The most difficult airway is the unanticipated one. Those eight words of advice that Robert W. Simon, DNP, MS, CRNA, CHSE, CNE, heard repeatedly throughout his anesthesia training proved prescient after he faced one of the most memorable difficult airway cases of his career. “We had a patient in an outpatient setting who didn’t fully disclose her respiratory history or her history of a difficult airway,” says Dr. Simon, the chief CRNA at Huntington Valley (Pa.) Anesthesia Associates. “There was also a language barrier, and even though we used a medical interpreter and asked the typical preoperative assessment questions, it’s always up to the patient to fully disclose their history, which this person did not.”
The plan for the case, says Dr. Simon, was to provide general anesthesia through an LMA, which he was not able to successfully place due to the airway issues. Then, a series of reactionary steps followed. First, the team converted from an LMA to an endotracheal tube, but they had a severely limited view with standard laryngoscopy with a MAC 3 blade. “Luckily, we were able to mask ventilate the patient and maintain her oxygen at 100% while we called for a video laryngoscope,” says Dr. Simon, who also serves as the assistant program director/didactic education coordinator at the Frank J. Tornetta School of Anesthesia at Einstein Medical Center Montgomery in Norristown, Pa. “The view of the airway improved, but it was extremely anterior and narrow, and I ended up passing a bougie through the vocal cords via direct visualization with the video laryngoscope.” Dr. Simon’s partner was then able to thread a 6.5 mm endotracheal tube over the bougie and the airway was secured.
“Later, the patient’s partner disclosed the patient had a history of a difficult airway, but it was 20 years ago,” says Dr. Simon. “He said that she didn’t think it was important to pass that information on since it was so long ago.”