CHAPTER 66: Documentation of Difficult and Failed Airway Management

CASE PRESENTATION

A 39-year-old woman is booked for laparoscopic cholecystectomy. She takes no medications, has no allergies, and denies reflux. She is 5′4″ (163 cm) and 220 lb (100 kg), BMI 38.6 kg·m⁻². On airway exam, she is Mallampati Class II, has 4 cm of mouth opening, good neck extension, and a thyromental distance of 5 cm. The anesthetic record from previous orthopedic surgery is requested but does not arrive before surgery.

After denitrogenation, anesthesia is induced with fentanyl 150 µg, propofol 200 mg, and rocuronium 60 mg. One-hand face-mask ventilation produces signs of airway obstruction and no capnograph. A two-hand technique with an oropharyngeal airway achieves a low-amplitude capnograph. Subsequent direct laryngoscopy reveals epiglottis only, with no improvement from external laryngeal manipulation. A tracheal introducer (commonly called “bougie”) inserted blindly enters the esophagus so it is removed. Repeat face-mask ventilation remains difficult and the patient is becoming hypoxemic. A size 3 second-generation extraglottic device (EGD) insertion fails to produce a capnograph; a size 4 leaks but permits rescue oxygenation.

Help and the difficult airway cart are summoned. Video laryngoscopy with a hyperangulated blade reveals blood and swelling around the epiglottis. After suctioning, there is a partial view of the larynx with a head lift and external laryngeal manipulation. A bougie and size 7.0-mm internal diameter (ID) endotracheal tube (ETT) are inserted, and intubation is confirmed by the presence of end-tidal CO₂.

Surgery is routine. Extubation is smooth and the surgical recovery is uncomplicated, but the patient has a severe sore throat and hoarse voice for several weeks postoperatively. This significantly affects her work as a teacher.

INTRODUCTION

How Could Access to Documentation of Previous Airway Management Improve This?

Suppose the previous anesthetic record did arrive in time, and its airway section stated:

• Face-mask ventilation: difficult

• EGD: 2nd generation, size #4

• Laryngoscopy: grade 2 with video laryngoscope; bougie used

Would this have changed the approach to the patient’s airway management?

What about this more detailed version, which documents both process and outcome?

• Face-mask ventilation: two-handed technique, oropharyngeal airway, muscle relaxation → minimal end-tidal CO₂

• EGD: second generation, size #3 → no capnograph; second generation, size #4 → low-amplitude capnograph, audible leak

• Direct Laryngoscopy: #3 Macintosh blade → Grade 3 view despite external laryngeal manipulation; bougie into the esophagus. Video laryngoscope with hyperangulated blade → Grade 2 view; bougie inserted with external laryngeal manipulation and head lift.

Here is the same case managed with knowledge of this detailed previous anesthetic record.

A 39-year-old woman presents for laparoscopic cholecystectomy. A history of difficulty with face-mask ventilation and direct laryngoscopy is noted. The anesthetic team plan to avoid face-mask ventilation, give high-flow nasal oxygen before and during denitrogenation, tailor induction ...