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anesthesia.preop-airway-evaluation.core.v1

Preoperative Airway Evaluation and Difficult Airway Management

critical_carechronicadultpediatricoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Lane-C anesthesia campaign — preoperative assessment + intraoperative difficult-airway plan. Acuity "chronic" since this is the planning/assessment engine (LAST and MH dossiers cover crisis flow). Drug RxCUIs all RxNav-verified live 2026-05-26: lidocaine 6387, benzocaine 1399 (avoid >20%), midazolam 6960, remifentanil 73032, propofol 8782, sugammadex 1726988, rocuronium 68139, succinylcholine_chloride 3565. PMIDs 34762729 (Apfelbaum ASA 2022), 26556848 (Frerk DAS 2015), 21447489 (Cook NAP4 2011), 4027773 (Mallampati 1985) all live-verified via PubMed MCP. Capnography is mandatory per NAP4 (undetected esophageal intubation is now a UK Never Event). Required chronic phases (CONTEXT, TREATMENT, MONITORING, FOLLOWUP) all present.

Entry points (5)

  • problem_list
    Preoperative anesthesia evaluation visit (any surgery requiring airway management) (ASA 2022)
    preop_anesthesia_evaluation
  • history
    Prior documented difficult intubation / failed intubation / surgical airway (ASA 2022)
    prior_difficult_intubation_documented
  • history
    Severe OSA, BMI >=40, history of failed mask ventilation (ASA 2022)
    osa_or_severe_obesity
  • history
    Head/neck pathology — tumor, radiation, RA, ankylosing spondylitis, Down syndrome, Pierre Robin, micrognathia (ASA 2022, DAS 2015)
    anatomic_airway_pathology
  • demographic
    Term pregnancy — physiologic airway edema + faster desaturation (ASA 2022)
    pregnancy_term

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Pediatric and elderly airways have distinct anatomic considerations (ASA 2022, DAS 2015)
  • bmirequired
    demographic • used at CONTEXT
    BMI >=40 raises mask-ventilation and intubation difficulty risk (ASA 2022)
  • pregnancy_status
    demographic • used at CONTEXT
    Pregnancy alters airway edema + desat speed; influences awake-fiberoptic threshold (ASA 2022)
  • prior_anesthetic_recordsrequired
    history • used at CONTEXT
    Documented prior difficult intubation is the single best predictor (ASA 2022)
  • osa_screenrequired
    history • used at CONTEXT
    STOP-BANG / Berlin / known PAP use; OSA increases supraglottic obstruction (ASA 2022)
  • head_neck_pathologyrequired
    history • used at CONTEXT
    Tumor, radiation, surgery, rheumatoid arthritis, ankylosing spondylitis (ASA 2022)
  • gerd_aspiration_riskrequired
    history • used at CONTEXT
    Drives RSI vs awake fiberoptic decision (ASA 2022)
  • mh_susceptibility_or_known_succinylcholine_contraindication
    history • used at CONTEXT
    MH susceptible patients require trigger-free anesthetic + alternative NMB plan (MHAUS 2023, ASA 2022)
  • mallampati_classrequired
    symptom • used at INITIAL_WORKUP
    Class III-IV (palate/uvula not visible) suggests difficult laryngoscopy (Mallampati 1985)
  • thyromental_distancerequired
    symptom • used at INITIAL_WORKUP
    <6 cm suggests difficult laryngoscopy (LEMON) (ASA 2022)
  • mouth_opening_inter_incisorrequired
    symptom • used at INITIAL_WORKUP
    <3 cm (one finger-breadth) suggests difficult laryngoscopy (LEMON) (ASA 2022)
  • neck_mobility_extensionrequired
    symptom • used at INITIAL_WORKUP
    Limited atlanto-occipital extension (<35 degrees) limits laryngoscopic view (ASA 2022)

12-phase flow (12)

  1. 1FRAME
    Confirm preoperative airway evaluation scope — risk-stratify and plan primary + backup + rescue strategies before induction (ASA 2022)
    inputs: age, bmi
    advance: evaluation initiated
  2. 2ENTRY
    Preop visit or in-hospital pre-procedure airway assessment (ASA 2022)
    advance: evaluation triggered
  3. 3CONTEXT
    Demographics, prior anesthetic records, OSA status, head/neck pathology, GERD/aspiration risk, MH susceptibility, NPO status (ASA 2022)
    inputs: age, bmi, prior_anesthetic_records, osa_screen, head_neck_pathology, gerd_aspiration_risk, pregnancy_status
    advance: history captured
  4. 4RED_FLAGS
    Stridor, severe trismus, large neck mass, recent radiation, unstable c-spine, known cannot-intubate-cannot-ventilate history -> awake fiberoptic / surgical airway plan (ASA 2022, DAS 2015)
    advance: red flags identified or excluded
  5. 5INITIAL_WORKUP
    Bedside exam: Mallampati class (I-IV); thyromental distance; mouth opening (inter-incisor); neck extension; LEMON assessment; mask-ventilation predictors (BONES); supraglottic device fit predictors (RODS) (ASA 2022, Mallampati 1985)
    inputs: mallampati_class, thyromental_distance, mouth_opening_inter_incisor, neck_mobility_extension
    advance: bedside assessment complete
  6. 6BRANCHING_WORKUP
    Nasendoscopy / flexible fiberoptic eval for known head/neck pathology; CT/MRI airway if mass or radiation; ENT consult if uncertainty (ASA 2022)
    advance: imaging / specialist input as needed
  7. 7DIFFERENTIAL
    Categorize: anticipated easy airway / anticipated difficult laryngoscopy / anticipated difficult mask ventilation / anticipated difficult SGA / anticipated difficult surgical airway (ASA 2022)
    advance: category assigned
  8. 8RISK_STRATIFICATION
    LEMON score, BONES (difficult BVM), RODS (difficult SGA), SHORT (difficult surgical airway); STOP-BANG for OSA (ASA 2022)
    inputs: mallampati_class, osa_screen
    advance: risk tier and strategy locked
  9. 9TREATMENT
    Plan A (primary): direct laryngoscopy or video-laryngoscopy with rocuronium (sugammadex reversal available) vs awake fiberoptic. Plan B: alternative laryngoscope / bougie / stylet. Plan C: SGA rescue (2nd-gen LMA — i-gel / LMA ProSeal). Plan D (CICO): emergency front-of-neck access — scalpel cricothyroidotomy (ASA 2022, DAS 2015)
    inputs: mh_susceptibility_or_known_succinylcholine_contraindication
    advance: four-plan strategy documented + team briefed
  10. 10DISPOSITION
    Anesthetic location decision (OR vs surgical airway-ready room vs ICU intubation); team composition (ENT, surgeon scrubbed) (ASA 2022)
    advance: location + team finalized
  11. 11MONITORING
    Continuous SpO2, EtCO2 (capnography is mandatory — NAP4 most common contributor to harm), arterial line if anticipated difficult / prolonged; assess for awake-fiberoptic plan if intubation fails twice (ASA 2022, NAP4 Cook 2011)
    advance: intraop monitoring plan documented
  12. 12FOLLOWUP
    Document difficult intubation on chart + MedicAlert; postop airway debrief (especially after CICO or front-of-neck access); patient counseling + future anesthetic-plan letter; Difficult Airway Society registry case report (ASA 2022, DAS 2015)
    advance: documentation + counseling + future-plan letter complete