Original Publication
Open Access

Obstructive Mucus Plug in the Prone Position

Published: February 27, 2015 | 10.15766/mep_2374-8265.10016

Included in this publication:

  • Arterial Blood Gas.JPG
  • Chest X-ray.JPG
  • Eggcrate.TIF
  • Handlers.TIF
  • Initial State.TIF
  • Mucus Plug Scenario.doc
  • Suction Tubing Close-up.jpg
  • Suction Tubing Connected.jpg

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Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications.


Introduction: This resource contains a medical simulation in which a 42-year-old male smoker undergoing a T7-T8 laminectomy and fusion in the prone position suddenly develops complete airway obstruction shortly after dissection has begun. This case provides an opportunity to discuss the risks associated with prone positioning, management of a patient who is a heavy smoker, as well as crisis resource management (CRM) in the setting of acute airway obstruction. It also highlights a commonly encountered phenomenon occurring in a field avoidance scenario and requires prompt diagnosis and timely management of loss of end tidal carbon dioxide (ETCO2) and ventilation. Methods: The case requires the learner to troubleshoot the airway obstruction while in the prone position and make a determination that the patient needs to be positioned supine in order to properly assess the airway. Results: This scenario has been delivered 12 times to anesthesia residents with good results, although not all the residents determined the root cause of the airway issue. This scenario has also been used by fully trained anesthesiologists participating in Maintenance in Certification of Anesthesia (MOCA) courses three times to date. In 92% of the cases, the residents initiated a termination of surgery and re-positioned the patient (supine) to assess/optimize an airway. In 100% of the cases performed during MOCA course the patient was suctioned and repositioned supine. Discussion: In addition to giving learners an opportunity to troubleshoot an airway obstruction while in the prone position, this case presents excellent examples to highlight the core principles of CRM: Call for help early, anticipate and plan, know the environment, use all information, allocate attention wisely, mobilize resources, use cognitive aids, communicate effectively, distribute the workload, establish role clarity, and designate leadership. CRM will be discussed using reflective debriefing at the conclusion of the case. Overall, a total of 15 providers have had this case presentation and 40 providers have surveyed the case and participated in the debriefing sessions following the scenarios.

Educational Objectives

By the end of this simulation, learners will be able to:

  1. Classify the anesthetic risks with smoking.
  2. Make recommendations regarding perioperative smoking cessation.
  3. Manage perioperative patients with a smoking history.
  4. Describe the physiologic changes associated with the prone position, as well as the risks of and processes for safely positioning a patient supine.
  5. Identify the differential diagnoses for loss of end tidal carbon dioxide.
  6. Formulate a plan to rule out causes of total airway obstruction.
  7. Manage hypotension and tachycardia.
  8. Prioritize and delegate tasks in a time of crisis.
  9. Employ the treatment of ventricular fibrillation as a result of ischemia.
  10. Lead a discussion with the operating room team regarding the decision to continue surgery post crisis.
  11. Identify and describe elements of crisis resource management.

Author Information

  • Darren Raphael, MD: University of California, Irvine, School of Medicine
  • Sharon Lin: Swedish Medical Center
  • Cecilia Canales, MPH: University of California, Irvine, School of Medicine
  • Keith Beaulieu, MBA: University of California, Irvine, School of Medicine
  • Cameron Ricks, MD: University of California, Irvine, School of Medicine

None to report.

None to report.


Raphael D, Lin S, Canales C, Beaulieu K, Ricks C. Obstructive mucus plug in the prone position. MedEdPORTAL. 2015;11:10016. https://doi.org/10.15766/mep_2374-8265.10016