Title: Respiratory Compromise in a Patient with a Known Difficult Airway
Authors: Murad Arif, MD
Affiliated Institution: Cedars Sinai Medical Center
Background: A 73 year old patient in the medical intensive care unit for treatment of acute respiratory decompensation is found to be requiring increasing oxygen support and developing increasing hypercapnea. The on-call anesthesia airway team is called for urgent intubation; prior airway documentation in the EMR lists the patient as having been previously intubated however with a grade 4 view requiring multiple attempts with a C-MAC video laryngoscope. A strategic plan to establish airway control is imminently required.
Case Description: Brief history and physical for this 73 year old female were taken and notable for influenza A diagnosis, morbid obesity, atrial fibrillation on anticoagulation, OSA, and difficult airway. Previously intubated several days ago and noted to be a grade 4 view with CMAC after multiple attempts by anesthesia staff and requiring a bougie for successful passage of ETT, also known difficult bag mask ventilation at that time. Physical notable for a morbidly obese woman in acute distress. Large circumference neck with minimal mouth opening. Apparent anterior neck mass with limited thyromental distance and recessed chin. Minimally responsive (opens eyes to stimulation and some grimacing).
Upon arrival to bedside, patient being bag mask ventilated by three providers. Oral airway placed and saturations 99-100%. Given previous difficult airway, patient prepped for awake fiberoptic intubation with 0.4 mg glycopyrrolate (with esmolol titrated to keep HR <120) and an ovassapian airway lubricated with 4% lidocaine jelly. Airway easily placed without difficulty, tolerated by patient. Difficult airway cart/equipment present and trauma surgery contact readily available. AFOI attempted x 2 without adequate visualization of glottic opening (only soft tissue and tongue seen).
Trauma surgery team was requested to be present before additional attempts at intubation be made, with concern for acute decompensation/loss of airway and need for surgical airway. Mask ventilation at this time became increasingly difficult and an LMA 4 was easily placed with adequate ventilation and oxygenation.
A fiberoptic scope was placed through LMA with good visualization of cords, which were topicalized with 2% lidocaine. A 6.0 ETT was then loaded on scope and patient intubated via scope through LMA. Due to body habitus, significant concerns that 6.0 ETT would not be adequate for ventilation. Decision made to proceed to OR for ETT exchange and possible tracheostomy.
In OR patient prepped and draped for potential tracheostomy. CMAC placed in oropharynx with view of LMA. Bougie placed in ETT and LMA/6.0ETT removed under direct visualization with CMAC in place. 7.5 ETT easily exchanged over bougie. EtCO2 confirmed.
Discussion: This case report highlights the importance of the difficulty airway algorithm as well as the need in such situations to have several backup plans available and ready.
