The difficult airway & rapid sequence induction — Viva

Viva Stems

1. Two optimised attempts have failed and the saturation is falling. What do you do next, and what do you not do? One more capped attempt at most then descend: Plan B intubation through a second-generation supraglottic airway conduit, then Plan C supraglottic rescue oxygenation, then declared Plan D scalpel–bougie–tube front-of-neck access — never a fourth laryngoscopy while the saturation falls. Each tier is a trigger to move on, not to try harder.^[1]

2. What did the IRIS trial actually show about cricoid pressure? A sham-controlled trial in 3,472 rapid sequence inductions: aspiration 0.6% with cricoid versus 0.5% with sham, with Cormack–Lehane grades 3–4 doubled (10% versus 5%) and intubations over 30 seconds more frequent (47% versus 40%). Apply it loosely if at all, release it the moment it obstructs, and let oxygenation outrank it.^[14]

3. How do you predict difficulty in this patient, and what are the limits of prediction? LEMON for anatomy plus MACOCHA for the critically ill physiology — seven items from 1,000 intensive-care intubations (11.3% difficult) validated in 400 more. Mallampati alone is weak and a sizeable minority of difficult airways are unanticipated, so preparation precedes the first drug regardless of the score.^[10][1]

4. Where does videolaryngoscopy fit, given the Cochrane review? First-line for the anticipated difficult airway and key rescue tool in experienced hands: 64 studies and 7,044 participants showed fewer failed intubations including the anticipated-difficult subgroup and less airway trauma, with the failed-intubation benefit confined to experienced operators and no clear effect on hypoxaemia or mortality. The device rewards drilling, not ownership.^[11]