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A 57-year-old male was admitted for laparoscopic appendectomy for acute appendicitis. He was otherwise healthy, apart from essential hypertension, for which he took hydrochlorothiazide. He had fasted for more than 12 hours.

On examination, he was lying on a stretcher in a moderate amount of pain. He was hemodynamically stable. His height was 183 cm and his weight was 80 kg, with a BMI 23.9 kg·m−2. His airway examination demonstrated a Mallampati score of II, mouth opening of 4.5 cm, thyromental distance of 6 cm, and good jaw protrusion. He had a full set of teeth, was not obese, and was estimated to be easy to ventilate. His cardiac and respiratory examinations were normal.

The patient was premedicated with intravenous midazolam 1 mg, fentanyl 200 µg, and this was followed by denitrogenation with 100% oxygen by face mask. As he did not have any indicators of a difficult airway, a decision was made to induce anesthesia with propofol 200 mg and rocuronium 50 mg. Face-mask ventilation (FMV) was established with an oral airway. Initial evaluation with direct laryngoscopy (DL), using a Macintosh laryngoscope, showed a Cormack-Lehane (C/L) grade 3 view. The first attempt with DL and an Eschmann Tracheal Introducer (ETI) resulted in an esophageal intubation. FMV was re-established and a GlideScope® was prepared. When the GlideScope was inserted, only the posterior arytenoids could be visualized, and two attempts with an endotracheal tube (ETT) stylet and a tracheal tube introducer were unsuccessful (and were associated with a small amount of bleeding in the oropharynx).

At this point, the decision was made to attempt flexible bronchoscopy (FB). Unfortunately, FMV became more difficult, the patient’s oxygen saturation dropped into the low 80s, and it became necessary to insert nasal and oral pharyngeal airways and begin a two-hand and two-person FMV technique. A #4 Laryngeal Mask Airway® (LMA®-Classic™) was rapidly prepared and inserted without complication, at which point it became possible to easily ventilate the patient. Sevoflurane was selected to maintain anesthesia, and to manage escalating tachycardia and hypertension. A pediatric bronchoscope with an ensleeved Aintree Intubation Catheter (AIC, Cook Medical Inc, Bloomington, IN) was then inserted through the LMA-Classic into the trachea. Both the bronchoscope and the LMA-Classic were then removed leaving the AIC in the trachea. An ETT was advanced into the trachea over the AIC. Correct tracheal placement was confirmed by auscultation and capnograph recording.

The surgery was uneventful, and the patient emerged from anesthesia fully awake, warm, with adequate analgesia, and with no residual neuromuscular blockade. The difficult airway cart was brought to the room. Tracheal extubation was uneventful, although he did complain of a sore throat in the postanesthetic care unit, which gradually improved. He was later informed of the difficulty and provided with a notice to inform any subsequent anesthesia practitioner of his difficult airway.


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