Airway Management Flashcards

A patient undergoing rapid sequence induction develops complete laryngospasm after intubation fails. Bag-mask ventilation is impossible and SpO2 is falling rapidly to 70%. You have applied 30–40 cmH2O of continuous positive airway pressure with no improvement. What is the most appropriate immediate next step?

Answer: Administer succinylcholine 1.5 mg/kg IV to break the laryngospasm

Complete laryngospasm unresponsive to CPAP constitutes a 'cannot intubate, cannot oxygenate' (CICO) scenario in evolution. A full intubating dose of succinylcholine (1.5 mg/kg IV) is the recommended pharmacological intervention to relax the laryngeal adductors before resorting to a surgical airway. The laryngospasm notch manoeuvre (Larson's manoeuvre) is appropriate for partial laryngospasm but has limited effect in true complete laryngospasm. Deepening anaesthesia alone is insufficient when SpO2 is critically low.

During videolaryngoscopy with a hyperangulated blade (e.g. C-MAC D-Blade), you achieve a Cormack-Lehane grade 1 view but are unable to advance the tracheal tube into the glottis despite multiple attempts. Which mechanism best explains this paradox?

Answer: The hyper-curved optics create a 'line-of-sight' mismatch between the lens angle and the tube trajectory

Hyperangulated videolaryngoscope blades achieve excellent glottic views by curving around the tongue, but this creates an acute angle mismatch: the camera 'sees' the glottis easily, yet the standard ETT trajectory diverges from the optical axis, causing the tube tip to hit the anterior tracheal wall or arytenoids. A pre-formed or malleable stylet curved to match the blade's angle is mandatory. This is a well-documented limitation of devices such as the C-MAC D-Blade, GlideScope, and McGrath Mac.

A 58-year-old patient with a known anterior mediastinal mass is anaesthetised in the supine position. After induction and neuromuscular blockade, SpO2 drops to 82% and ventilation becomes impossible despite high airway pressures. Fibreoptic bronchoscopy reveals severe external compression of the distal trachea at the carina. Which intervention is most likely to restore ventilation?

Answer: Change to lateral or prone positioning immediately

Anterior mediastinal masses can cause life-threatening tracheobronchial compression under general anaesthesia due to loss of spontaneous breathing and muscle tone. Positioning the patient laterally or prone can relieve extrinsic compression by shifting the mass away from the airway. This is a recognised rescue manoeuvre described in major airway management guidelines. Advancing the ETT into a main bronchus may temporarily ventilate one lung but does not relieve the compression. Increasing ventilatory parameters against a fixed mechanical obstruction will not help and risks barotrauma.

You are managing a patient via a Proseal LMA when you notice the bite block is being chewed and airway pressures are rising. Fibreoptic inspection through the LMA reveals the epiglottis is folded down, occluding 75% of the aperture bars. Which manoeuvre is most appropriate to correct this WITHOUT removing the LMA?

Answer: Partially deflate the cuff, extend the head and neck, then re-inflate

Epiglottic downfolding during LMA placement reduces effective glottic aperture and impairs ventilation. Partial cuff deflation reduces the pressure holding the epiglottis in the folded position, while gentle head extension and LMA repositioning (slight withdrawal then reinsertion) can re-seat the device to achieve correct anatomical alignment before re-inflation. Over-inflating the cuff worsens mucosal pressure and does not correct the malposition. Rotation manoeuvres are more applicable to rotational malposition. Advancing an ETT blindly risks trauma.

A 70 kg patient undergoing elective surgery requires awake fibreoptic intubation (AFOI) due to severe ankylosis of the cervical spine. After adequate topicalisation, you advance the bronchoscope nasally through the glottis into the trachea and confirm tracheal rings are visible. As you railroad the ETT over the bronchoscope, the tube repeatedly catches at the right arytenoid despite correct scope position. Which manoeuvre is most effective to facilitate tube passage?

Answer: Rotate the ETT 90° counter-clockwise (anti-clockwise) and re-attempt advancement

When railroading an ETT over a fibreoptic bronchoscope, the bevel of the tube faces anteriorly in the standard orientation, predisposing to catching on the right arytenoid or aryepiglottic fold. Rotating the ETT 90° counter-clockwise repositions the bevel posteriorly and to the left, which typically allows the tube to slide past the arytenoid and into the larynx without resistance. This is a well-established technique in AFOI literature (Ovassapian, Benumof). Downsizing the tube sacrifices seal and is not a first-line manoeuvre.

During a prolonged ICU stay, a patient with a tracheostomy develops a pulsatile, high-volume bleed from the stoma site. Bedside bronchoscopy reveals an ulcerated anterior tracheal wall at the level of the tracheostomy cuff. What is the most appropriate IMMEDIATE temporising measure before definitive surgical intervention?

Answer: Remove the tracheostomy tube and insert a finger to compress the innominate artery against the sternum via the stoma

Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication of tracheostomy, typically presenting with a sentinel bleed 1–3 weeks post-procedure. The immediate temporising manoeuvre described in surgical literature (Utley manoeuvre) is to remove the tracheostomy tube and insert a finger through the stoma to compress the innominate artery against the posterior sternum, providing direct haemostasis while the patient is transported for emergency median sternotomy. Over-inflating the cuff provides only partial and unreliable tamponade against arterial pressure and delays definitive control. Embolisation is too slow for acute arterial haemorrhage.