryngoscopy.

Question 10

What is the first key strategy for anticipated difficult airways?

Answer 10

Anticipate Difficulty: Perform thorough preoperative assessment including airway history, Mallampati score, thyromental distance, neck mobility, and past difficult intubation.

Question 11

What is Plan A in airway management?

Answer 11

Plan A: Optimized video or direct laryngoscopy.

Question 12

What is Plan B in airway management?

Answer 12

Plan B: Supraglottic airway or fiberoptic intubation.

Question 13

What is Plan C in airway management?

Answer 13

Plan C: Surgical airway (cricothyrotomy or tracheostomy).

Question 14

What should be done to optimize ventilation and positioning?

Answer 14

Maintain spontaneous ventilation until airway is secured, use awake intubation if severe airway risk is present, and preoxygenate thoroughly.

Question 15

What equipment should be prepared for difficult airway management?

Answer 15

Prepare laryngoscopes (video & direct), bougies, LMAs, fiberoptic scopes, and cricothyrotomy kits.

Question 16

What is the ASA Difficult Airway Algorithm?

Answer 16

A structured response improves outcomes when intubation or ventilation fails, involving preparation, suspecting difficulty, and using familiar techniques.

Question 17

What is Plan A in the DAS Difficult Intubation Guideline?

Answer 17

Plan A: Tracheal Intubation with a goal to secure airway on the first attempt with full preparation.

Question 18

What is Plan B in the DAS Difficult Intubation Guideline?

Answer 18

Plan B: Supraglottic Airway, moving to a second-generation supraglottic airway if intubation fails.

Question 19

What is Plan C in the DAS Difficult Intubation Guideline?

Answer 19

Plan C: Facemask Ventilation, attempting mask ventilation if SAD fails.

Question 20

What is Plan D in the DAS Difficult Intubation Guideline?

Answer 20

Plan D: Surgical Airway, proceeding directly to cricothyrotomy if unable to ventilate.

Question 21

What should be included in a preoperative airway assessment?

Answer 21

Review anesthesia history, perform a structured physical exam, and communicate with the patient regarding awake intubation.

Question 22

What medications should be selected for intraoperative anesthesia management?

Answer 22

Use sedation cautiously, prefer glycopyrrolate for antisialogogues, and apply topical anesthetics like lidocaine for awake intubation.

Question 23

What are the techniques for awake intubation?

Answer 23

Techniques include fiberoptic bronchoscopy, video laryngoscopy, optical stylets, and preparing for surgical airway backup.

Question 24

What triggers laryngospasm during awake intubation?

Answer 24

Laryngospasm is triggered by airway stimulation during awake intubation and may prevent ventilation.

Question 25

What should be done if ventilation or intubation fails?

Answer 25

Follow the 'Can’t Intubate, Can’t Ventilate' protocol, use SAD, attempt rescue maneuvers, and proceed to surgical airway.

Question 26

What is critical in surgical airway management?

Answer 26

Be prepared with scalpel-bougie cricothyrotomy and make early decisions to save lives.

Question 27

Which of the following are common causes of altered airway anatomy that can complicate airway management? (Select all that apply) A. Treacher Collins Syndrome B. Down Syndrome C. Asthma D. Neck Trauma E. Prior Radiation Therapy

Answer 27

Correct Answers: A, B, D, E Rationale: Treacher Collins Syndrome and Down Syndrome are congenital conditions associated with craniofacial abnormalities, such as micrognathia and macroglossia, which complicate mask ventilation and intubation. Neck trauma and prior radiation therapy can lead to fibrosis and anatomical distortion. Asthma, however, is a reactive lower airway condition, not an anatomical abnormality (Elisha et al., 2023, p. 437).

Question 28

What is the most appropriate initial step when a difficult airway is anticipated preoperatively? A. Administer muscle relaxants B. Perform rapid sequence induction C. Attempt direct laryngoscopy D. Prepare for awake intubation with patient education and informed consent E. Proceed with mask ventilation only

Answer 28

Correct Answer: D Rationale: In patients with anticipated difficult airways, the safest initial approach is to prepare for awake intubation, which includes thorough patient education, obtaining informed consent, assembling appropriate equipment, and ensuring team readiness. This strategy helps preserve spontaneous ventilation and allows for controlled airway management (Elisha et al., 2023, pp. 447-452).

Question 29

Which anatomical alteration most directly compromises optimal positioning for laryngoscopy? A. Macroglossia B. Limited cervical spine mobility C. Obesity D. Enlarged tonsils E. Deviated nasal septum

Answer 29

Correct Answer: B Rationale: Limited cervical spine mobility disrupts the alignment of oral, pharyngeal, and laryngeal axes, preventing the sniffing position needed for optimal laryngoscopic view. (Elisha et al., 2023, pp.

Question 30

Which Plan B strategy is recommended when Plan A (tracheal intubation) fails, according to the DAS Difficult Intubation Guideline? A. Attempt blind nasal intubation B. Insert oropharyngeal airway C. Use second-generation supraglottic airway D. Perform emergency cricothyrotomy E. Paralyze and reattempt intubation

Answer 30

Correct Answer: C Rationale: The DAS guideline recommends using second-generation supraglottic airway devices as the next step when initial intubation attempts fail, avoiding blind techniques (Elisha et al., 2023, p. 449).

Question 31

During an awake intubation, which medication is most appropriate to reduce upper airway secretions? A. Midazolam B. Fentanyl C. Glycopyrrolate D. Lidocaine E. Atropine

Answer 31

Correct Answer: C Rationale: Glycopyrrolate is an effective antisialogogue that reduces salivary secretions and enhances visualization during awake intubation without crossing the blood-brain barrier

Question 32

According to the ASA Difficult Airway Algorithm, what is the next step when a provider can ventilate but cannot intubate? A. Proceed with surgical airway B. Paralyze and retry intubation C. Wake the patient immediately D. Attempt alternative intubation techniques E. Stop and observe for improvement

Answer 32

Correct Answer: D Rationale: When ventilation is still possible, but intubation fails, the ASA algorithm advises attempting alternative methods such as video laryngoscopy or fiberoptic techniques before resorting to invasive options (Butterworth et al., 2022, p. 329).