Airway Management Flashcards

A 58-year-old patient with known radiation fibrosis of the neck requires awake fiberoptic intubation. After adequate topicalisation, you advance the bronchoscope to the carina but cannot advance the tracheal tube over it despite multiple attempts. The MOST likely cause is:

Answer: The tube bevel catching on the right arytenoid cartilage

When a tracheal tube loads correctly onto a bronchoscope but will not advance past the cords, the bevel catching on the right arytenoid is the classic cause. The fix is to rotate the tube 90° anti-clockwise so the bevel faces posteriorly, allowing smooth passage. Subglottic stenosis would impede the scope itself. Scope-to-tube diameter mismatch causes difficulty loading, not tube advancement failure once scoped. Deepening anaesthesia is inappropriate during an awake technique for this reason.

During jet ventilation via a rigid bronchoscope for subglottic stenosis resection, the patient's SpO₂ drops acutely to 82% with sudden onset of marked resistance to chest rise. Breath sounds are absent on the left. Which of the following is the SINGLE MOST appropriate immediate action?

Answer: Withdraw the bronchoscope proximally and attempt manual bag-mask ventilation

The clinical picture is tension pneumothorax or main bronchus intubation secondary to distal migration of the bronchoscope during jet ventilation — a known hazard. The immediate priority is to withdraw the bronchoscope to restore bilateral ventilation and allow passive exhalation before any further intervention. Increasing driving pressure risks worsening barotrauma. A double-lumen tube cannot be placed with a rigid bronchoscope in situ. Calling for thoracic surgery without first addressing ventilation would be fatal.

You perform a surgical cricothyrotomy in a 'cannot intubate, cannot oxygenate' scenario. After inserting a size 6.0 cuffed tube and inflating the cuff, you note end-tidal CO₂ trace is present but airway pressures are unexpectedly high and bilateral wheeze is heard. The MOST likely explanation is:

Answer: The distal tube is positioned in the right main bronchus causing dynamic hyperinflation

A standard 6.0 ETT inserted through the cricothyrotomy is short relative to the distance to the carina, making right main bronchus intubation very common in this technique — especially if the tube is advanced fully. ETCO₂ confirms tracheal placement, excluding oesophageal intubation. Dynamic hyperinflation from one-lung ventilation produces bilateral wheeze (referred from the hyperinflated right lung) and high airway pressures. The fix is to withdraw the tube 2–3 cm. Cuff herniation is rare and would produce more of a gas leak. Laryngospasm above the tube cuff is unlikely to produce bilateral wheeze.

When using a videolaryngoscope with a hyperangulated blade (e.g., C-MAC D-Blade or GlideScope) you obtain an excellent Cormack–Lehane grade 1 view, but are unable to advance the tracheal tube despite multiple attempts. Which of the following strategies is MOST evidence-based for resolving this?

Answer: Use a pre-shaped stylet with a ≥90° anterior bend at its distal end to match blade curvature

Hyperangulated videolaryngoscope blades create a 'around-the-corner' view that is paradoxically harder to intubate because the line of sight does not correspond to the axis of tube travel. The tube must be sharply pre-curved (≥90° anteriorly at the distal 4–6 cm) to follow the blade geometry. A 60° or shallower bend — appropriate for standard blades — will cause the tube to impact the anterior tracheal wall or arytenoids. BURP and direct laryngoscopy do not address the geometric mismatch inherent to hyperangulated blades. This is a common advanced airway pitfall in the EDAIC curriculum.

A patient with acromegaly presents for transsphenoidal hypophysectomy. Preoperative assessment shows Mallampati III, large tongue, interdental distance 4 cm, neck extension adequate, and previous uneventful intubation 8 years ago. Which airway feature SPECIFIC to acromegaly most significantly alters your anaesthetic strategy?

Answer: Subglottic narrowing from tracheal cartilage hypertrophy

Subglottic narrowing due to hypertrophy of the tracheal cartilages is a unique and dangerous feature of acromegaly that is not detected by standard external assessment and was not present 8 years ago if the disease has progressed. It requires smaller tube size selection (often 6.5–7.0 in adults) and can cause post-extubation stridor or complete obstruction. Prognathism actually facilitates laryngoscopy by opening the oral axis. OSA is common but is not itself an indication for awake fiberoptic intubation unless other features are present. Macroglossia affects mask seal but videolaryngoscopy usually compensates. The subglottic issue is the EDAIC-level distinction.

Following apparently uncomplicated extubation in PACU, a patient develops progressive stridor, paradoxical chest movement, and SpO₂ 88% that fails to improve with 15 L/min oxygen via non-rebreather mask. Direct laryngoscopy reveals bilateral vocal cord medialization. Which is the MOST appropriate immediate intervention?

Answer: Application of continuous positive airway pressure (CPAP) at 10 cmH₂O

Bilateral vocal cord paresis/paralysis post-extubation causes inspiratory stridor and hypoxaemia. The cords are medialized (adducted) and cannot be abducted. In contrast to post-extubation laryngospasm (fully closed cords responding to positive pressure and jaw thrust), bilateral cord paresis leaves a fixed, small glottic aperture. CPAP stents the glottis open pneumatically, dramatically improving airflow without the risks of reintubation in a partially obstructed airway. Reintubation is a last resort due to aspiration and trauma risk when cords are immobile. Heliox reduces turbulence but does not address the mechanical obstruction. Steroids and nebulised adrenaline are for oedema, not paresis.