A 73-year-old patient with a history of ankylosing spondylitis and type 2 diabetes presents with severe respiratory failure.
You are asked to review the patient in the Emergency Department as there has been progressive deterioration since presentation. The patient is clearly dyspnoeic with a respiratory rate of 35 breaths/min and oxygen saturation of 86% on supplemental oxygen of 15 L/min through a non-rebreather mask. A decision has been made to progress to urgent intubation.
Discuss potential difficulties or challenges you foresee and your strategies for dealing with them under the following headings.
a) Infection control measures during the airway procedure. (20% marks)
b) Securing the airway. (80% marks)
The first two marks of this question are dedicated to a topic which, during the COVID pandemic, had a remarkable amount of ink spilled over it. Trainees may recall how countless airway management policies were hastily drafted and revised to minimise staff exposure to aerosols, draping the patient in various plastic sheets, clamping tubes and performing checklist rituals. This "infection control measures during the airway procedure" section expects those same trainees to purify the last two years of confusing and rapidly mutating guidelines into some kind of point-form condensate, for under fifty words.
The best resource for this that probably crosses the most international boundaries is the NEJM video from 2021 by Shrestha et al. To narrow things even more, for COVID patients with difficult airways, this 2021 set of guidelines from the Society of Airway Management spells out all the issues that need to be considered. The reader is warned that these are not standard guidelines by any means, i.e the recommendations they make may not be endorsed by every jurisdiction around the world, and every airway expert is likely to have their own opinion on this situation. As the result, the possible range of answers to this question is quite broad, and what follows should be viewed as a guide or suggestion for how to approach this SAQ rather than any sort of model answer
Infection control measures
Preparation for intubation
Shrestha, Gentle Sunder, et al. "Emergency Intubation in Covid-19." The New England Journal of Medicine 384.7 (2021): e20-e20.
Apfelbaum, Jeffrey L., et al. "Practice Guidelines for Management of the Difficult Airway An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." The Journal of the American Society of Anesthesiologists 118.2 (2013): 251-270.
Foley, Lorraine J., et al. "Difficult airway management in adult coronavirus disease 2019 patients: statement by the Society of Airway Management." Anesthesia & Analgesia 133.4 (2021): 876-890.