B is the correct answer. Why?

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A Active bleeding into the airway
B Anticipated difficult airway
C History of multiple intubations
D Severe obstructive lung disease exacerbation


Emergency physicians are experts in managing critical and challenging airways. Any patient presenting with a need for intubation should be preoxygenated to allow optimal time during the procedure and minimize hypoxia. Appropriate setup should include bag-mask ventilation; suction (sometimes double suction); medications (often a sedative and a paralytic); postsedation medications, fluids, or vasopressors if hypotension exists; and appropriate primary and secondary methods of intubation. Studies on the use of video laryngoscopy have evidence to support an increased rate of first-pass intubation. It is generally the preferred method of intubation in patients with a predicted difficult airway, which may include a history of challenging intubation, a short or immobile neck, a Mallampati score of class III and above, and significant maxillofacial trauma. It is important to have multiple intubation methods readily available, including a rigid stylet, bougie, and surgical airway kit. Calling for help prior to intubation when patients have known difficult airways is also optimal care.

Active bleeding into the airway (A) may be one of the few instances in which video laryngoscopy may be a worse option, given that blood and secretions may obstruct the camera.

A history of multiple intubations (C) does not necessarily suggest that video laryngoscopy would be superior to direct laryngoscopy. Rather, a history of multiple intubations without documentation of a challenging airway may suggest the patient is easy to intubate.

A severe obstructive lung disease exacerbation (D) is more concerning for challenges with ventilation and oxygenation while on the ventilator. In an obstructive lung disease exacerbation, breath stacking may occur, and ventilation may be particularly challenging. A prolonged expiratory phase and lung-protective volumes may be indicated, and a slower respiratory rate may be needed to allow for full exhalation.

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