LEARNing Rounds: Lessons Learned From An Unanticipated Difficult Airway or “Oops, I Need Fresh Underwear!”

Learn, Evaluate, Adopt…Right Now!

Colin G. Kaide, MD, FACEP, FAAEM // Editor Michael G. Barrie MD

LEARN airway word document version of this resource


This patient was an obese male in his 50’s who developed respiratory failure in the ED.  Intubation by a senior resident and a very experienced attending using first GlideScope® (GS) then direct laryngoscopy (DL) were unsuccessful.  They placed a size 5 LMA and were able to successfully oxygenate the patient.  I was called to assist with the airway.  They said they could visualize the cords with DL and with the GS.  They were unable to guide the ETT into position because of what was described as a large amount of “redundant tissue” and some anatomic issue that prevented 2 experienced doctors from guiding the ETT thru the cords.

I repositioned the patient into a semi-seated position, ear to sternal notch, and used a KingVision® scope with a pre-loaded 8-0 ETT to attempt intubation.  I also could visualize the cords but even with the ETT in the track and in my visual field, I could not guide the tube in because it kept hitting “something” (looked like redundant tissue).  Despite multiple manipulations with the device, I couldn’t get the tube thru the glottic opening.  When the O2 saturation hit 85%, we reintroduced the LMA and were able to bag up to 97%.  I tried again, this time with the resident pulling the tongue out with Magill® forceps.  I buried the KingVision® and could see the cords but still could not maneuver the tube in.  I passed a bougie thru the pre-loaded ETT and rotated it and it pushed past the “tissue” and went thru the cords (dramatic internal sigh of relief).  The ETT was then able to be passed easily over the bougie and placement into the trachea was confirmed with color change capnography followed by waveform capnography.

LEARNing Points

So, the learning points that can be gleaned from this case are as follows:

  1. His obesity predicted a possible difficult airway and the initial docs acknowledged this but did not think there would be a big issue. I would likewise have believed that he may have been a little difficult, but I would not have expected this degree of difficulty that we encountered.

Lesson—Prepare for the unanticipated difficult airway by having a good plan B.  Their plan B consisted of DL attempt after failed GS and placement of a rescue device such as an LMA.  The LMA was a VERY good choice since it allowed them to successfully oxygenate this patient.  Never underestimate the power of the dark side of the airway to sneak up on you when you least expect it!!  Nobody expects the Spanish Inquisition (or Donald Trump) either!!

  1. Their next plan B was to try an intubating LMA, however the airway cart they were using did not have one. This is another unanticipated problem.

Lesson—Don’t count on someone who does not have a vested interest in the game to be sure your carts are appropriately stocked.  At the beginning of a shift or at least when you anticipate an intubation, check to be sure you have what you need.

Bonus Lesson—You can sometimes intubate thru a standard LMA by passing a bougie first, then feeding an ETT over the bougie after removing the LMA.  There is one thing you have to do BEFORE inserting the bougie to make this work.  There are 2 little plastic bars at the glottic end of the LMA that need to be removed to allow a bougie to pass.  I cut them out with scissors or a scalpel when I need to possibly use the LMA like an intubating LMA.  I’m not sure why they are there except to frustrate the creative intubator who is trying to pass a bougie.

  1. They appropriately called for help.

Lesson—Always ask someone who has a fresh perspective to come and try to help.  A fresh perspective and a different set of eyes and skill set can be very useful.  Besides, it is better to go down “en mass” than to go down alone ;-).  Also, remember than calling anesthesia MAY NOT improve the situation, especially if the response is by a PGY2 or PGY3 anesthesia resident who may have a distinct lack of composure or experience in an uncontrolled crash intubation scenario!  I very much respect my anesthesia colleagues, however they work in a different, more controlled environment. You must NOT factor them into your plan B…maybe C or D. In the preexisting difficult airway who has required fiberoptic intubation in the past, maybe anesthesia is the best “plan A” if time is not a rate-limiting factor.  Choose your airway peril wisely!!

  1. I have used the AirTraq® and KingVision® many times to rescue a difficult airway, especially when visualization is not the problem but rather manipulation of the tube thru the cords is difficult.

Lesson—Consider learning the AirTraq® or KingVision® skill set.  It can be a great save tool. It takes a little practice so you should do a few on easy airways so you can learn how to best manipulate the device to get the tube correctly aimed thru the cords.

  1. I could not have gotten the tube to go in without first passing a bougie thru the pre-loaded ETT. The bougie, aka a “tracheal introducer” was smaller and more rigid than the ETT and has an angled tip which I could manipulate past the blocking structure.

Lesson—Learn to take advantage of a bougie, and learn to think in terms of additive strategies in order to successfully problem solve!

  1. What if this didn’t work?? There are still other options such as retrograde intubation or simply BVMing thru the LMA and wait for help from someone who does fiberoptic intubation.  An LMA is not a definitive airway but can be used for a long time while awaiting a better, more definitive solution.  Plan in advance that for every patient you intubate, you are mentally prepared to do a cric if needed.  A´la Scott Weingart (to paraphrase the venerable critical care guru) verbalize in advance your plans and talk about cric “out loud” as a possible end game so you and the team can think of it as the next logical step in a failed airway algorithm rather than as a failure of your intubation skill set.

Lesson—Crics are usually not difficult…deciding to do one is significantly harder than the procedure itself, especially if you think of it as “your failure” instead of the next logical step in a “can’t intubate, can’t oxygenate” (failed airway) scenario.  Go as far as to mark the cric site before starting if you anticipate trouble.

  1. Chance favors the prepared.

Lesson—Hope for the best, but plan for the worst…or in the immortal words of Sun Tsu (paraphrased to be sure), “plan not for what you think your enemy may do, but rather for what your enemy is capable of!”