In the Difficult Airway Society algorithm, after failed intubation in an anesthetized patient with adequate oxygenation maintained by bag-mask ventilation, what is the NEXT recommended step?

## Difficult Airway Algorithm: Unanticipated Difficult Intubation with Adequate Oxygenation **Key Point:** When intubation fails but oxygenation is maintained via bag-mask ventilation, the algorithm mandates sequential attempts with alternative techniques (Plan B, C, D) before resorting to emergency surgical airway (Plan E). **High-Yield:** The DAS algorithm follows a **structured escalation pathway**: - Plan A: Initial intubation attempt (failed) - Plan B: Alternative intubation techniques (videolaryngoscopy, bougie, different blade) - Plan C: Maintain oxygenation (LMA, supraglottic airway) - Plan D: Awake fiberoptic intubation (if time permits) - Plan E: Emergency surgical airway (only if CICO — cannot intubate, cannot oxygenate) **Clinical Pearl:** The presence of adequate oxygenation is the **key decision point** — it buys time for alternative techniques and prevents premature escalation to surgical airway. ### Decision Tree for Failed Intubation ```mermaid flowchart TD A[Intubation Failed]:::outcome --> B{Oxygenation adequate?}:::decision B -->|Yes| C[Plan B: Try alternative technique]:::action B -->|Yes| D[Plan C: LMA/supraglottic airway]:::action B -->|No| E{Able to oxygenate by any means?}:::decision E -->|No| F[Plan E: Emergency surgical airway]:::urgent E -->|Yes| G[Continue oxygenation + Plan C/D]:::action C --> H{Success?}:::decision H -->|Yes| I[Secure airway]:::outcome H -->|No| D ``` **Mnemonic:** **ABCDE Plan** = Attempt initial intubation, Backup techniques (videolaryngoscopy/bougie), Combitube/LMA, Delayed fiberoptic, Emergency surgical airway. [cite:Difficult Airway Society Guidelines 2015]