2024.1 Day 1 VIVA 1
Airway Management
You are assessing a patient on your list for the next day. He is a 55-year-old man who is to have an excision of a 3cm x 3cm superficial swelling over the postero-lateral aspect of the neck.
The surgical assessment is that this is possibly a lymph node that can be excised in the Supine position with the head tilted away. The expected surgical duration of 30 minutes.
The patient has no known allergies, and he is not on any regular medications. He does admit to snoring and has a bushy beard but is otherwise fit and well. He weighs 88 Kgs (BMI = 29).
How would you do an airway assessment on this patient?
Comprehensive History:
OSA Screening: STOP-BANG score (snoring, tiredness, observed apnoea, BP >140/90, BMI >35, age >50, neck circumference >40cm, male gender) - this patient scores at least 3 (snoring, male, age)
Airway History: Previous difficult intubation, neck radiation, trauma or surgery
GERD symptoms: Increased aspiration risk during induction
Functional capacity: Assess cardiopulmonary reserve
Systematic Physical Exam:
Mouth opening (inter-incisor gap <3cm predicts difficult laryngoscopy)
Mallampati classification (Class III/IV suggests reduced pharyngeal space)
Thyromental distance (<6cm suggests anterior larynx)
Sternomental distance (<12.5cm predicts difficulty)
Neck mobility: Assess extension at atlanto-occipital joint
Dentition: Loose teeth, prominent incisors, dental appliances
Mandibular protrusion (inability to advance lower teeth past upper teeth indicates potential difficulty)
Special Considerations for This Case:
Bushy beard: Reduces mask seal efficacy; consider:
Trimming if acceptable to patient
Use of viscous gel to improve mask seal
Early transition to two-handed technique
Neck mass: Assess for tracheal deviation, compression symptoms
Positioning: Head tilt may:
Improve surgical access but worsen airway obstruction
Alter normal airway anatomy for intubation
Investigations:
Consider sleep study if strong OSA suspicion (though not practical pre-op)
Neck CT if concern about mass compromising airway
Airway Plan:
Preferred technique: ETT over SGA because:
Surgical field near airway
Potential for prolonged procedure
Higher security against displacement
Induction:
RSI vs modified RSI based on aspiration risk
Have double setup ready (plan A/B)
Equipment:
Video laryngoscope as first choice
Frova introducer available
Second generation SGA (e.g. i-gel) as backup
Positioning:
Ramped position (head elevated 25°)
Optimal sniffing position
Would you consider awake fiberoptic intubation for this patient?
Not routinely indicated based on current information
Would reconsider if:
Additional risk factors emerge (e.g. limited neck extension)
Mass appears to be compressing airway on further exam
Benefits vs risks of awake technique must be weighe
How does the beard specifically affect your airway management plan?
Primary concern is difficult mask ventilation:
Have oral/nasal airways immediately available
Consider supraglottic airway early if mask ventilation fails
Two-person technique may be required
Doesn't directly affect intubation success but may delay rescue oxygenation
What pre-oxygenation strategy would you use given his BMI?
3-5 minutes of tidal volume breathing with 100% O2
Head-up position to prolong safe apnea time
Consider CPAP/PEEP during pre-oxygenation
Target EtO2 >90% before induction
How would you modify your plan if the mass was larger (5cm) and fixed?
More thorough imaging (CT/MRI) to assess airway compromise
Consider awake fiberoptic intubation
Have ENT available for possible tracheostomy
Discuss possibility of staged procedure
The patient develops respiratory distress in PACU. What are your differentials and management?
Immediate Assessment (ABCDE approach):
Airway: Stridor, voice changes, secretions
Breathing: RR, SpO2, chest movement symmetry
Circulation: HR, BP, capillary refill
Disability: GCS, pupil response
Exposure: Check surgical site, temperature
Differential Diagnosis:
Surgical Complications:
Neck hematoma (expanding, tense swelling)
Recurrent laryngeal nerve injury (hoarse voice, inspiratory stridor)
Pneumothorax (unilateral breath sounds)
Airway Issues:
Laryngospasm (sudden onset post-extubation)
Edema (from intubation or fluid overload)
Secretions/mucous plugging
Other:
Anaphylaxis (rash, wheeze, hypotension)
Pulmonary edema (pink frothy sputum)
Opioid-induced respiratory depression
Focused Management:
Call for help immediately
100% oxygen via non-rebreather mask
Inspect neck:
If hematoma:
Release sutures/clips at bedside
Prepare for reintubation
Have FONA equipment ready
Auscultate:
Wheeze: Consider bronchodilators
Stridor: Consider nebulized adrenaline
Drugs:
Consider IV dexamethasone for airway edema
Have succinylcholine ready for laryngospasm
Investigations:
ABG/VBG (assess oxygenation, ventilation)
Bedside ultrasound (hematoma size, pneumothorax)
CXR if stable enough
How would you differentiate between laryngospasm and hematoma?
Laryngospasm:
Sudden onset post-extubation
No neck swelling
Improves with CPAP/succinylcholine
Hematoma:
Progressive symptoms
Visible swelling
Tracheal deviation possible
The surgeon says the hematoma is small. What would you do?
Still release pressure immediately because:
Small hematomas can expand rapidly
Airway compromise may become life-threatening
Can always re-close if needed
Prepare for reintubation while releasing
What are your criteria for reintubation?
Impending airway obstruction
SpO2 <90% despite maximal oxygen
Rising CO2 with respiratory acidosis
Decreasing GCS
Fatigue from increased work of breathing
How would you manage suspected anaphylaxis?
Immediate IM adrenaline (500mcg)
IV fluids bolus
Hydrocortisone 200mg IV
Chlorphenamine 10mg IV
Secure airway early if swelling progresse
The patient deteriorates: SpO2 60%, no air entry, and you cannot intubate or ventilate. What next?
Declare CICO Emergency:
Clear announcement: "This is a CICO situation"
Mobilize entire team - assign specific roles
Immediate Actions:
Continue 100% oxygen attempts
Confirm cannot intubate, cannot oxygenate
Position: Neck extension if possible (unless contraindicated)
Scalpel-Bougie Technique (ANZCA Guidelines):
Landmark Identification:
Locate cricothyroid membrane (between thyroid and cricoid cartilage)
If unclear, use 3-finger technique (index on thyroid notch)
Stabilization:
Have assistant hold trachea stable
Consider local if time allows (1-2ml 1% lidocaine)
Incision:
Vertical 4-5cm skin incision
Horizontal stab through cricothyroid membrane
Bougie Insertion:
Insert bougie caudally (30° angle)
Feel for tracheal rings confirmation
Tube Placement:
Railroad 6.0 ETT over bougie
Inflate cuff, secure tube
Confirmation:
Primary: Waveform capnography (gold standard)
Secondary: Chest rise, misting, SpO2 improvement
Tertiary: Auscultation (though less reliable in emergency)
Post-Procedure:
Call ENT for formal tracheostomy
CXR to confirm position
ICU transfer
Full documentation
Team debrief
Why choose scalpel-bougie over cannula technique?
Higher success rates in studies
More reliable airway diameter
Less risk of barotrauma
ANZCA guidelines recommend as first-line
How would you confirm tube placement in this emergency?
EtCO2 is mandatory - only definitive confirmation
Secondary signs: Chest rise, SpO2 improvement
Avoid relying solely on auscultation
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