Airway station: exam, algorithm, device choice (2027)
Stem
Airway scenario (illustrative; the ABA has not published this station's format). A 58-year-old man, 124 kg, BMI 41, with obstructive sleep apnea on CPAP and a full beard, is scheduled for elective laparoscopic cholecystectomy. As you examine him, the facilitator reports: Mallampati 4, interincisor gap 3 cm, cannot protrude his lower incisors past the upper, thick neck with limited extension, and a cricothyroid membrane you cannot feel.
Question
Walk me through your airway assessment, and how will you secure his airway?
Ideal answer
HeadlineHe predicts difficulty on every rescue route and meets the ASA awake criteria, so I plan an awake flexible bronchoscopic intubation.1
- History: prior anesthetics, airway letter, sleep apnea, reflux. Including snoring; the same routine for every airway.
- Exam the ASA features; none alone predicts. Mouth opening, Mallampati, dentition, jaw protrusion, thyromental and sternomental distances, neck circumference and mobility, the beard.1
- Laryngeal handshake for the cricothyroid membrane. Whether front-of-neck access will work changes the plan.2
- Predict each route aloud. Difficult mask ventilation (beard, obesity, sleep apnea), difficult laryngoscopy (Mallampati, small mouth opening, poor jaw protrusion, limited extension), short safe apnea time, difficult surgical airway.
- Topical lidocaine, minimal sedation, oxygen throughout. Lidocaine under 9 mg/kg lean body weight, remifentanil or dexmedetomidine;3 carina seen before advancing, capnography confirms.3
Breaking down the answer
The 2027 outline adds airway management: examination with markers of difficult mask ventilation and intubation, landmarks for airway blocks and an emergency surgical airway, navigation of the ASA algorithm, and choice and use of devices.4 In August 2026 the ABA announced an unscored eighth OSCE station pilot for 2027 in which each candidate takes either an airway management or a team-based scenario; it has not published the station's timing, format or equipment.5 I prepare for the outline content, not a guessed format.
- Awake versus asleep is a rule, not a preference — the ASA recommends awake intubation when difficult intubation is suspected with difficult ventilation, poor tolerance of apnea, or expected difficult invasive rescue; he has all three. Asleep only when benefits outweigh risks.1
- A conclusion, not a list — stating mask, supraglottic airway, laryngoscopy and front-of-neck access as four predictions shows judgment; signs without a conclusion do not.
- Oxygen is continuous — before management starts and throughout, by nasal cannula, mask or supraglottic insufflation.1
- Count attempts and time — the ASA asks me to track time, attempts and saturation and to ventilate between attempts;1 DAS limits laryngoscopy to three attempts, a fourth only by a more experienced colleague.2
- Landmarks — superior laryngeal block at the greater cornu of the hyoid; transtracheal injection and cricothyroidotomy through the cricothyroid membrane between thyroid and cricoid cartilages.
Follow-up question
He refuses an awake technique. After a careful discussion you induce, and two videolaryngoscopy attempts fail. His saturation is 86%, and two-person mask ventilation is barely moving the bag. What do you do?
Follow-up answer
HeadlineFailed intubation, and oxygenation is failing; I say it aloud, call for help and the difficult airway cart, and stop laryngoscopy.
Oxygen continues. A second-generation supraglottic airway, no more than three insertion attempts.2 If it oxygenates him, I stop and think: the safest course is to wake him and reverse the block fully, rather than chase the tube.2 If it and mask ventilation fail, I declare can't intubate, can't oxygenate, ensure full neuromuscular blockade, and go to front-of-neck access: with the membrane not clearly palpable, a vertical midline skin incision up to 8 cm, then scalpel, bougie and a 6.0 cuffed tube.6 Capnography confirms; I reassess saturation and ventilation.
Pitfalls that cost points
- Choosing asleep induction in a patient who meets the awake criteria.
- Hesitating at the neck while hoping the saturation recovers; once CICO is declared, I cut.2
- Repeating laryngoscopy past three attempts while saturation falls.
Rapid-fire
Q: Maximum topical lidocaine for awake intubation? A: 9 mg/kg lean body weight.3
Q: How many attempts at awake intubation? A: Three by the primary operator and a fourth by a more experienced operator; reassess and call for help after the first failure.3
Q: What confirms tracheal placement? A: Capnography; when position is uncertain, remove the tube and ventilate or use additional confirmation.1
Q: Is the 2027 pilot station scored? A: No; the ABA states pilot scores are for evaluation only and do not affect results.5
Numbers to know
| Item | Value |
|---|---|
| Laryngoscopy attempts | 3, plus 1 by a more experienced colleague2 |
| Supraglottic attempts | Maximum 32 |
| Topical lidocaine | ≤9 mg/kg lean body weight3 |
| Front-of-neck tube | 6.0 mm cuffed2 |
| Vertical skin incision | Up to 8 cm; the default unless the membrane is clearly palpable or ultrasound-marked6 |
| Airway section in outline | Testing from 20274 |
Links
- Anticipated difficult airway and the ASA algorithm, Awake fiberoptic intubation: topicalization and sedation, Cannot intubate, cannot oxygenate, VL, SGA, FOB, lung isolation, cricothyroidotomy, exchange catheter, jet ventilation, Morbid obesity and bariatric surgery
- Atlas: Airway ultrasound structures (2027); Airway blocks: superior laryngeal and transtracheal (2027)
- ASA Practice Guidelines for Management of the Difficult Airway (2022); DAS unanticipated difficult intubation (2015) and awake tracheal intubation (2020) guidelines
Sources
- 1.2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway · ASA, 2022 · asa2.silverchair.com
- 2.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults · DAS, 2015 · ebi.ac.ukFull text via Europe PMC (PMC4650961).
- 3.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults · DAS, 2020 · ebi.ac.uk
- 4.APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline · ABA · theaba.orgSection B.4, Airway Management (testing to start 2027).
- 5.ABA Announces 8th OSCE Station Pilot for 2027 APPLIED Exams · ABA, 2026 · theaba.orgAnnounced Aug 25, 2026: unscored pilot; each 2027 candidate takes either an airway management or a team-based scenario. Duration, format and equipment not published.
- 6.Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults · DAS, 2025 · sea.org.ecAhmad et al., Br J Anaesth 2026;136:283-307 (online 7 Nov 2025), doi 10.1016/j.bja.2025.10.006; full English text hosted by the Sociedad Ecuatoriana de Anestesiología. Plan D: vertical skin incision (up to 8 cm) is the default eFONA incision unless the cricothyroid membrane is clearly palpable or ultrasound-marked; number 10 blade, bougie, 6.0 cuffed tube.
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.