A patient in ICU requires intubation and is known to have a previous Grade 1 view on laryngoscopy.
a. Outline the physiological factors that could increase the risk of adverse events during intubation (4 marks)
b. Outline your strategies for optimising a physiologically unstable patient to minimise the risk of adverse events during intubation (6 marks)
Syllabus topic/section: 2.1.19 Intensive Care Procedures; 2.1.4 Cardiovascular Intensive Care; 2.1.5 Respiratory Intensive Care
Candidates are again reminded to carefully read the question. The question explicitly rules out the anatomically difficult airway and asks for the physiological factors, and many candidates wrote extensively about anatomical and other factors that did not attract marks. Similarly in Part B. whilst the question asked for physiological factors, many candidates wrote extensively about Front of Neck Access (FONA) and other structural/anatomical issues.
Candidates who used the template of an ABCD format to answer the question were distracted by the template focusing on A and B (anatomical) while candidates who used a system based or problem-based approach were better able to target their answers to the question and gain more marks. A useful strategy in the perusal time is to determine which structure will give the most accurate response to the content required.
Candidates who scored better in the question addressed the physiological factors such as hypoxia/oxygenation, arrhythmias, haemodynamic supports and shock management etc. The above standard candidate included management of acidosis, tiered therapies of inotrope deployment including timing and anticipation of further instability during the rigor of intubation. As with all questions, a clear structure helped answers to gain more marks.
The question could be read a number of ways, predominantly because "adverse events" is sufficiently broad to encompass an enormous amount of material. Is aspiration an "adverse event" related to a physiologically difficult airway? The Delphi consensus group from Karamchandani et al (2024) didn't think so, but most hospital's Serious Incident Review Committee members would disagree. Moreover, though the examiner's comments about the effort wasted on discussing anatomical airway problems are valid, one must also admit that the anatomical difficulty factors into the number of attempts and total apnoea time, which is exactly the sort of thing that one cannot afford if the patient is also physiologically difficult. So it's all interconnected, innit.
Anyway: for four marks, 80-100 words is all that could be reasonably expected from this "outline" answer, which the answer given below would exceed even if none of the parenthesised explanations were included. The only option in this situation is to give a less than comprehensive answer, focusing on the basics (eg. hypovolemia) at the cost of clever rare stuff (thyrotoxicosis, aortic dissection, etc).
a. Outline the physiological factors that could increase the risk of adverse events during intubation:
b) Strategies for optimising a physiologically unstable patient to minimise the risk of adverse events during intubation:
Mosier, Jarrod M., et al. "The physiologically difficult airway." Western Journal of Emergency Medicine 16.7 (2015): 1109.
Mosier, Jarrod M., and Franz Rischard. "The physiologically difficult airway: Hemodynamics." Manual of Airway Management in Critical Care: eBook Without Multimedia. Wolters Kluwer Health, 2024.
Kornas, Rebecca L., et al. "Evaluation and management of the physiologically difficult airway: consensus recommendations from Society for Airway Management." Anesthesia & Analgesia 132.2 (2021): 395-405.
Karamchandani, Kunal, et al. "Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study." Intensive care medicine 50.10 (2024): 1563-1579.