Difficult Intubation — FRCA Final MCQ

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ModerateAirway ManagementDifficult IntubationFRCA Final

An adult undergoing rapid sequence induction has unanticipated difficult tracheal intubation. Oxygenation is maintained between attempts, and each subsequent attempt is optimised by changing the operator, device or technique. According to the DAS 2025 guidelines, what is the maximum total number of tracheal intubation attempts permitted within Plan A before failed intubation is declared?

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Reveal the answer and explanation

Correct answer: A — 4

The correct answer is A: four attempts in total. DAS describes a maximum of three tracheal intubation attempts, with one additional attempt permitted by a more experienced operator—the “3+1” limit. Each repeat attempt should have a realistic prospect of success and must involve optimisation, such as changing the operator, device, technique or patient position. After the fourth unsuccessful attempt, failed intubation should be declared and the team should proceed to Plan B using a second-generation supraglottic airway device. Option B counts only the initial three attempts and omits the additional expert attempt. Five attempts exceeds the recommended ceiling, whereas one or two attempts would declare failure prematurely when oxygenation is maintained and an appropriately optimised further attempt remains available.

Reference: Ahmad I, El-Boghdadly K, Iliff H, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Plan A: tracheal intubation. Br J Anaesth. 2026;136(1):283-307. Epub 7 November 2025. https://pubmed.ncbi.nlm.nih.gov/41203471/