A 52-year-old male with a history of ankylosing spondylitis presents for elective lumbar spine fusion. On airway examination, he has a fixed cervical spine with severely limited neck extension, Mallampati Class IV, and an inter-incisor distance of 2 cm. Induction is planned with propofol and succinylcholine. After loss of consciousness, mask ventilation is adequate, but direct laryngoscopy reveals only the epiglottis (Cormack-Lehane Grade 3). What is the most appropriate next step in the difficult airway algorithm?

Explanation

## Difficult Airway Algorithm: Cormack-Lehane Grade 3 with Adequate Mask Ventilation **Key Point:** When direct laryngoscopy fails (Grade 3–4) but mask ventilation is adequate, the algorithm mandates attempting alternative intubation techniques BEFORE waking the patient. Video laryngoscopy with a hyperangulated blade (e.g., McGrath, C-MAC D-blade) has a high success rate (>90%) in Grade 3 views. **High-Yield:** The Difficult Airway Society (DAS) algorithm distinguishes two pathways: 1. **Failed intubation + adequate mask ventilation** → Try alternative devices (video laryngoscopy, bougie, supraglottic airway) while maintaining oxygenation. 2. **Failed intubation + inadequate mask ventilation** → Emergency surgical airway. **Clinical Pearl:** A bougie (gum elastic bougie) is useful as a **rescue technique** when you can see the epiglottis but cannot pass the tube directly—it is placed blindly into the trachea and the endotracheal tube is railroaded over it. However, video laryngoscopy should be attempted first because it provides real-time visualization and higher success rates. **Mnemonic: FONA (Failed Oxygenation, Need Airway)** — Reserved for the emergency surgical airway pathway when both intubation AND mask ventilation have failed. ## Why Video Laryngoscopy Is the Next Step | Feature | Direct Laryngoscopy | Video Laryngoscopy | Bougie | |---------|--------------------|--------------------|--------| | **Visualization** | Limited (Grade 3) | Enhanced; sees beyond epiglottis | Blind placement | | **Success in Grade 3** | ~30% | >90% | ~70% (if epiglottis visible) | | **Time to secure airway** | Rapid if successful | Slightly longer setup | Moderate | | **When to use** | First-line attempt | Failed DL + adequate ventilation | Rescue technique | **Tip:** Hyperangulated video laryngoscope blades (60–90° angulation) are superior to standard blades for anterior airways and Grade 3 views because they allow visualization beyond the epiglottis without requiring extreme neck extension—critical in this ankylosing spondylitis patient.