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Mr. R was a 68-year-old male presenting for coronary bypass graft surgery and aortic valve replacement for severe aortic stenosis, and triple vessel coronary artery disease.

His past medical history was significant for ankylosing spondylitis and kyphosis that had rendered him relatively immobile, except when walking slowly with the assistance of a four-wheel walker. Relating to his spinal disease he had a restrictive respiratory deficit on his lung function tests and baseline oxygen saturation on room air of 92%. His preoperative echo showed a reduced left ventricular ejection fraction of 30%.

His preoperative airway assessment revealed severe kyphosis, with a fixed cervical spine, unable to extend, flex, or rotate. He had full native dentition, mouth opening of 3 finger breadths, and a Mallampati score of 4.

The anesthesia practitioner decided to perform an awake flexible bronchoscopic intubation for his bypass surgery. This decision was based on the airway assessment outlined above informed by a history of awake flexible bronchoscopic intubations being performed for his previous surgeries. The intubation went smoothly, as did the operation. The patient was extubated in the intensive care unit on postoperative day 1. He was found to have suffered an acute kidney injury and had low urine output. His overall fluid balance was over 5 L positive for the preceding 24 hours. Over the course of the 2 hours postextubation, he exhibited increased work of breathing and escalating oxygen requirements. An arterial blood gas showed a mixed respiratory and metabolic acidosis, with a PaO2 of 50 mmHg on a non-rebreathing face mask at 15 L·min−1 oxygen flow. His most recent postextubation chest X-ray was consistent with pulmonary edema. A decision was made by the intensive care unit (ICU) fellow to reintubate the patient emergently.

The ICU fellow felt that the intubation needed to be performed expeditiously and decided to perform the intubation employing a hyperangulated video laryngoscope with a styleted endotracheal tube (ETT).

Oxygen was administered via a non-rebreather face mask at 100% FiO2. Two milligrams of midazolam and 100 mg of succinylcholine were administered. Oxygen saturation before the attempt at laryngoscopy was 88%. The first attempt at laryngoscopy revealed that it was difficult to insert the video laryngoscope blade into the patient’s mouth due to the handle abutting the patient’s chest. The fellow found that attempts to optimize the position in the ICU bed were difficult as they, and the other people in the room, were not familiar with this new type of bed and were unable to manipulate the bed precisely to the position they wanted.

They called for help from someone else in the ICU familiar with the new bed and asked for the on-call anesthesiologist to be paged overhead to assist. While this was happening the patient’s oxygen saturation fell to 82%, and the systolic blood pressure decreased from 130 ...

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