Following failed direct laryngoscopy (Cormack-Lehane grade 4) in a non-fasted patient, oxygenation is maintained by face mask. According to the NAP4 / Difficult Airway Society 2015 guidelines, what is the NEXT appropriate step?
- A Immediate surgical airway
- B Wake the patient and plan awake fibreoptic intubation
- C Second-generation supraglottic airway device insertion as a conduit for intubation ✓
- D Repeat direct laryngoscopy with a bougie
Explanation
The DAS 2015 'can't intubate, can oxygenate' algorithm after Plan A failure proceeds to Plan B: insertion of a second-generation supraglottic airway device (SAD) such as the ProSeal LMA or i-gel, which has a drain channel for gastric tube insertion and provides a better seal than first-generation SADs. The SAD can also serve as a conduit for intubation using a fibreoptic scope. Plan C is face-mask ventilation optimisation (two-person technique, adjuncts). Plan D (the emergency front-of-neck airway) is reserved for 'can't intubate, can't oxygenate' scenario. Repeated direct laryngoscopy without changing technique is discouraged after two failed attempts.
Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.