Difficult airway

[lvspro]

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62 CF Hx DM2, HTN, CAD, small MI (s wall motion abn 10 yrs ago) is getting a lap supracerv hysterectomy yesterday, and has a very short, thick neck, MP4, and almost looked like she had microagnathia. I ask her if she was ever told on previous surgeries if she has a difficult airway, she says no. We induce w/prop, sux, and take a look w/a MIL3. I have to mention that I've started using the miller for the last 2 days in order to get a good feel for it. Anyhow, I get in there and see nothing... posterior pharynx. I get some cric pressure, the epiglottis slips off the blade, and I repos'n s success. I try again, fail, and the attending decides to take a look. He has similar difficulties, and despite plenty of cric pressure, perfect pos'n, experienced operator etc... we still have some difficulty finally getting a smidgen of the very bottom mm of airway and he "guesses" the tube into place (which happened to be right). So I ask him, "was that inexperience, or did she really have a tough one, and if we could start over, would you do an awake f/o?"

Lets hear what your airway strategy is. (btw, i know the algorithm, but I'm curious to see how you folks deviate from the cookbook).

 

[VentdependenT]

62 CF Hx DM2, HTN, CAD, small MI (s wall motion abn 10 yrs ago) is getting a lap supracerv hysterectomy yesterday, and has a very short, thick neck, MP4, and almost looked like she had microagnathia. I ask her if she was ever told on previous surgeries if she has a difficult airway, she says no. We induce w/prop, sux, and take a look w/a MIL3. I have to mention that I've started using the miller for the last 2 days in order to get a good feel for it. Anyhow, I get in there and see nothing... posterior pharynx. I get some cric pressure, the epiglottis slips off the blade, and I repos'n s success. I try again, fail, and the attending decides to take a look. He has similar difficulties, and despite plenty of cric pressure, perfect pos'n, experienced operator etc... we still have some difficulty finally getting a smidgen of the very bottom mm of airway and he "guesses" the tube into place (which happened to be right). So I ask him, "was that inexperience, or did she really have a tough one, and if we could start over, would you do an awake f/o?"

Lets hear what your airway strategy is. (btw, i know the algorithm, but I'm curious to see how you folks deviate from the cookbook).

Was she ventilatable?

 

[fval28]

very short, thick neck, MP4, and almost looked like she had microagnathia= Awake fiberoptic intubation in my book, why mess around and besides awake FOI's are fun!

 

[Planktonmd]

62 CF Hx DM2, HTN, CAD, small MI (s wall motion abn 10 yrs ago) is getting a lap supracerv hysterectomy yesterday, and has a very short, thick neck, MP4, and almost looked like she had microagnathia. I ask her if she was ever told on previous surgeries if she has a difficult airway, she says no. We induce w/prop, sux, and take a look w/a MIL3. I have to mention that I've started using the miller for the last 2 days in order to get a good feel for it. Anyhow, I get in there and see nothing... posterior pharynx. I get some cric pressure, the epiglottis slips off the blade, and I repos'n s success. I try again, fail, and the attending decides to take a look. He has similar difficulties, and despite plenty of cric pressure, perfect pos'n, experienced operator etc... we still have some difficulty finally getting a smidgen of the very bottom mm of airway and he "guesses" the tube into place (which happened to be right). So I ask him, "was that inexperience, or did she really have a tough one, and if we could start over, would you do an awake f/o?"

Lets hear what your airway strategy is. (btw, i know the algorithm, but I'm curious to see how you folks deviate from the cookbook).

Propofol + Sux no Narcotics and no Midazolam, take a look with your favorite blade if not able to intubate try ventilating with oral airaway, If you can ventilate then you have time and you can do asleep fiberoptic or use a glidescope or whatever you like.
If you can not ventilate with oral airway place fastrach and intubate through it.

 

[Mman]

If the decision was made to induce I'd take a look or two with my favorite blade and see what was there. If nothing visible, I'd probably want to have a fasttrack LMA or shikani or c-track or whatever your favorite difficult airway device is handy and take a shot with that.

This is all assuming she is ventilatable so I've got time.


From your description of MP4 + short, fat neck + small mouth opening (and i'm guessing a full set of teeth?) I would give serious consideration to awake fiberoptic.

 

[lvspro]

Yes... she was ventilatable, and I didn't even need an airway.

 

[Mman]

Yes... she was ventilatable, and I didn't even need an airway.

Then you've got plenty of time to get your favorite airway toy ready to go if you can't get a view with a DL. Heck, if nothing was working you could just do an asleep fiberoptic.

 

[InGasWeTrust]

I would have done exactly as you did.

Only difference is I always have an AirQ LMA within arms reach(...not the old school fasttrachs). These things are money in the bank. If you have not used one I urge you to use it, they seat very well and you can intubate blindly with them, though we always have the bronchoscope.

 

[johankriek]

when you get into a situation like that grab a eschmanns stylet and use that.. almost always will get you out of trouble..

i prolly would have done an awake fiberoptic.. why chance it?

 

[Jeff05]

you have no way of knowing for sure if you are able to ventilate this patient while paralyzed until she is paralyzed. you are suspecting a difficult airway.

putting a pt like this to sleep/paralyzing her coupled with a negative airway related outcome would be undefendable in court.

the safest technique in this case is an awake fiberoptic intubation.

 

[Planktonmd]

You can never be wrong with awake fiberoptic, but over the years I found that the number of patients that I really feel need that has shrunk dramatically.

 

[VentdependenT]

I would have done exactly as you did.

Only difference is I always have an AirQ LMA within arms reach(...not the old school fasttrachs). These things are money in the bank. If you have not used one I urge you to use it, they seat very well and you can intubate blindly with them, though we always have the bronchoscope.

Whats an AirQ LMA?

 

[Beck928]

when you get into a situation like that grab a eschmanns stylet and use that.. almost always will get you out of trouble..

i prolly would have done an awake fiberoptic.. why chance it?

I LOVE the bougie! Has already saved my ass a time or two.

 

[Fastrach]

Whats an AirQ LMA?

This was a new one on me too. Here's what I found:

http://www.metropolitanmedical.com/prod/NewairDis_11.htm

 

[VentdependenT]

This thing is pretty bad-arse too. We use em every once in a while.

http://www.remotemedical.com/King-L...eadsource=C3&gclid=CMDAkKy0j44CFQwsOAodjF3SDw

 

[Beck928]

Check out this puppy:
http://www.lmana.com/mcgrath.php

I got to try it when our department had this thing on loan from one of the reps, was freakin' sweet. Only thing is it costs around $8000 and someone could easily pocket it. Would be awesome for difficult airways, but you could get lazy if you used it all the time!

 

[Fah-Q]

and despite plenty of cric pressure, perfect pos'n, experienced operator etc... we still have some difficulty finally getting a smidgen of the very bottom mm of airway and he "guesses" the tube into place (which happened to be right).

What do you mean by perfect positioning? Did you try the sniff position? If you looked and saw posterior pharynx then I would suggest placing quite a few blankets under head to create an exaggerated sniffing position. This displaces the larynx posterior relative to the base of tongue and oropharynx.

My first look would have been sniff with a straight blade. No dice...bust out the glidescope.