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Anticipated Difficult Airway with Aspiration Risk — FRCA Final MCQ

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HardAirway ManagementAnticipated Difficult Airway with Aspiration RiskFRCA Final

A 40-year-old man requires emergency laparotomy for small-bowel obstruction. He remains at high risk of regurgitation despite nasogastric decompression. He is cooperative and is no longer actively vomiting. A previous anaesthetic record documents failed tracheal intubation after induction despite optimised direct and videolaryngoscopy, together with difficult facemask ventilation. Appropriate experienced assistance, suction and equipment are available. What is the most appropriate primary airway strategy?

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Correct answer: A — Awake oral flexible-bronchoscopic tracheal intubation

Awake oral flexible-bronchoscopic intubation is most appropriate. The record predicts failure of intubation by both direct and video laryngoscopy and difficulty with rescue facemask ventilation; inducing anaesthesia would therefore risk a cannot-intubate, cannot-oxygenate emergency. Awake intubation preserves spontaneous ventilation and airway tone until tracheal placement is confirmed by waveform capnography. Aspiration risk is not abolished: gastric decompression, head-up positioning, effective topicalisation with minimal or no sedation, continuous suction and a predefined failed-awake-intubation plan remain essential. Rapid-sequence induction with either direct or video laryngoscopy repeats previously failed strategies. A supraglottic airway is an unreliable primary strategy in bowel obstruction and does not provide equivalent aspiration protection. Sevoflurane induction is slow, does not secure the airway and may produce obstruction during an uncontrolled transition to anaesthesia.

Reference: Ahmad I et al. Difficult Airway Society guidelines for awake tracheal intubation in adults. Anaesthesia. 2020;75:509–528. https://pubmed.ncbi.nlm.nih.gov/31729018/