The difficult airway on oral boards

Examiners want a plan before induction, a backup, and a clear point at which you change course.

Last reviewed October 2026. Guidelines change — check the ASA guideline and your institution’s algorithm.

Before induction: assess and plan

Start with the history (prior difficult airway, obstructive sleep apnea, head and neck surgery or radiation) and a focused exam. Then say whether you expect difficulty with mask ventilation, supraglottic airway, laryngoscopy, intubation or a surgical airway, and whether there is a risk of aspiration or rapid desaturation. The 2022 ASA guidelines organize decisions around these factors.

Awake or asleep?

If difficulty is predicted, explain whether you would secure the airway awake and why. Name the preparation in general terms: explain to the patient, topicalize, use judicious sedation that preserves spontaneous breathing, and choose a device such as a flexible scope or video laryngoscope. Say what you would do if awake intubation fails or is not possible.

Unexpected difficulty after induction

  1. Call for help and the difficult airway cart.
  2. Keep oxygenating: mask ventilation, supraglottic airway.
  3. Limit intubation attempts and change something each time (device, operator, position).
  4. Consider waking the patient up if you can oxygenate and the case can wait.
  5. If you cannot intubate and cannot oxygenate, move to an emergency invasive airway without delay.

After the event

Examiners often finish with extubation planning and follow-up: extubate when criteria are met with a plan for reintubation, then tell the patient, document the difficulty, and make sure future clinicians know. That last part also fits the communication topics on the OSCE outline; see OSCE tips.

More crisis practice: LAST and malignant hyperthermia.

Common questions

What guideline should I know?

The American Society of Anesthesiologists’ 2022 Practice Guidelines for Management of the Difficult Airway (Anesthesiology, 2022), which include adult and pediatric algorithms.

When should I say awake intubation?

When you predict a difficult airway and also expect difficult ventilation, a risk of aspiration, poor tolerance of apnea, or difficulty with an emergency invasive airway, awake intubation is a common answer. Explain why.

What is the most important principle?

Oxygenation. Throughout any plan, say how you are keeping the patient oxygenated, and limit repeated intubation attempts.

Rehearse your airway plan

Say your plan A, B and C out loud to DOME’s AI examiner and see what the debrief catches.

See how DOME works →Browse practice cases

Pricing

Educational only — not medical advice and not a substitute for the ASA guideline or your institution’s protocols. DOME is not affiliated with or endorsed by the ABA or the ASA.

Sources