a difficult airway…

The Case.

The ‘Batphone’ alerted us of a 68 year old female who is postictal following two seizures in rapid succession. She has a history of ‘a brain tumour’.

P 120. BP 176 systolic !! GCS 8/15. Afebrile. Sats 98% (15L NRB + guedel airway).

She arrives direct to your resus bay 4-5 minutes later and she is actively seizing.

A) Obstructed (Guedel on floor). Trismus ++.

        • Bilateral nasopharyngeal airways inserted
        • Two-handed jaw thrust
        • Ventilating well on 100% BVM.

 B) Bilateral air entry. Sats 99% on O2. No added sounds.

 C) P 130 (sinus) BP 185 systolic. Diaphoretic. Warm peripheries.

        • 2x IVC inserted
        • 500mL N.Saline bolus

D) Actively seizing (GTCS with movement in all 4 limbs). Pupils 4mm (L+R).

        • 2x 5mg IV Midazolam (seizure resolved)
        • 1gram IV Phenytoin (loading commenced at cessation of seizure)

E) Temp 37*C. BSL 13. No rashes, contusions etc.


Status Epilepticus (3x seizures with no return to normal mental state)

    • ? secondary to ‘brain tumour’ or associated haemorrhage
    • No other medical history available
    • “Family are bringing in her medications”

Following resolution of her seizure she remains obtunded, GCS (E1V1M4) 6/15 and still obstructing her airway. A decision is made to RSI for airway control and prevention of secondary brain injury, followed by urgent CT.

The Issue.

This patient is short, obese & has barely got a neck (soft tissues ++).
What neck she does have, has minimal range of motion.
Her mouth is small. Her mandible receded.

Our saving grace = she is surprising easy to bag-valve mask ventilate with just one user.

The Plan.

Ramped position (close to 45 degrees). Ear to sternal notch.

PreO2 + high-flow nasal cannula.

Standard RSI (we used Thio & Sux)

C-Mac video laryngoscope + bougie + size 7.0 ETT

Size 3 LMA supreme (opened & tested).

Whilst we did not verbalise the plan for a surgical airway in this lady, one ED physician nearby did come to the bedside and palpate the anterior neck prior to induction. Certainly I recall knowing what his intentions where at the time…

The Reality.

As far as we were all concerned, we had optimal patient positioning from the get-go.

Thio. Sux. Go….

Size 3 C-Mac blade in…
As this is occurring I am recalling the mantra “epiglottoscopy before laryngoscopy”
… Well the epiglottoscopy was easy. In fact that was all I could see. One giant pale, fat & floppy epiglottis which took up both my DL view and the entire C-Mac video-screen.

      • I visualised the laryngoscope blade into the vallecula but due to anatomical difficulties, I could not lift the blade/scope. I could not see the arytenoids. ELM / BURP made no difference.
      • I attempted to advance the blade beyond the epiglottis in attempt to ‘pick it up’ however the large curve of C-Mac and her narrow airway made this impossible.
      • So I withdrew the blade, reapplied O2 via BVM and found that again she was easy to bag-valve mask ventilate.
      • Concerned, but calm.

Considering our options, whilst searching for our Miller blade I am handed a standard Mac-3 to have another go…..

      • Same story. Big epiglottis. No view. Can’t pick the damn thing up…
      • I took a bougie and attempted to lift the epiglottis with that. Same result…. No view.
      • I made a single attempt at a blind bougie pass which was clearly oesophageal, so again I withdrew & again she was easy to ventilate.
      • Sats have remained at 99% throughout.
      • I hand the duties over to my supervising physician & take over the team-leading role….

As it pans out; there are three further attempts at direct & video laryngoscopy. With each further attempt there is more & more blood pooling in the oropharynx. There are two attempts of intubation over bougie (both oesophageal). During the first two of three attempts, the patient was still incredibly easy to ventilate and her oxygen saturations did not fall from 99%…..

The Finale.

Following the final attempt at an unsuccessful intubation, her saturations plummet from 99% to 60% to 50% in a period of 4-5 seconds. There is a two-user attempt of BVM (me with two hands holding mask to face with jaw thrust & Consultant #1 on the bag).

      • Oxygenation does not improve. I call for my LMA & Consultant #2 sprays the anterior neck with Betadine…
      • As I insert the larygneal mask, the surgical airway kit is opened on the patients chest.
      • The LMA is in with oxygen saturations of 16% !!!!! (Heart rate ~ 110)
      • I have three squeezes on the reservoir bag (1, 2… uh oh; bag is rigid and will not ventilate)
      • I announce to the team that we can no longer ventilate from the top end.
      • The nod is given to Consultant #2 who takes scalpel to neck and as finger is placed within the trachea (before the Shiley is inserted) I am suddenly able to ventilate into the chest from the top end…. Sats jump into the 90’s.
      • The Shiley is secured.

The Outcome.

      • ENT arrive and are happy with the airway for now. They will look at it formally in the OT tomorrow….
      • CT-Brain demonstrates a complicated meningioma involving the right cavernous sinus (a little worse than last scan), but there is no haemorrhage.
      • Her family arrive and hand me her medication bag. The first box I take out is…….. Warfarin !!!! (Recently diagnosed PE).
      • She has a smooth course in the ICU and at day 7 is reported to be back to her normal level of consciousness.

The Reflection.

I have found myself analysing and reliving this case over and over since it occurred (now, well over a 6 weeks ago) for many reasons.

  • It was my first failed intubation in the ED for over 3 years.
      • I was enjoying a purple patch of airways.
      • I needed this case to avoid complacency with ED airway.
  • It was my first involvement in an emergency surgical airway.
  • I had (and still have) swinging emotions between failure and success.
      • I felt I had failed this patient with my inability to get an oral airway
      • As a team we were successful in our ultimate goal and she had not suffered for it.
  • I want to do better next time…

I have come to the conclusion that as a team we did a number of things well. The set-up for the intubation (including pre-oxygenation, optimal patient position and ongoing apnoeic oxygenation) gave us the best opportunity for success from the first attempt. We not only recognised a patient with a predicted difficult airway but had discussed our difficult airway algorithm and back-up plan aloud prior to induction. We successfully moved through our algorithm and (eventually) placed a endotracheal tube to secure a definitive airway.

The retrospectoscope is a power tool and I know there are certain things we could have done better. Had I known this patient was on warfarin, there would have certainly been less blind attempts at passing the tube. In fact, I would not have persevered beyond a second attempt at laryngoscopy. I am convinced the progressive airway bleeding was the tipping point in converting a “can’t intubate, CAN ventilate” into a “can’t intubate, CAN’T ventilate” situation. I believe there was a blood clot within the trachea that blocked my ability to ventilate with the LMA and it was dislodged with the placement of a finger in the trachea on cricothyroidotomy.

If I could play this scenario through a second time around, I would hold back after the second laryngoscopy attempt and either place an LMA or continue the easy BVM-ventilation. A fibre-optic intubation would have been wonderful here and in our shop, this would have bought us time for Anaesthetics to arrive and facilitate that for us. Whilst we recognised that this lady was going to be a difficult intubation we did not actually verbalise the potential need for a surgical airway prior to induction (and proceeding to this made some staff uneasy). If there is a next time I would have prepped her neck ahead of time and marked out her cricothyroid membrane with a pen.

When discussing my airway algorithm aloud prior to all subsequent intubations, I now include surgical airway as a finale and the kit is bought to the bedside within arms reach.

I will no longer let perseverance get in the way of our ability to oxygenate and ventilate.

I would be interested to hear your feedback or comments on this case that still has me pondering, “What if ?”.


10 thoughts on “a difficult airway…

  1. (i) the pulse oximeter is retrospective – changes may take 45s + to occur.

    (ii) airways are like willies – the more you fiddle, the harder they get. Don’t piss around doing repeated attempts unless change something. Max three attempts in RSI, change position/blade/operator etc

    (iii) consider placing a supraglottic and intubation through that, with malleable fibreoptic stylet or flexible fibreoptic scope if trained

    (iv) CICV is rare. But it can happen. Too many people rely on anecdote-based medicine. Statements like “I’ve never had to use a bougie” and “no need for difficult airway equipment as it’s so rare” abound = these guys are going to get a nasty shock some day.

    • Thanks Tim.
      I think you’ve highlighted what is for me the ultimate frustration of the pulse-ox… ie. it starts beeping and alarming about something you should have done differently close to a minute ago !! (a medical ‘I told you so’) This case really did reinforce that issue.

  2. Hi Chris
    found this article via LITFL review, so thanks Kane.
    thankyou for sharing and its somewhat coincidental as was reviewing difficult intubation case yesterday from a colleague. whilst such cases shake our confidence in our airway skills, they are helpful to allow us to reflect and improve as you describe.
    your airway prepartion and planning sounded perfect. it looked difficult and it was difficult! the warfarin issue is interesting. if you had known about it, would it have mattered to your airway plan..in some respects it might have made it more intimidating to proceed with surgical airway.
    it does shake your belief in the beneficence of life and fate when your best oral intubation attempts are utterly fruitless..but here to me lies the most important lesson of the case..and as always its a human factor issue. The need to give up and the ability to control glottic fascination syndrome. The best way I have found as you say is to program a trigger into your airway team..usually its SaO2 limit but in this case it illustrates the importance of setting an intubation attempt limit..just like they do in the DAS guidelines and similar guidelines. The confounding factor is the ability to BVM oxygenate. This may give us the false promise of being able to have as many attempts as we like to intubate…including blind attempts with pointy rigid objects which is not so cool in the warfarinised patient.
    its difficult to control glottic fascination syndrome but this case well illustrates the pitfalls of the syndrome and how CAnnot intubate can oxygenate be converted to CICV by not setting limits

    Hypothetically, if this case were replayed, one might consider at the most two best attempts then insertion of LMA Supreme and wait for backup. Intubating LMAs can be helpful here either the Fastrach for a blind tube with a soft tip silicone reinforced ETT, or the iGel or AirQ which allow fibreoptic imaging of the airway via the device for a shielded intubation attempt which can be helpful in the airway that might bleed.

    One last point, if you never have used a Miller straight blade in anger, be careful doing so as a rescue technique. straight bladed technique is not easy due to poorer tongue control cw mac blades.

    I think your resus team did a great job in a high risk airway and the fact you proceeded to complete the surgical airway shows you at least do not have complete glottic fascination syndrome and therefore I count this case as a successful lesson.

    its not easy sharing cases in which one might think personal skills were shaken, but this is the best way we learn how to deal with risk and situations like this
    thankyou again

  3. oh and I forgot to say this to you.
    Chris, you will do better next time. Of that I have little doubt.
    The mark of the true professional is their ability constantly question their competence.

  4. Having just come off the back of a difficult airway myself, this case brings back the cold sweats. I congratulate you on your eventual successful replacement of the tube.
    When I was a reg one of my consultants told me his philosophy…” three strikes and you are out…move on!! (he was talking about airways not my training!).
    I have used this for the rest of my career and have found it helpful. I am sure I would have been involved in the death of a 5 day old on a retrieval if i didnt have this mantra..(..it was so close…so close…if i just… one more…). I had three tries and then got a rural GP out of bed and into the godforsaken hospital. on the second go he intubated successfully and then the fragile tissues bled and we were sucking blood stained secretions all the way back to Brisbane in the fixed wing. I would have killed it if Id kept going.
    If i am reading your retrospectoscope correctly one of things you thought you could improve upon was the number of attempts made (i think I counted 6?). “had I know she was on warfarin….” .
    one of the problems with the CICV flowchart is it tells you HOW to move on and not WHEN.
    may i humbly suggest that a self imposed limit which was given to me as advice might help you.
    as a side effect, when you announce flatly to the team ” THATS THREE STRIKES… I AM OUT AND WE WILL MOVE ON” . Its amazing how the dynamic in the room changes. as the team leader there is a palpable change from the team silently willing you to succeed and you not wanting to let them down….to a brisk attacking of the new problem… it clears your own mind as well and allows you and your team to focus without backward regret. Its a phrase with amazing closure.

    Its one of the best pieces of advice I ever got.
    All the best

  5. Awesome case!! and I think you should count that as a win.
    Something I realised from a blinding retrospectoscope… If you think it is going to be a difficult airway and its an option, why not call for the people who do airways all day – your anaesthetic colleagues. An ED in one of my old hospitals audited how many intubations they did, and the results weren’t as many as they thought they did. If you were getting your appendix out you wouldn’t call the cardiac surgeons….they might have taken an appendix out a couple of times before, but wouldn’t you want the guys who take out appendices all the time to take your appendix out if you thought it was going to be difficult… yes that rule doesn’t apply to everyone all the time, but if there is an expert available why not use them?

  6. …if there is an expert available.

    For us rural guys, we are it.

    Verbalising plans and limits is gold

    “OK guys, we’regoing to do a std RSI with X mg propofol and Y mg sux.there will be 4 mins of proxygenation with xoncomitant apnoeic oxygenation via nasal cannulae.

    Plan A will be DL with a Mac 3 blade, size blah ETT and a bougie, with cricoid pressure. If difficulty I will move to change position, release cricoid or use a VL. If unsuccessful after 3 attempts we will move to Plan B, use iLMA to maintin pxygenation and consider boind or fibreoptic intubation theough that. If unable to pass an LMA, will revert to Plan C, BM ventilation. Awakening will be an option – but if cannot intubate/cannpt oxygenate will move to Plan D – cricotyroidotome via scalpel-finger-ETT via pre-marked CT membrane”

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