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Anticipated Difficult Airway — FRCA Final MCQ

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ModerateAirway ManagementAnticipated Difficult AirwayFRCA Final

A 29-year-old woman (ASA II, 65 kg) with a large multinodular goitre is listed for total thyroidectomy. A previous anaesthetic record documents Cormack–Lehane grade 4 direct laryngoscopy and difficult two-person facemask ventilation. CT demonstrates tracheal deviation with moderate compression, but nasendoscopy shows a patent laryngeal inlet. She has no stridor or orthopnoea. The cricothyroid membrane is impalpable because of the goitre. What is the most appropriate primary airway management plan?

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Correct answer: B — Awake tracheal intubation using a flexible bronchoscope

The best plan is **B: awake tracheal intubation using a flexible bronchoscope**. Previous grade 4 laryngoscopy, difficult facemask ventilation and distorted neck anatomy predict difficulty with both intubation and rescue oxygenation after induction. Awake intubation permits controlled tube placement while maintaining spontaneous ventilation and airway tone. Flexible bronchoscopy is particularly suitable for navigating a deviated trachea. Rapid-sequence or standard intravenous induction would remove this safety margin, while an inhalational induction does not guarantee airway patency and leaves the trachea unsecured. Awake tracheostomy may be appropriate for critical or non-traversable obstruction, but is unnecessarily invasive here because nasendoscopy confirms a patent laryngeal inlet and there is no stridor or orthopnoea. A complete plan must also include skilled assistance, oxygenation, topical anaesthesia, limited sedation, failed-awake-intubation planning and ENT availability.

Reference: Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020;75:509–528. https://pubmed.ncbi.nlm.nih.gov/31729018/