A Difficult Airway

All my training came to this moment.

Imagine if all your hard work and training were put to the test in a single moment. Have you ever faced a situation where something as basic as breathing becomes a struggle? A difficult airway is a sudden medical crisis that can leave both patients and medical professionals feeling overwhelmed. In this post, we will delve into the causes, symptoms, and treatment options of this critical issue. So, grab your stethoscope and join us on this important journey to better understand the complexities of managing a difficult airway.

Anesthesiologists spend years honing their skills, preparing for any challenge that may come their way: 4 years of pre-medical studies, 4 years of medical school, one or more years of internal medicine or surgery, then 3 solid years of anesthesia residency. Much like an airline pilot, you train for the worst, keeping up on the latest technology, and hoping you will never have to use your training.

The Story

CJ is a pleasant 56-year-old male undergoing a complex heart catheterization to repair completely stenosed (blocked) left and right coronary arteries. His past medical history is complex. He’s an obese individual, once weighing over 700 pounds, had a gastric bypass procedure, and is now 375 pounds. Subsequently, he has myocardial ischemia with shortness of breath, type 2 diabetes, hypertension, chronic heart disease, and sleep apnea and uses a machine. He’s also chronically anemic and recently had life-threatening kidney failure. His anemia results from his kidney disease in that he no longer produces the proper hormones to stimulate the production of red blood cells.

In The Hospital

CJ was pre-admitted to the hospital overnight to receive intravenous fluids and a blood transfusion before the procedure. He was medically optimized for the procedure, as well as he could have been, given that the cardiologist felt he could not hold off any longer to repair his heart.

On exam, CJ is pleasant, ready to complete the procedure, and like many, “doesn’t want to know anything;” he wants to be sedated as much as possible. This is one reason why this procedure requires an anesthesiologist and not nurse sedation. CJ’s physical exam shows that he has good dentition, can open his mouth normally, and has a full range of neck motion. His neck is large and obese. The rest of his physical exam is unremarkable, and we prepare him for the procedure.

In The Cath Lab

He received sedation via IV while receiving oxygen via a standard mask. The cardiologist inserted catheters in his femoral veins and arteries and threaded the lines into his heart. A right-sided internal carotid vein catheter was also inserted, and a temporary pacemaker wire was lined into the wall of the heart, called the ventricle, as a precaution.

The three-hour procedure went smoothly. The cardiologist made cuts into the calcified atherosclerotic plaques using a device called the “wolverine.” Stents were then inserted into the coronary arteries, and the optimization of blood flow could be visualized.

First Signs of Trouble

Near the end of the procedure, I recognized that CJ’s breathing became more laborious, and the right side of his neck and chin was swollen because of a blood collection called a hematoma, and it had filled the right side and the front of his neck up to his chin. The hematoma resulted in part by the aggressive anticoagulation necessary for the procedure. The blood vessel's internal carotid vein, which contained the catheter in his neck, could not seal properly, leaking blood and causing a hematoma. The swelling was not initially evident because of his obesity. I attempted to support his ventilation with an oral airway device and a mask, which wasn’t optimal due to the size of the neck. It was apparent he would need to be intubated because of the expanding hematoma. An endotracheal tube needed to be placed to secure the airway.

CJ was given enough sedation to tolerate the intubation attempt. Using an advanced intubating video scope, intubation was attempted, and as expected, the airway anatomy appeared edematous and distorted from the hematoma that had formed in his neck. The vocal cords were visualized, but I could not pass the tube into the vocal cords. I made two attempts.

The Conundrum

Ventilation was attempted once more with a mask, which proved to be ineffective. The code team was then called as CJ's oxygen saturation started to drop. The intensivist suggested intubating CJ using etomidate and a paralytic, but I objected due to concerns about the airway. I insisted on attempting intubation without the paralytic first. Etomidate was administered, and the paralytic was prepared for use. Despite using an advanced video scope, the intensivist still struggled to successfully intubate CJ. He was about to push the paralytic when I vehemently objected. I stated, “A breathing patient is an alive patient.” He knew what this meant; if we gave the paralytic and were unsuccessful with the intubation, the patient would certainly die from hypoxemia.

Other Options

Thinking about what other options were available, I pulled out what is called a laryngeal mask airway, not knowing if it would work to ventilate the patient. I inserted the device, and CJ was able to breathe! And then he was able to breathe on his own. The decision was made to let CJ completely wake up and see if he could support his airway. After ten minutes, CJ was utterly awake; I explained to him that we needed to support his airway and for him to relax and get into his “Zen state” of mind. I suctioned his airway and removed the airway device. Immediately he struggled to breathe, and when I asked him if he could breathe, he shook his head violently from side to side. I reinserted the breathing device, which again bridged his airway, and he realized what it was doing for him and keeping him alive. He did not fight the device, and sedation was given, and he was transferred to the CT scanner for imaging and then to the ICU with the airway device. CJ was breathing for the time being with the plastic airway device, but it would not last long. He would surely die if it dislodged at night and couldn’t be intubated with a secure airway.

The Final Attempt

The decision was made to give steroids to decrease the inflammation, wait a couple of hours, and then try to intubate the airway. The ICU doctor and I gathered four means of intubation, the most sophisticated tools available. We discussed the plan and agreed that if CJ could not be intubated, we would take him directly to the operating room, where a surgeon would attempt to cut into his neck and place a surgical airway called a tracheostomy.

CJ was given sedation, and then we attempted the intubation, again without a paralytic. First, a bronchial video scope using a special airway through the mouth was attempted. This yielded no results, too much blood, and edema. Then we attempted to go through the nasal passages with a camera; again, the tissues were so edematous and bloodied by this point the anatomy was unrecognizable. Now, the situation was worse than before. We tried using the camera scope through the mouth again and could not secure the airway. Finally, we gave more sedation and built up his oxygen stores, always keeping him breathing. Knowing this was our last chance, we placed the camera scope near where we thought the vocal cords ought to be, waited for him to breathe, and visible bubbles exited from the windpipe. The camera was aimed at that point, and miraculously, we were in the trachea. The endotracheal tube was inserted into the trachea and secured. Disaster averted.

Every bit of my twenty-five years of training came to this point. It came to the decision not to use paralytics. It came to the faith that his trachea lay beyond the air bubbles. One wrong decision in this process would have been deadly. CJ was intubated and ventilated for two days. Finally, the swelling of the hematoma subsided, and we removed the breathing tube. He was calm, knowing that we had saved his life.