okay so let's start with this so i want you now to assess this patient's airway i've given you
the data there and then i want you to make a judgment call so in this first example i think
they did a really good really good job we already went through the fact that this was a pretty
brilliant you know pretty um standard patient aside from the beard the way i think about
this patient this is just a patient without a beard with a beard you wouldn't treat this any
differently but the number of times in the viva that i'll give this to a you know senior registrar
and they'll want to do a fiber optic intubation is quite often um and that's because they you
know they get in the headspace of wondering what is right to you know what is right and what should
be done but really this is just difficult bag mask but everything else will be fine
bagmas difficulty to beard lma no issues expected endotracheal intubation issues expected i'd just
give a fast acting relaxant so i don't have to bag mass too long or have to rely on that
exactly right so you know if someone's willing to shave their beard fantastic but if there's no
other indicators of badness i think there's not many of us who'd insist on shaving the beard if
this patient was an impossible looking airway or difficult from many points of bag mask lman
to ett access i would ask them to shave their beard that's a really good point
okay this one i want you guys to make a decision say take 30 seconds to a minute 40 year old
sorry male not female large incisional hernia repair and this patient's assessment looks like
this again i want you to make a judgment call bag mask difficult easy lma etg difficult easy
so based on all numbers it looks okay i can see that it's for an incisional hernia repair
but i guess if i had to do i think if he was having something like a scope where
he had to support his own airway just all that soft tissue might cause some problems
so for an lma um we hope that insertion would be fairly easy if he wasn't paralyzed maybe the
he looks like a larger guy so just ventilating might be a bit more difficult yes um and for an
ett just yeah with those numbers it doesn't look like it should have too much trouble
absolutely i completely agree so because of the size of the patient bag mask and lma could
just be inherently difficult because you need very high pressures to be able to ventilate
increase the risk of everything so for me this is just a straight intubation but with a fast i can
relax it really relaxing and i really need good positioning and you'll often see these patients
ramped up with this oxford pillow or other pillows and using a video scope just in case
just note that all it takes is to add some complexity to make this difficult so
imagine that this patient you know you had to anaesthetize them in a foreign environment with
a junior assistant or the patient had sick lungs or heart suddenly what was not not the worst
airway is suddenly far more difficult and you might need to even just give the cardiovascular
management to someone completely different so you can focus on the airway just something to
think about the airway is never in airway isolated because it can often involve other complexities 55
year old ml shoulder reconstruction you do your five second airway exam here are your findings um
so i say he'll be he's got a bit of a mustache but i think the bag mask ventilation should be fine
i'm having a good dowel on standby just in case but i think it'll be fine i think
lma should be okay and i'd say ett is going to be difficult due to the melon patty of four and
i'd want to um video lyringer scope fantastic that's exactly that's exactly the system i want
you to talk through bag mask okay lms should be okay ett may be difficult so melon patty 4 means
over crowding into structures as long as i can get past this with a good dell lma or video scope the
airway shouldn't be too difficult again in an experienced hand so i wouldn't expect a junior
reg to be doing this at all on their own let alone even a senior age without some assistance 21 year
old male ruptured spleen post mba so melonpad is a bit unknown because the collar is still on
mouth opening is four neck extension is not there because of the c collar environmental distance 6.5
and jaw protrusion a bag mask ventilation should hopefully be okay or they might be difficult with
the c-spine precautions um ett will be difficult with the lack of neck extension due to these fine
precautions and the unknown paddy score um and lma would possibly be easy but may also be difficult
yeah and especially because it's probably a trauma patient needing a rapid sequence
induction the ability of the bag mask and lma is maybe limited not ideal uh but mechanically
it is fine so no issues but the aspiration risk is a problem maybe there's blood in the airway
they talk about a long gospel grade decreasing by one when you've got c-spine immobilization
or manual in-line stabilization that's great as you can see i'm getting you to talk through
each of these outlining the difficulty because the way you manage stuff is through the bag mask lm or
etc format and means far more than if you were to say it's a difficult area or not difficult
without specifying that how do you assess this patient uh six-year-old female anterior section
for bowel cancer and here are the details um i think that bagging this lady should probably
be okay it might be a bit hard to get a seal if she's got sort of floppy skin on her face
lma should probably be all right she can open her mouth enough and she's a melon patty too and
then ett i think this would be a difficult sort of intubation she's got you know a great b jaw um and
a short thyromental distance so you'd want someone experienced and have some options like video or
maybe awake fiber or something perfect so bag mask okay element and and every now and again i'll see
this kind of patient every few months and they've just got a very particular look with the very
you know narrow the thyromental distance and your protrusion in this will be the ones that mean that
i just it's it's like there's a bit of an anterior larynx which means i can't the angle is even more
hyper acute and that's what makes this difficult to visualize for intubation exactly you said video
scope shouldn't be too difficult and if i can bag mask and lma these patients which i invariably can
every single time i've done this and i can always do in a sleep a sleep fiber optic as well
if i thought it and weight fiber optic was not necessary again these are kind of advanced
decisions but i would just want you to know that this is the way we would think about this uh this
patient's airway a 64 year old male for a wrist gap mountain paddy one mouth opening five but the
next is neck is fixed because he's got ankylosing spondylitis so you can't really assess the
thyromental distance and your protrusion is a and so uh what do you guys think of this yes obviously
sort of 90 degrees out from where you'd hope you would be um in terms of his neck fixation with no
extension so and even like if you're trying to bag valve masking there might be lots of soft tissue
issues and high pressures you might not be able to get past lma similarly issues just because you've
you'd be hard to get around that bend um and then particularly out of the att tube so imagine you
want some kind of video assistance if not fibre optic or something like that
absolutely so this is an example where it's such a gross abnormality it's so ridiculously
bad that you just don't even know all bets are off everything could be difficult and i wouldn't
even risk it this is a weight fiber optic or just do it on the local whatever it is so in summary
this is how i target my assessment to make sure it relates to my management and naturally leads
to a plan it's so clinically relevant i just encourage you all to think of it this way it's
you know just shows a lot of clinical acumen to talk about like this um and that's really the way
that anesthesia has uh kind of progressed over the last decade or so to target this style of talking
you