2022 ASA Practice Guidelines for Management of the Difficult Airway

#!/usr/bin/env python3
"""
Build: ASA Difficult Airway Management - Comprehensive AIIMS Study Document
"""

from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import copy

# ─────────────────────────────────────────────
# HELPERS
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# ─────────────────────────────────────────────
# DOCUMENT BUILD
# ─────────────────────────────────────────────

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# ══════════════════════════════════════════════
# COVER PAGE
# ══════════════════════════════════════════════
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r = cover_p.add_run('\n2022 ASA PRACTICE GUIDELINES\nFOR MANAGEMENT OF THE\nDIFFICULT AIRWAY\n')
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sub_p = cover_cell.add_paragraph()
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sr = sub_p.add_run('Comprehensive Study Guide for AIIMS MD Anaesthesia Examination\n')
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sr2 = sub_p2.add_run('\nBased on: Apfelbaum JL et al., Anesthesiology 2022\nASA | AIDAA | EAMS | SAM | ESAIC | SPA\n\n')
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doc.add_paragraph()

# Quick reference banner
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qr_data = [
    ('ANTICIPATE', 'Preoperative airway assessment + risk scoring', '2E6B9E'),
    ('PREPARE', 'Equipment, team, patient, preoxygenation', '1A7A4A'),
    ('STRATEGIZE', 'Awake vs. asleep | Noninvasive vs. invasive | CICO plan', '8B2020'),
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doc.add_page_break()

# ══════════════════════════════════════════════
# TABLE OF CONTENTS
# ══════════════════════════════════════════════
add_colored_heading(doc, 'TABLE OF CONTENTS', 1, '1A2E5A')
add_divider(doc)
toc_items = [
    ('1.', 'Background & Introduction', '3'),
    ('2.', 'Definitions of Difficult Airway', '3'),
    ('3.', 'Preoperative Airway Assessment', '4'),
    ('4.', 'Preparation for Difficult Airway Management', '5'),
    ('5.', 'Anticipated Difficult Airway - Strategy', '6'),
    ('6.', 'Awake Tracheal Intubation (ATI)', '7'),
    ('7.', 'Unanticipated/Emergency Difficult Airway', '9'),
    ('8.', 'Cannot Intubate - Cannot Oxygenate (CICO)', '10'),
    ('9.', 'Confirmation of Tracheal Intubation', '11'),
    ('10.', 'Extubation of the Difficult Airway', '11'),
    ('11.', 'Follow-up Care & Documentation', '12'),
    ('12.', 'Devices: Evidence Summary', '13'),
    ('13.', 'Key Changes: 2013 vs 2022 Guidelines', '14'),
    ('14.', 'High-Yield Points for AIIMS Exam', '15'),
    ('15.', 'Rapid Revision: Mnemonics & Tables', '16'),
]
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doc.add_page_break()

# ══════════════════════════════════════════════
# SECTION 1: BACKGROUND
# ══════════════════════════════════════════════
add_colored_heading(doc, '1. BACKGROUND & INTRODUCTION', 1, '1A2E5A')
add_divider(doc)

add_styled_para(doc, 'The 2022 ASA Practice Guidelines for Management of the Difficult Airway represent the most recent and internationally developed update, replacing the 2013 guidelines. They were developed by a 15-member international task force representing 11 anesthesiology and airway organizations.', size=11)
doc.add_paragraph()

add_two_col_table(doc,
    ['Organization', 'Abbreviation'],
    [
        ['American Society of Anesthesiologists', 'ASA'],
        ['All India Difficult Airway Association', 'AIDAA'],
        ['European Airway Management Society', 'EAMS'],
        ['European Society of Anaesthesiology and Intensive Care', 'ESAIC'],
        ['Society for Airway Management', 'SAM'],
        ['Society for Pediatric Anesthesia', 'SPA'],
        ['Society of Critical Care Anesthesiologists', 'SOCCA'],
        ['Society for Head and Neck Anesthesia', 'SHNA'],
        ['Trauma Anesthesiology Society', 'TAS'],
        ['Italian Society (AAROI-EMAC)', 'AAROI'],
        ['Society for Ambulatory Anesthesia', 'SAMBA'],
    ],
    col_widths=[4.5, 2.0]
)

add_note_box(doc, 'Evidence base: 12,544 unique citations screened; 597 articles accepted. Literature covers Jan 2002 - Mar 2021. These are PRACTICE GUIDELINES (not absolute standards) - they can be modified per clinical judgment.')

# ══════════════════════════════════════════════
# SECTION 2: DEFINITIONS
# ══════════════════════════════════════════════
add_colored_heading(doc, '2. DEFINITIONS OF DIFFICULT AIRWAY', 1, '1A2E5A')
add_divider(doc)

add_styled_para(doc, 'A difficult airway is defined as a clinical situation in which a physician trained in anesthesia care encounters anticipated or unanticipated difficulty or failure with one or more of the following:', size=11)
doc.add_paragraph()

add_two_col_table(doc,
    ['Term', 'Definition'],
    [
        ['Difficult Face Mask Ventilation (DFMV)',
         'Inability to provide adequate ventilation (confirmed by EtCO2) due to:\n• Inadequate mask seal\n• Excessive gas leak\n• Excessive resistance to gas ingress/egress'],
        ['Difficult Laryngoscopy',
         'Inability to visualize ANY portion of the vocal cords after MULTIPLE attempts at conventional laryngoscopy'],
        ['Difficult SGA Ventilation',
         'Inability to provide adequate ventilation due to:\n• Difficult placement (multiple attempts)\n• Inadequate SGA seal or excessive gas leak\n• Excessive resistance to gas flow'],
        ['Difficult/Failed Tracheal Intubation',
         'Tracheal intubation requires multiple attempts OR fails altogether despite multiple attempts'],
        ['Difficult/Failed Extubation',
         'Loss of airway patency and adequate ventilation during or after removal of the tracheal tube'],
        ['Difficult Invasive Airway',
         'Difficulty with or failure of percutaneous/surgical cannulation of the airway (cricothyrotomy, tracheostomy)'],
    ],
    col_widths=[2.5, 4.5]
)

add_key_point_box(doc, 'IMPORTANT SCOPE: What these guidelines DO and DO NOT cover', [
    'COVER: Anticipated + unanticipated difficult airways; adults, pediatric, obstetric, ICU/critically ill patients',
    'COVER: GA, sedation, regional anesthesia, and elective airway management without a procedure',
    'DO NOT COVER: Airway management during CPR',
    'DO NOT COVER: Physiologically difficult airways that are NOT anatomically difficult',
    'DO NOT COVER: Patients at risk of aspiration WITHOUT anatomically difficult airways',
    'DO NOT COVER: Education, training, or certification requirements',
])

# ══════════════════════════════════════════════
# SECTION 3: AIRWAY ASSESSMENT
# ══════════════════════════════════════════════
add_colored_heading(doc, '3. PREOPERATIVE AIRWAY ASSESSMENT', 1, '1A2E5A')
add_divider(doc)

add_styled_para(doc, 'Recommendation: Perform a comprehensive airway risk assessment BEFORE initiating anesthetic care. No single test is adequate - multiple features must be combined.', bold=True, size=11)
doc.add_paragraph()

add_colored_heading(doc, 'A. History', 2, '2E4A7A')
add_key_point_box(doc, 'Historical Risk Factors for Difficult Airway', [
    'Previous difficult intubation or airway management',
    'Distorted airway anatomy (congenital or acquired)',
    'Snoring / Obstructive Sleep Apnea (OSA)',
    'Diabetes mellitus (stiff joint syndrome - atlanto-axial, TMJ)',
    'Prior head/neck surgery, radiation, or trauma',
    'Morbid obesity',
    'Rheumatoid arthritis, ankylosing spondylitis',
    'Findings from diagnostic tests (CT, MRI, X-ray)',
    'Patient/family history via interviews or questionnaires',
])

add_colored_heading(doc, 'B. Physical Examination', 2, '2E4A7A')
add_two_col_table(doc,
    ['Assessment Tool', 'Normal / Favourable Finding', 'Difficult Airway Threshold'],
    [
        ['Mallampati (Modified)', 'Class I/II (uvula and tonsillar pillars visible)', 'Class III/IV'],
        ['Mouth Opening (Interincisor Distance)', '>4 cm (3 finger breadths)', '<3 cm'],
        ['Thyromental Distance (TMD)', '>6.5 cm (3 finger breadths)', '<6 cm (Patil test)'],
        ['Sternomental Distance (SMD)', '>12.5 cm', '<12 cm'],
        ['Neck Mobility / Extension', '>35° extension at atlanto-occipital joint', 'Reduced / Absent'],
        ['Upper Lip Bite Test (ULBT)', 'Class I: lower incisors bite upper lip mucosa', 'Class III: cannot bite'],
        ['Prognathism', 'Able to prognath (Class A - lower teeth anterior to upper)', 'Class C'],
        ['Hyomental Distance Ratio', '>1.0', '<1.0'],
        ['Neck Circumference', '<40 cm', '>43 cm'],
        ['Beard', 'Absent', 'Present (mask seal difficulty)'],
    ],
    col_widths=[2.2, 2.4, 2.0]
)

add_colored_heading(doc, 'C. Additional Investigations', 2, '2E4A7A')
table_rows = [
    ['Ultrasound', 'Skin-to-hyoid distance, tongue volume, skin-to-epiglottis distance; assess for subcutaneous tissue at cricothyroid membrane'],
    ['CT/MRI Reconstruction', 'Virtual laryngoscopy/bronchoscopy; identifies laryngeal deviation, cervical fractures, abscesses, masses'],
    ['Plain Radiograph', 'Cervical spine views; identifies instability, degenerative changes'],
    ['Bedside Endoscopy', 'Nasopharyngoscopy/laryngoscopy; revises airway management plan in ~26% of patients'],
    ['3D Printing', 'Emerging tool; insufficient evidence currently for routine use'],
    ['Patient Questionnaires', 'Validated tools can identify patients at risk of difficult ventilation and intubation (Category B3)'],
]
add_two_col_table(doc, ['Investigation', 'Clinical Value'], table_rows, col_widths=[2.0, 4.6])

add_note_box(doc, 'AIIMS Pearl: No single predictive test has adequate sensitivity and specificity. The combination of Mallampati Class III/IV + reduced TMD + limited neck extension has the highest predictive value for difficult laryngoscopy.')

# ══════════════════════════════════════════════
# SECTION 4: PREPARATION
# ══════════════════════════════════════════════
add_colored_heading(doc, '4. PREPARATION FOR DIFFICULT AIRWAY MANAGEMENT', 1, '1A2E5A')
add_divider(doc)

add_key_point_box(doc, 'Core Preparation Checklist (Mandatory)', [
    'Difficult airway CART/TROLLEY immediately available at all anesthetizing locations',
    'Skilled assistant immediately available when difficult airway is known/suspected',
    'Inform the patient (or guardian) of the special risks and planned procedures',
    'Properly POSITION the patient before induction (sniffing/ramped position)',
    'PREOXYGENATE before initiating airway management',
    'Continue SUPPLEMENTAL OXYGEN throughout ALL stages of difficult airway management, including extubation',
    'Ensure ASA BASIC MONITORING (SpO2, EtCO2, ECG, NIBP) before, during, and after airway management',
])

add_colored_heading(doc, 'Preoxygenation Protocols', 2, '2E4A7A')
add_two_col_table(doc,
    ['Method', 'Target/Detail'],
    [
        ['Standard Tidal Volume Breathing', '3-5 min at FiO2 = 1.0; Target EtO2 ≥ 0.90'],
        ['Forced Vital Capacity Breaths', '4-12 deep breaths in 1 min at FiO2 = 1.0 (faster but less effective)'],
        ['NIV/BiPAP Preoxygenation', 'For obese, OSA, or hypoxic patients; PS 8-10 cmH2O + PEEP 5-8 cmH2O'],
        ['High Flow Nasal Oxygen (HFNO)', '60-70 L/min; provides apnoeic oxygenation during laryngoscopy (extends safe apnoea time significantly)'],
        ['Position', 'Ramped/sniffing position for obese patients (ear to sternal notch alignment)'],
    ],
    col_widths=[2.5, 4.1]
)

add_colored_heading(doc, 'Difficult Airway Cart: Essential Contents', 2, '2E4A7A')
add_two_col_table(doc,
    ['Category', 'Equipment'],
    [
        ['Ventilation', 'Various facemask sizes, oral/nasal airways (all sizes), bag-valve-mask'],
        ['Supraglottic Airways', '1st generation LMA (Classic, Flexible), 2nd generation (ProSeal, Supreme, i-gel, LMA-Fastrach)'],
        ['Laryngoscopy', 'Alternative blade designs (McCoy, Seward, Polio), multiple sizes Macintosh and Miller blades'],
        ['Videolaryngoscopy', 'Channel-guided (King Vision, Airtraq) and non-channel (C-MAC, McGrath) VL'],
        ['Intubation Aids', 'Gum elastic bougie (multiple sizes), stylets, tube exchangers (Cook AEC), Aintree catheter'],
        ['Flexible Scope', 'Flexible intubation bronchoscope (FIB) - adult and pediatric sizes'],
        ['Optical/Lighted', 'Lighted stylets, optical stylets (Bonfils, Shikani)'],
        ['Invasive Airway', 'Surgical cricothyrotomy kit (scalpel, 6.0 cuffed ETT), percutaneous kit (Melker), needle cricothyrotomy with jet ventilation'],
        ['Drugs', 'Topical anesthetic (4% lignocaine), sedatives (midazolam, dexmedetomidine, ketamine), remifentanil, sugammadex'],
        ['Confirmation', 'EtCO2 detector/capnography, colorimetric CO2 detector'],
    ],
    col_widths=[2.2, 4.4]
)

# ══════════════════════════════════════════════
# SECTION 5: ANTICIPATED DIFFICULT AIRWAY
# ══════════════════════════════════════════════
add_colored_heading(doc, '5. ANTICIPATED DIFFICULT AIRWAY: MANAGEMENT STRATEGY', 1, '1A2E5A')
add_divider(doc)

add_styled_para(doc, 'A PREFORMULATED STRATEGY is mandatory. The strategy depends on: type of surgery, patient condition, patient cooperation, patient age, and anesthesiologist skills/preferences.', bold=True, size=11)
doc.add_paragraph()

add_key_point_box(doc, 'Four-Point Strategy Framework (Must Know for AIIMS)', [
    '(1) Strategy for AWAKE INTUBATION - when is ATI indicated?',
    '(2) Strategy for patient who CAN be ventilated but is DIFFICULT TO INTUBATE',
    '(3) Strategy for patient who CANNOT BE VENTILATED OR INTUBATED (CICO)',
    '(4) Strategy for DIFFICULTY WITH EMERGENCY INVASIVE AIRWAY RESCUE',
])

add_colored_heading(doc, 'Decision: Awake vs. Anesthetized Intubation', 2, '2E4A7A')
add_two_col_table(doc,
    ['Scenario', 'Preferred Approach'],
    [
        ['Difficult intubation + DIFFICULT VENTILATION anticipated (face mask/SGA)', 'AWAKE INTUBATION'],
        ['Difficult intubation + INCREASED RISK OF ASPIRATION (full stomach)', 'AWAKE INTUBATION'],
        ['Difficult intubation + Patient CANNOT TOLERATE APNOEA (poor respiratory reserve)', 'AWAKE INTUBATION'],
        ['Difficult intubation + DIFFICULT EMERGENCY INVASIVE AIRWAY anticipated (e.g., morbid obesity, neck irradiation)', 'AWAKE INTUBATION'],
        ['Difficult intubation but ventilation OK, low aspiration risk, tolerates apnoea', 'Consider ANESTHETIZED INTUBATION with full preparation'],
        ['Uncooperative/pediatric patient (ATI not feasible)', 'Inhalational induction with MAINTENANCE OF SPONTANEOUS VENTILATION'],
        ['Benefits of GA clearly outweigh risks', 'Proceed with GA after full preparation and with rescue plan'],
    ],
    col_widths=[3.5, 3.1]
)

doc.add_paragraph()
add_note_box(doc, 'AIIMS Key Point: Any ONE of the 4 indications for ATI is sufficient to proceed with awake intubation. ATI success rate = 88-100% in anticipated difficult airway (Category B3 evidence).')

add_colored_heading(doc, 'Anesthetized Intubation: Decision Algorithm', 2, '2E4A7A')
steps = [
    'Ensure FULL PREPARATION: cart, assistant, preoxygenation, HFNO, monitoring',
    'Determine: NONINVASIVE vs. INVASIVE approach (noninvasive preferred first)',
    'Select PREFERRED SEQUENCE of noninvasive devices before starting',
    'Attempt with BEST FIRST TECHNIQUE (videolaryngoscopy recommended)',
    'After EACH attempt: PROVIDE AND TEST MASK VENTILATION',
    'Be aware of: PASSAGE OF TIME | NUMBER OF ATTEMPTS | SpO2 trend',
    'LIMIT total intubation + SGA attempts to avoid compounding injury',
    'If individual techniques fail: try COMBINATION TECHNIQUES',
    'If INVASIVE approach is needed: identify preferred intervention; ensure trained personnel; perform AS RAPIDLY AS POSSIBLE',
    'If invasive approach fails or not feasible: initiate ECMO (if available)',
]
add_key_point_box(doc, 'Step-by-Step Anesthetized Intubation Protocol', steps)

# ══════════════════════════════════════════════
# SECTION 6: AWAKE TRACHEAL INTUBATION
# ══════════════════════════════════════════════
add_colored_heading(doc, '6. AWAKE TRACHEAL INTUBATION (ATI)', 1, '1A2E5A')
add_divider(doc)

add_styled_para(doc, 'ATI is the gold standard for the anticipated difficult airway. It preserves spontaneous ventilation and airway tone throughout, maintaining airway patency even if intubation is challenging.', size=11)
doc.add_paragraph()

add_colored_heading(doc, 'A. Topicalization / Airway Anaesthesia', 2, '2E4A7A')
add_two_col_table(doc,
    ['Region', 'Technique', 'Drug'],
    [
        ['Nose (nasal ATI)', 'Co-phenylcaine spray / cocaine 4%', 'Xylometazoline + lignocaine'],
        ['Oropharynx / Tongue base', 'Spray-as-you-go (SAYGO) / gargle', '4% Lignocaine (topical)'],
        ['Supraglottic / Larynx', 'SAYGO through bronchoscope working channel; nebulisation', '4% Lignocaine, max 4-9 mg/kg (mucosal absorption lower)'],
        ['Transtracheal Block', 'Needle puncture through CTM at end-expiration; inject 2-4 mL 2-4% lignocaine; patient coughs to distribute', 'Lignocaine 2-4%'],
        ['Superior Laryngeal Nerve Block', 'Bilateral injection lateral to hyoid/thyrohyoid membrane', '2% Lignocaine 2 mL each side'],
        ['Glossopharyngeal Nerve Block', 'Tonsillar pillar injection; blocks gag reflex', '2% Lignocaine'],
    ],
    col_widths=[1.8, 2.6, 2.2]
)

add_colored_heading(doc, 'B. Sedation for ATI (Must Maintain Cooperation + Ventilation)', 2, '2E4A7A')
add_two_col_table(doc,
    ['Drug', 'Dose', 'Advantage', 'Disadvantage'],
    [
        ['Remifentanil TCI', '1-3 ng/mL (Minto model)', 'Best tolerance; titratable; very short-acting', 'Apnoea risk if too high; requires TCI pump'],
        ['Dexmedetomidine', '1 mcg/kg over 10 min, then 0.2-0.7 mcg/kg/hr', 'Sedation + analgesia; NO respiratory depression; cooperative patient', 'Bradycardia/hypotension; longer onset'],
        ['Midazolam', '1-2 mg IV titrated', 'Anxiolysis; amnestic', 'Respiratory depression at higher doses; unpredictable'],
        ['Ketamine', '0.3-0.5 mg/kg slow IV', 'Preserves airway tone and spontaneous ventilation; bronchodilator', 'Secretions increase (add glycopyrrolate); dissociation; laryngospasm if inadequate topicalization'],
        ['Propofol TCI', '0.5-1.5 mcg/mL', 'Smooth; familiar', 'High apnoea risk; not preferred for ATI'],
    ],
    col_widths=[1.8, 1.8, 2.1, 2.0]
)

add_colored_heading(doc, 'C. ATI Techniques', 2, '2E4A7A')
add_key_point_box(doc, 'Flexible Intubation Bronchoscopy (FIB) - Gold Standard for ATI', [
    'Success rate: 78-100% (Category B3 evidence)',
    'Oral: use Berman/Ovassapian airway as conduit to prevent biting',
    'Nasal: preferred when mouth opening limited; pass bronchoscope through nostril → nasopharynx → larynx',
    'SAYGO: inject lignocaine 2 mL through working channel at each level (nasopharynx, supraglottis, cords, trachea)',
    'Thread ETT over bronchoscope AFTER confirming tracheal rings and carina visualized',
    'Confirm EtCO2 + direct visualization before removing bronchoscope',
])

add_two_col_table(doc,
    ['Technique', 'Key Details', 'Success Rate'],
    [
        ['Flexible Intubation Bronchoscope (FIB)', 'Gold standard; oral or nasal; SAYGO technique', '78-100% (Category B3)'],
        ['Videolaryngoscopy (Awake)', 'C-MAC / McGrath / King Vision awake; good view but tube delivery can be challenging', '85-98%'],
        ['Awake Direct Laryngoscopy', 'Rarely used; adequate topicalization required', 'Variable'],
        ['Awake Blind Nasal Intubation', 'Only when no other option; listen for breath sounds; not preferred', 'Variable'],
        ['Retrograde Wire-guided (Awake)', 'CTM puncture → guide wire → ETT; rescue technique', 'Limited data'],
        ['Combination (VL + FIB)', 'VL for view + FIB through channel or alongside; used when individual techniques fail', 'High (limited data)'],
    ],
    col_widths=[2.3, 3.2, 1.2]
)

add_note_box(doc, 'AIIMS Key: The ASA 2022 Guidelines recommend videolaryngoscopy as a primary technique even for awake intubation. Dexmedetomidine is the most "safe" sedative for ATI due to preserved respiratory drive. Remifentanil provides the best patient comfort.')

# ══════════════════════════════════════════════
# SECTION 7: UNANTICIPATED DIFFICULT AIRWAY
# ══════════════════════════════════════════════
add_colored_heading(doc, '7. UNANTICIPATED & EMERGENCY DIFFICULT AIRWAY', 1, '1A2E5A')
add_divider(doc)

add_styled_para(doc, 'The unanticipated difficult airway occurs when difficulty is encountered AFTER induction of anesthesia, despite a normal preoperative assessment. It demands a calm, systematic, pre-planned response.', size=11)
doc.add_paragraph()

add_key_point_box(doc, 'Immediate Response - Step by Step', [
    'STEP 1: CALL FOR HELP immediately (senior anesthesiologist, airway team, ENT surgeon)',
    'STEP 2: OPTIMIZE OXYGENATION - apply HFNO 60 L/min; 2-person mask ventilation technique',
    'STEP 3: DECLARE the situation to the team; refer to COGNITIVE AID / ALGORITHM',
    'STEP 4: DECIDE - benefit of WAKING THE PATIENT vs. continuing management under anesthesia',
    'STEP 5: DECIDE - NONINVASIVE vs. INVASIVE approach',
    'STEP 6: If noninvasive selected - identify PREFERRED SEQUENCE OF DEVICES',
    'STEP 7: Attempt rescue with each device; test mask ventilation between ALL attempts',
    'STEP 8: Track TIME, attempt NUMBER, and SpO2 continuously',
    'STEP 9: LIMIT total attempts to prevent compounding injury ("the airway disaster spiral")',
    'STEP 10: If CICO - declare emergency, proceed to eFONA WITHOUT DELAY',
])

add_colored_heading(doc, 'Rocuronium-Sugammadex as Rescue Strategy', 2, '2E4A7A')
add_note_box(doc, 'NEW in 2022: Rocuronium (1.2 mg/kg) + Sugammadex (16 mg/kg) is explicitly recognized as an alternative to succinylcholine for RSI, offering the ability to rapidly reverse paralysis (within 3 min) in a CICO scenario - restoring spontaneous ventilation as a rescue. This is a major AIIMS exam topic.')

add_colored_heading(doc, 'Rescue Devices for Unanticipated Difficult Airway', 2, '2E4A7A')
add_two_col_table(doc,
    ['Device/Technique', 'Key Evidence', 'Role'],
    [
        ['Second-generation SGA (ProSeal, Supreme, i-gel)', 'Rescue ventilation: 78-94.1% success (Category B3)', 'First-line rescue ventilation; intubation conduit'],
        ['Videolaryngoscope', 'Success 85-100%; first attempt 51-100% (Category B3)', 'Best rescue intubation device'],
        ['Gum Elastic Bougie (GEB)', 'Widely endorsed; adjunct to direct/video laryngoscopy', 'Facilitate tube passage through limited view'],
        ['Lighted Stylet / Lightwand', 'Rescue success 77-100% after failed DL (Category B3)', 'Rescue intubation; especially when VL not available'],
        ['Flexible Intubation Scope', 'Success 78-100% (Category B3)', 'Rescue; especially through SGA (Aintree technique)'],
        ['Combination (SGA + lighted stylet)', 'Success 97.7%; first attempt 86.4% (Category B3)', 'Excellent rescue combination'],
        ['Tube Exchanger', 'Case reports of successful emergency ventilation (Category B4)', 'Expiratory ventilation assistance'],
        ['Rigid Bronchoscope', 'Case report of successful emergency airway obstruction (Category B4)', 'Specialist rescue'],
    ],
    col_widths=[2.2, 2.3, 2.1]
)

# ══════════════════════════════════════════════
# SECTION 8: CICO
# ══════════════════════════════════════════════
add_colored_heading(doc, '8. CANNOT INTUBATE - CANNOT OXYGENATE (CICO)', 1, '1A2E5A')
add_divider(doc)

# Red urgent box
table_urgent = doc.add_table(rows=1, cols=1)
table_urgent.style = 'Table Grid'
cell_u = table_urgent.rows[0].cells[0]
set_cell_bg(cell_u, '8B0000')
pu = cell_u.paragraphs[0]
pu.alignment = WD_ALIGN_PARAGRAPH.CENTER
ru = pu.add_run('  ⚠  LIFE-THREATENING EMERGENCY - IMMEDIATE ACTION REQUIRED  ⚠')
ru.bold = True
ru.font.size = Pt(12)
ru.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
doc.add_paragraph()

add_styled_para(doc, 'CICO = failed intubation + failed oxygenation (SpO2 falling despite all rescue attempts with face mask and SGA). This is a "can\'t intubate, can\'t oxygenate" scenario requiring IMMEDIATE emergency front-of-neck airway (eFONA).', bold=True, size=11)
doc.add_paragraph()

add_key_point_box(doc, 'CICO Response Protocol', [
    '1. DECLARE: "This is a CICO situation - we need emergency front-of-neck airway NOW"',
    '2. CALL FOR HELP: ENT/surgical team if not already present',
    '3. RELEASE CRICOID PRESSURE (if being applied)',
    '4. POSITION: neck extended, head stabilized, landmark the cricothyroid membrane',
    '5. eFONA METHOD: Scalpel-Bougie-Tube (Surgical Cricothyrotomy) is PREFERRED',
    '6. If eFONA fails or not feasible: consider alternative invasive technique',
    '7. ECMO: Initiate if appropriate and available (NEW in 2022 guidelines)',
    '8. Continue HFNO throughout (provides oxygenation even with partial airway)',
])

add_colored_heading(doc, 'eFONA Techniques: Comparison', 2, '2E4A7A')
add_two_col_table(doc,
    ['Technique', 'Steps', 'Pros', 'Cons'],
    [
        ['Scalpel-Bougie-Tube\n(PREFERRED in adults)',
         '1. Horizontal stab incision through CTM skin\n2. Vertical extension if needed\n3. Insert bougie (caudally)\n4. Railrail 6.0 cuffed ETT\n5. Inflate, confirm EtCO2',
         'Reliable, definitive, adequate ventilation possible',
         'Requires training; time ~30-60 sec'],
        ['Needle Cricothyrotomy\n+ Jet Ventilation',
         '14G IV cannula through CTM; connect to jet ventilator (HFJV)\nOR Manujet at 50 psi',
         'Faster; familiar to anesthesiologists',
         'High barotrauma risk; CO2 not cleared; NOT definitive; NOT preferred for adults'],
        ['Percutaneous Kit\n(Melker)',
         'Seldinger technique: needle → wire → dilator → cuffed tube',
         'More reliable than needle alone',
         'Multiple steps; time-consuming in emergency'],
        ['Surgical Tracheostomy',
         'Full incision, dissection, tracheostomy tube',
         'Definitive; familiar to surgeons',
         'Slow (minutes); requires trained surgeon'],
    ],
    col_widths=[1.8, 2.5, 1.5, 1.8]
)

add_note_box(doc, 'AIIMS High-Yield: The scalpel-bougie-tube technique is now the preferred eFONA method per ASA 2022. Needle cricothyrotomy is NOT recommended as the primary adult eFONA due to high barotrauma risk and inability to clear CO2 (hypercapnia). ECMO is newly mentioned as a rescue option in extreme situations.')

# ══════════════════════════════════════════════
# SECTION 9: CONFIRMATION OF INTUBATION
# ══════════════════════════════════════════════
add_colored_heading(doc, '9. CONFIRMATION OF TRACHEAL INTUBATION', 1, '1A2E5A')
add_divider(doc)

add_two_col_table(doc,
    ['Method', 'Evidence / Detail'],
    [
        ['Capnography / EtCO2 (GOLD STANDARD)', 'Confirms intubation in 88.5-100% of difficult airway patients (Category B3). MANDATORY per ASA 2022. Waveform capnography preferred over colorimetric.'],
        ['Colorimetric CO2 Detector', 'Acceptable when waveform capnography unavailable. Color change (yellow = CO2 = trachea) confirms placement.'],
        ['Direct Visualization', 'Tube passing between cords; but NOT reliable alone - not confirmed by literature to definitively confirm tracheal placement in difficult airways'],
        ['Flexible Bronchoscopy', 'Visualizes tracheal rings/carina through tube - definitive but rarely used solely for confirmation'],
        ['Chest Rise + Auscultation', 'Clinical assessment; NOT reliable as sole confirmation (especially in difficult airway)'],
        ['Ultrasound', 'Tracheal intubation vs. esophageal intubation in real-time; emerging confirmation tool, especially in ICU'],
        ['If uncertain about tube position', 'REMOVE THE TUBE and re-attempt ventilation - do NOT assume correct placement'],
    ],
    col_widths=[2.5, 4.1]
)

# ══════════════════════════════════════════════
# SECTION 10: EXTUBATION
# ══════════════════════════════════════════════
add_colored_heading(doc, '10. EXTUBATION OF THE DIFFICULT AIRWAY', 1, '1A2E5A')
add_divider(doc)

add_styled_para(doc, 'The extubation strategy is as important as the intubation strategy. Extubation of the difficult airway must be planned with equal care as a "difficult reintubation" scenario.', bold=True, size=11)
doc.add_paragraph()

add_key_point_box(doc, 'Extubation Readiness Checklist', [
    'Hemodynamically stable',
    'Fully reversed neuromuscular blockade (TOF ratio >0.9)',
    'Adequate spontaneous ventilation (TV >5 mL/kg, RR 10-20)',
    'Awake, cooperative, follows commands (for awake extubation)',
    'No evidence of significant airway edema or injury',
    'Procedure-related factors: no ongoing hemorrhage, no airway surgery requiring protected airway',
    'Appropriate time of day + skilled personnel present',
])

add_colored_heading(doc, 'Extubation Strategies', 2, '2E4A7A')
add_two_col_table(doc,
    ['Strategy', 'Indication', 'Details'],
    [
        ['AWAKE EXTUBATION\n(PREFERRED for difficult airway)',
         'All difficult airways; high risk of reintubation',
         'Extubate when patient is awake, responsive, protective reflexes intact. Safer - patient can cooperate with mask ventilation if needed.'],
        ['Airway Exchange Catheter (AEC)\nStaged Extubation',
         'Known or expected difficult re-intubation',
         'Cook AEC (11F/14F): pass through ETT before extubation → patient breathes through AEC → if reintubation needed, railroad new ETT over AEC. Success: 92% (Category B3). AVOID in pediatric patients.'],
        ['Bailey Maneuver (SGA Exchange)',
         'When deep extubation preferred (e.g., reactive airway)',
         'Under deep anesthesia, insert LMA alongside ETT → withdraw ETT while holding LMA in position → patient emerges on LMA.'],
        ['Deep Extubation\n(NOT preferred for difficult airway)',
         'Smooth emergence needed (bronchospasm risk); only when reintubation is expected to be easy',
         'Patient at RISK of airway loss. Only acceptable when difficult airway issue was manageable and reintubation simple.'],
        ['Elective Surgical Tracheostomy\n(Pre-extubation)',
         'Predicted inability to maintain airway post-extubation; prolonged ventilation likely',
         'Best performed electively before extubation rather than emergently after failure.'],
    ],
    col_widths=[2.0, 2.0, 2.6]
)

add_note_box(doc, 'AIIMS Key: The AEC (Cook Airway Exchange Catheter) allows "safe bridge" to extubation. It must be lubricated, passed no further than 25-26 cm in adults (to avoid endobronchial placement), and OXYGEN can be insufflated at 1-2 L/min through it if needed. Minimize AEC use in children (risk of airway trauma).')

# ══════════════════════════════════════════════
# SECTION 11: FOLLOW-UP CARE
# ══════════════════════════════════════════════
add_colored_heading(doc, '11. FOLLOW-UP CARE & DOCUMENTATION', 1, '1A2E5A')
add_divider(doc)

add_key_point_box(doc, 'Mandatory Follow-up Actions After Difficult Airway', [
    'Postextubation STEROIDS (e.g., dexamethasone 8 mg IV) +/- RACEMIC EPINEPHRINE nebulization when airway edema suspected',
    'INFORM the patient (or guardian): what difficulty occurred, why, what was done, and what it means for future anesthesia',
    'DOCUMENT in medical records: nature of difficulty, number of attempts, devices used, final technique, complications',
    'Issue a DIFFICULT AIRWAY ALERT CARD to patient (MedicAlert or institutional card)',
    'REGISTER with a difficult airway notification service (e.g., MedicAlert Foundation)',
    'Provide written LETTER to patient and referring physician for permanent medical records',
])

add_note_box(doc, 'AIIMS Note: A case report showed that records of previous difficult intubations were UNAVAILABLE when a patient was awakened after failed intubation - highlighting the medico-legal importance of documentation and patient notification (Category B4-H evidence).')

# ══════════════════════════════════════════════
# SECTION 12: DEVICES EVIDENCE SUMMARY
# ══════════════════════════════════════════════
add_colored_heading(doc, '12. DEVICES: EVIDENCE SUMMARY (AIIMS Exam Focus)', 1, '1A2E5A')
add_divider(doc)

add_two_col_table(doc,
    ['Device', 'Success Rate', 'Evidence Category', 'Key Points'],
    [
        ['Videolaryngoscope (VL) - overall', '85-100% intubation; 51-100% first attempt', 'Category B3-B', 'Recommended as primary technique for difficult airway; channel vs. non-channel VL = equivocal (Category A3-E)'],
        ['Hyperangulated vs. Non-angulated VL', 'Equivocal for all outcomes', 'Category A2-E', 'No clear superiority - choose based on anatomy'],
        ['Flexible Intubation Bronchoscope (FIB)', '78-100% success', 'Category B3-B', 'Gold standard for ATI; intubation through SGA via Aintree catheter'],
        ['Supraglottic Airway (2nd gen)', 'Rescue ventilation 78-94.1%', 'Category B3-B', 'i-gel/ProSeal preferred for difficult airway; conduit for FIB/VL intubation'],
        ['Lighted Stylet / Lightwand', '77-100% rescue; shorter intubation time vs. DL (Category A2)', 'Category A2-B / B3-B', 'Shorter intubation time than DL; useful when VL not available'],
        ['Gum Elastic Bougie', 'Widely used adjunct', 'Category B / Expert consensus', 'Essential adjunct; always available'],
        ['Levering Laryngoscope (McCoy)', 'Shorter intubation time; fewer maneuvers vs. standard', 'Category B3-B', 'Alternative blade; useful in limited mouth opening'],
        ['Rigid Bronchoscope', 'Insufficient evidence', 'Insufficient', 'Specialist rescue technique'],
        ['BURP / OELM maneuvers', 'Case reports of success', 'Category B4-B', 'Simple, always available; attempt with every DL'],
        ['Retrograde Wire-Guided Intubation', 'Case reports', 'Category B4-B', 'Rescue when flexible scope not available; technically demanding'],
    ],
    col_widths=[2.0, 1.8, 1.8, 2.0]
)

# ══════════════════════════════════════════════
# SECTION 13: 2013 vs 2022 COMPARISON
# ══════════════════════════════════════════════
add_colored_heading(doc, '13. KEY CHANGES: 2013 vs 2022 ASA GUIDELINES', 1, '1A2E5A')
add_divider(doc)

add_two_col_table(doc,
    ['Feature', '2013 Guidelines', '2022 Guidelines'],
    [
        ['Task Force Composition', 'ASA only (US-based)', 'International - 11 organizations (ASA + AIDAA + EAMS + ESAIC + SAM + SPA + SOCCA + TAS + SHNA + SAMBA + AAROI)'],
        ['ECMO', 'NOT mentioned', 'EXPLICITLY mentioned as rescue option in CICO and CIVO scenarios'],
        ['Videolaryngoscopy', 'Listed as one of many devices', 'Strongly recommended as PRIMARY rescue and anticipated difficult airway technique; meta-analytic evidence presented'],
        ['High-Flow Nasal Oxygen (HFNO)', 'Not addressed', 'Recommended for preoxygenation and apnoeic oxygenation throughout airway management'],
        ['Cognitive Aids / Algorithms', 'Not mentioned', 'Explicitly recommended: refer to algorithm/cognitive aid when unanticipated difficult airway encountered'],
        ['Combination Techniques', 'Limited mention', 'Expanded section: VL + FIB, SGA + lighted stylet, SGA + FIB (Aintree), etc.'],
        ['Extubation Strategy', 'Brief section only', 'Full structured strategy with specific recommendations: AEC, Bailey maneuver, awake extubation'],
        ['Rocuronium + Sugammadex', 'Not mentioned as RSI alternative', 'Explicitly recognized as RSI alternative; sugammadex as rescue for paralysis reversal in CICO'],
        ['Supplemental O2 during ATI + extubation', 'Limited recommendation', 'Explicit strong recommendation to continue supplemental O2 throughout ALL stages including extubation'],
        ['HFNO / Apnoeic Oxygenation', 'Not addressed', 'Recommended to extend safe apnoea time during all intubation attempts'],
        ['Patient questionnaires', 'Not addressed', 'Now included as valid tool to identify difficult airway patients (Category B3)'],
        ['ICU / Critically ill patients', 'Brief mention', 'Explicitly included in scope; NIV preoxygenation addressed'],
    ],
    col_widths=[2.0, 2.2, 2.4]
)

# ══════════════════════════════════════════════
# SECTION 14: HIGH-YIELD AIIMS POINTS
# ══════════════════════════════════════════════
add_colored_heading(doc, '14. HIGH-YIELD POINTS FOR AIIMS MD ANAESTHESIA EXAM', 1, '1A2E5A')
add_divider(doc)

add_key_point_box(doc, 'Most Frequently Tested Concepts', [
    '1. DEFINITION: All 6 types of difficult airway - memorize verbatim definitions',
    '2. INDICATIONS for ATI: Any ONE of 4 = difficult ventilation, aspiration risk, cannot tolerate apnoea, difficult eFONA',
    '3. ATI SUCCESS RATE: 88-100% (Category B3-B evidence)',
    '4. CICO MANAGEMENT: Declare → eFONA (scalpel-bougie-tube) → ECMO if available',
    '5. PREFERRED eFONA: Scalpel-bougie-tube technique (NOT needle cricothyrotomy in adults)',
    '6. AEC: 92% success for difficult extubation (Category B3); minimize in pediatrics',
    '7. CAPNOGRAPHY: Mandatory; confirms intubation in 88.5-100% (Category B3)',
    '8. HFNO: 60 L/min; extends safe apnoea time - NEW emphasis in 2022',
    '9. ROCURONIUM-SUGAMMADEX: RSI alternative; sugammadex reversal as rescue in CICO',
    '10. ECMO: New addition in 2022 as last resort rescue',
    '11. DOCUMENTATION + PATIENT NOTIFICATION: Mandatory after every difficult airway',
    '12. NO SINGLE PREDICTOR is adequate - combination assessment mandatory',
    '13. VIDEOLARYNGOSCOPY: Recommended as primary technique for anticipated difficult airway',
    '14. 2nd GENERATION SGA: Preferred over 1st generation for rescue in difficult airway',
])

add_colored_heading(doc, 'Common Exam Question Formats', 2, '2E4A7A')
add_two_col_table(doc,
    ['Question Type', 'Expected Answer'],
    [
        ['Indications for awake intubation?', '4 indications: (1) Difficult ventilation anticipated, (2) Aspiration risk, (3) Cannot tolerate apnoea, (4) Difficult emergency invasive airway anticipated'],
        ['Gold standard for ATI?', 'Flexible intubation bronchoscopy (FIB) via oral or nasal route with SAYGO technique'],
        ['Preferred eFONA technique?', 'Scalpel-bougie-tube (surgical cricothyrotomy) - definitive; insert 6.0 cuffed ETT'],
        ['How is tracheal intubation confirmed?', 'Waveform capnography (EtCO2) - gold standard; confirms in 88.5-100% (Category B3)'],
        ['What is new in 2022 vs 2013 ASA guidelines?', 'ECMO, HFNO, VL as primary, Cognitive aids, Rocuronium-Sugammadex RSI, expanded extubation strategy'],
        ['Extubation rescue tool?', 'Cook Airway Exchange Catheter (AEC) - 92% success; bridges extubation with re-intubation option'],
        ['Best rescue technique for CICO?', 'Emergency Front-of-Neck Airway (eFONA) - scalpel-bougie-tube at cricothyroid membrane'],
        ['What must you do after every difficult airway?', 'Document, notify patient (and guardian), issue alert card, consider registration with MedicAlert service'],
        ['Preferred sedative for ATI?', 'Dexmedetomidine (preserves respiratory drive) OR Remifentanil TCI (best patient comfort)'],
        ['Number of organizations that endorsed 2022 guidelines?', '11 international anesthesiology and airway organizations (ASA + 10 others)'],
    ],
    col_widths=[3.0, 3.6]
)

# ══════════════════════════════════════════════
# SECTION 15: RAPID REVISION
# ══════════════════════════════════════════════
add_colored_heading(doc, '15. RAPID REVISION: MNEMONICS & SUMMARY TABLES', 1, '1A2E5A')
add_divider(doc)

add_colored_heading(doc, 'Mnemonics', 2, '2E4A7A')
add_two_col_table(doc,
    ['Mnemonic', 'Stands For', 'Use'],
    [
        ['"BONES"', 'B-eard, O-besity, N-o teeth, E-lderly, S-noring/Sleep apnoea', 'Risk factors for DIFFICULT MASK VENTILATION'],
        ['"LEMON"', 'L-ook, E-valuate (3-3-2 rule), M-allampati, O-bstruction, N-eck mobility', 'Bedside difficult intubation prediction (ATLS/DAS)'],
        ['"3-3-2 Rule"', '3-finger mouth opening, 3-finger TMD, 2-finger hyoid-to-thyroid', 'Clinical airway assessment'],
        ['"RODS"', 'R-igid neck, O-besity, D-istorted airway, S-noring', 'Difficult SGA placement risk factors'],
        ['"SMART"', 'S-upine-M-ask-A-irway-R-etrieval-T-ool', 'Equipment check before induction'],
        ['"DAV-CICO"', 'D-eclare, A-ssist, V-ideolaryngoscope, C-ICO = eFONA', 'Response escalation for failed intubation'],
        ['"SAYGO"', 'S-pray-A-s-Y-ou-G-O', 'ATI topicalization technique through bronchoscope'],
    ],
    col_widths=[1.8, 3.2, 1.8]
)

add_colored_heading(doc, 'One-Page Summary: ASA 2022 Difficult Airway Algorithm', 2, '2E4A7A')
# Algorithm summary as nested tables
algo_table = doc.add_table(rows=6, cols=1)
algo_table.style = 'Table Grid'
algo_data = [
    ('1. PREOPERATIVE ASSESSMENT', 'EEF3FB', '1A2E5A',
     'History + Physical Exam (Mallampati, TMD, SMD, ULBT, neck mobility) + Additional tests (US, CT, endoscopy)\nConclusion: ANTICIPATED DIFFICULT AIRWAY or likely normal?'),
    ('2. PREPARATION (if difficult airway anticipated)', 'EEF3FB', '1A2E5A',
     'Cart ready | Skilled assistant | Patient informed | Preoxygenation (HFNO) | Positioning | Monitoring'),
    ('3. ANTICIPATED DIFFICULT AIRWAY STRATEGY', 'FFF0E0', '8B4500',
     'ATI indicated? → YES → Flexible bronchoscopy / VL awake + topicalization + sedation\nATI NOT indicated? → Anesthetized intubation with full preparation + rescue plan'),
    ('4. UNANTICIPATED DIFFICULT AIRWAY', 'FFF0E0', '8B4500',
     'Call for help | Optimize O2 | Use cognitive aid | Wake patient vs. continue\nRescue sequence: VL → SGA (2nd gen) → FIB through SGA → Combination techniques'),
    ('5. CICO - CANNOT INTUBATE CANNOT OXYGENATE', 'FFE0E0', '8B0000',
     'DECLARE CICO → eFONA (Scalpel-Bougie-Tube) → Alternative invasive → ECMO\nContinue HFNO throughout | Sugammadex if rocuronium given'),
    ('6. EXTUBATION + FOLLOW-UP', 'E0FFE8', '1A5A2E',
     'Awake extubation (preferred) | AEC for staged extubation | Supplemental O2 throughout\nDocument | Notify patient | Issue MedicAlert card'),
]
for i, (title, bg, title_color, content) in enumerate(algo_data):
    cell = algo_table.rows[i].cells[0]
    set_cell_bg(cell, bg)
    p_title = cell.paragraphs[0]
    rt = p_title.add_run(f'  {title}')
    rt.bold = True
    rt.font.size = Pt(11)
    rt.font.color.rgb = RGBColor(
        int(title_color[0:2], 16),
        int(title_color[2:4], 16),
        int(title_color[4:6], 16)
    )
    p_content = cell.add_paragraph()
    p_content.paragraph_format.left_indent = Inches(0.15)
    rc = p_content.add_run(content)
    rc.font.size = Pt(10)

doc.add_paragraph()

# Final key evidence summary table
add_colored_heading(doc, 'Evidence Snapshot: Key Numbers for the Exam', 2, '2E4A7A')
add_two_col_table(doc,
    ['Clinical Fact', 'Number/Value'],
    [
        ['ATI success rate in anticipated difficult airway', '88-100% (Category B3-B)'],
        ['Videolaryngoscope intubation success', '85-100% (Category B3-B)'],
        ['Videolaryngoscope first-attempt success', '51-100% (Category B3-B)'],
        ['FIB success rate for ATI', '78-100% (Category B3-B)'],
        ['SGA rescue ventilation success (unanticipated)', '78-94.1% (Category B3-B)'],
        ['SGA + lighted stylet combination success', '97.7%; first attempt 86.4% (Category B3-B)'],
        ['AEC for difficult extubation success', '92% (Category B3-B)'],
        ['Capnography confirms intubation in difficult airway', '88.5-100% (Category B3-B)'],
        ['Bedside endoscopy revises airway plan in', '26% of patients (Category B3-B)'],
        ['Literature search dates covered', 'Jan 2002 - Mar 2021'],
        ['Total citations screened', '12,544 unique citations'],
        ['Total articles accepted as evidence', '597 articles'],
        ['Maximum lignocaine dose for topicalization', '4-9 mg/kg (mucosal absorption 20-30% of systemic dose)'],
        ['Rocuronium for RSI (full paralysis dose)', '1.2 mg/kg IV'],
        ['Sugammadex to reverse rocuronium in CICO', '16 mg/kg IV'],
        ['Cook AEC safe depth in adults', '≤25-26 cm at lips (prevent endobronchial placement)'],
        ['HFNO flow rate for apnoeic oxygenation', '60-70 L/min, FiO2 1.0'],
        ['Preoxygenation target (EtO2)', '≥0.90'],
    ],
    col_widths=[4.0, 2.6]
)

# ══════════════════════════════════════════════
# BACK PAGE: REFERENCES
# ══════════════════════════════════════════════
doc.add_page_break()
add_colored_heading(doc, 'SOURCE REFERENCE', 1, '1A2E5A')
add_divider(doc)
add_styled_para(doc, 'Primary Source:', bold=True, size=11)
add_styled_para(doc, 'Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA Jr, Mercier D, Myatra SN, O\'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022 Jan 1;136(1):31-81. doi: 10.1097/ALN.0000000000004002.', italic=True, size=10.5)
doc.add_paragraph()
add_styled_para(doc, 'Endorsing Organizations:', bold=True, size=11)
add_styled_para(doc, 'ASA | AIDAA | EAMS | ESAIC | AAROI-EMAC | SAM | SAMBA | SHNA | SPA | SOCCA | TAS', size=10.5)
doc.add_paragraph()
add_note_box(doc, 'This document is intended for educational purposes for AIIMS MD Anaesthesia examination preparation. All clinical decisions should be guided by the full published guidelines and institutional protocols.')

# ══════════════════════════════════════════════
# SAVE
# ══════════════════════════════════════════════
output_path = '/tmp/workspace/asa-airway-guide/ASA_Difficult_Airway_2022_AIIMS_Study_Guide.docx'
doc.save(output_path)
print(f'Document saved to: {output_path}')
print(f'Pages: Approximately {len(doc.paragraphs)//20 + 1} pages estimated')