UBP Oral boards stem and difficult airways

[Peterluger]

Some of the material on UBP has me going WTF, especially when discussing potentially difficult airways in uncooperative patients.
One particular case from UBP comes to mind, the scoliosis case in the 11 y/o with Duchenne’s and macroglossia. There was a question about using ketamine to induce, and the answer implied that you should use ketamine to maintain spontaneous ventilation and “maintain airway reflexes” so they dont aspirate, and also you wouldn’t paralyze for intubation

To me this entire answer is totally foreign. When you have a patient who is NOT a candidate for awake fiberoptic, and is an aspiration risk, then you induce GA with RSI to avoid aspiration and try to optimize your intubating conditions. And since he could be potentially difficult, then you can do asleep fiberoptic as backup. There is no “in between” as far as i trained. You either intubate awake, or you do so following inducing GA WITH paralysis. Everything in between is a waste of your time. Giving this high aspiration risk 11 y/o kid with macroglossia ketamine, not paralyzing, and hoping that you can somehow quickly intubate before he aspirates seems like a joke to me. RSI dose roc with a sedative hypnotic should be the answer in my humble opinion.

I don’t know if this idea of not paralyzing patients with difficult airways who wont tolerate awake fiberoptic is just some vestige of old thinking that is polluting oral boards reviews, but please, someone enlighten me on what the hell is going on here.

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[anbuitachi]

Some of the material on UBP has me going WTF, especially when discussing potentially difficult airways in uncooperative patients.
One particular case from UBP comes to mind, the scoliosis case in the 11 y/o with Duchenne’s and macroglossia. There was a question about using ketamine to induce, and the answer implied that you should use ketamine to maintain spontaneous ventilation and “maintain airway reflexes” so they dont aspirate, and also you wouldn’t paralyze for intubation

To me this entire answer is totally foreign. When you have a patient who is NOT a candidate for awake fiberoptic, and is an aspiration risk, then you induce GA with RSI to avoid aspiration and try to optimize your intubating conditions. And since he could be potentially difficult, then you can do asleep fiberoptic as backup. There is no “in between” as far as i trained. You either intubate awake, or you do so following inducing GA WITH paralysis. Everything in between is a waste of your time. Giving this high aspiration risk 11 y/o kid with macroglossia ketamine, not paralyzing, and hoping that you can somehow quickly intubate before he aspirates seems like a joke to me. RSI dose roc with a sedative hypnotic should be the answer in my humble opinion.

I don’t know if this idea of not paralyzing patients with difficult airways who wont tolerate awake fiberoptic is just some vestige of old thinking that is polluting oral boards reviews, but please, someone enlighten me on what the hell is going on here.

when reading these things, you have to realize that you arent preparing for real life, you are preparing for your ABA board exam. the correct answers are what the board examiners think are correct, not what you think is correct

 

[Peterluger]

when reading these things, you have to realize that you arent preparing for real life, you are preparing for your ABA board exam. the correct answers are what the board examiners think are correct, not what you think is correct

Ok. How is it correct to induce a high aspiration risk patient in such a way that securing the airway will be more difficult and take more time because of no paralysis, during which the patient may aspirate?

 

[anbuitachi]

Ok. How is it correct to induce a high aspiration risk patient in such a way that securing the airway will be more difficult and take more time because of no paralysis, during which the patient may aspirate?

im not a board examiner

there are many things you can argue. how well does ketamine even preserve airway reflexes. how do you even know this and what are you titrating to?

thats why people say there are real life answers, then there are board answers.

 

[Peterluger]

im not a board examiner

there are many things you can argue. how well does ketamine even preserve airway reflexes. how do you even know this and what are you titrating to?

thats why people say there are real life answers, then there are board answers.

In my experience, ketamine doesnt really preserve airway reflexes, except for laryngospasm LOL. The question is, when they give you an uncooperative patient who is full stomach and MAYBE difficult airway, for non emergent case, wouldnt RSI with DL/VL and fiberoptic backup be pretty much the ONLY sensible way to do it?

Who does this half ass **** with patient completely sedated, with full stomach, and spontaneously breathing? Thats ******ed. Theyre gonna aspirate and die.

 

[Katheudontas parateroumen]

Still going through this process myself and find it frustrating as well. I’ve been taught first to do what you would do in real life and be able to defend your answer with reasoning and also be flexible and seeing their side when they question your answer. The “board answer” doesn’t mean it’s the only answer. For a question like this I would say, I would induce general anesthesia with propofol and RSI rocuronium after having standard ASA monitors, fully preoxygenated and positioned appropriately. I would attempt with DL. I recognize that this may be a difficult airway given the macroglossia so I would have VL and FOB at hand along with oral airway and nasal airway in case of difficult BVM as well. I would avoid awake intubation given the patient is not able to follow commands. I am doing RSI due to high aspiration risk. I’m sure they would start questioning what if I can’t get the airway, what if BVM is difficult, etc.
I also don’t necessarily agree with the UBP answer as well. If we are truly afraid of aspiration, yes it’s either awake or RSI. I do believe this sedated spontaneously breathing thing has it’s place for things like mediastinal mass, tracheal foreign body but not in an aspiration risk patient.
What do you all think?

 

[anbuitachi]

just so you know. i read UBP for mostly information, and their logic. i didnt agree with some stuff, and for stuff i didnt agree, i ignored it (after doing some research on the topic if needed). on the board exam, i answered the way i felt most comfortable, not following UBP. it was fine.

one example is use of PA catheter and CVP monitoring. It's not something i do day to day even though i do big cases. so on the board, so i didnt say put in a PA catheter just bc UBP said so. I said what i felt was reasonable and just hope the examiner agree with me

 

[Lecithin5]

Nonetheless, I found ubp to be the best resource when I took the orals several years ago. Almost every question I had on the real exam was reflected in one way or another on UBP.

 

[Justice4all]

UBP is to provide a compilation of scenarios and answers. I used it as a guide to formulate answers although not as long winded as they do it. Anesthesia can be do so many ways and safely . Is it cost effective? That’s another question the boards doesn’t care about. Use it to consolidate knowledge and if your residency is worth it’s salt, you will pass eventually.

 

[vector2]

Ultimately the examiners don't care which way you secure the airway as long as you mention that you're doing technique X even though you are well aware that reasons A, B, and C pose a challenge to using technique X. And then you tell them you will implement measures D, E, and F to mitigate the challenges posed by A, B, and C.

It's a game that doesn't always have right answers. What they care about is that you know the consequences and have anticipated the necessary damage control required to go down your particular chosen path.

 

[Ronin786]

https://www.ultimateboardprep.com/contact/

 

[pasgasser2]

Some of the material on UBP has me going WTF, especially when discussing potentially difficult airways in uncooperative patients.
One particular case from UBP comes to mind, the scoliosis case in the 11 y/o with Duchenne’s and macroglossia. There was a question about using ketamine to induce, and the answer implied that you should use ketamine to maintain spontaneous ventilation and “maintain airway reflexes” so they dont aspirate, and also you wouldn’t paralyze for intubation

To me this entire answer is totally foreign. When you have a patient who is NOT a candidate for awake fiberoptic, and is an aspiration risk, then you induce GA with RSI to avoid aspiration and try to optimize your intubating conditions. And since he could be potentially difficult, then you can do asleep fiberoptic as backup. There is no “in between” as far as i trained. You either intubate awake, or you do so following inducing GA WITH paralysis. Everything in between is a waste of your time. Giving this high aspiration risk 11 y/o kid with macroglossia ketamine, not paralyzing, and hoping that you can somehow quickly intubate before he aspirates seems like a joke to me. RSI dose roc with a sedative hypnotic should be the answer in my humble opinion.

I don’t know if this idea of not paralyzing patients with difficult airways who wont tolerate awake fiberoptic is just some vestige of old thinking that is polluting oral boards reviews, but please, someone enlighten me on what the hell is going on here.

I also think the boards are designed to see how you weigh risk vs risk in crappy situations- a ketamine or inhalational induction elevates your risk of aspiration but a RSI elevates your risk of losing the airway...what's worse loss of airway vs aspiration? With an induction method that maintains spontaneous respirations you can at least say "Though I recognize the risk of aspiration, I believe that risk of losing the airway is greater than the risk of aspiration" ?