RT Book, Section
A1 Foley, Lorraine J.
A1 Murphy, Michael F.
A1 Hung, Orlando R.
A2 Hung, Orlando
A2 Murphy, Michael F.
SR Print(0)
ID 55873953
T1 Chapter 60. Documentation of Difficulty and Failure in Airway Management
T2 Management of the Difficult and Failed Airway, 2e
YR 2012
FD 2012
PB The McGraw-Hill Companies
PP New York, NY
SN 978-0-07-162344-5
LK accessanesthesiology.mhmedical.com/content.aspx?aid=55873953
RD 2024/04/16
AB A  39-year-old  woman  is  scheduled  for  a  laparoscopic  cholecystectomy  under  general  anesthesia.  She  is  5  ft  4  in  (161  cm),  220  lb  (100  kg),  with  a  BMI  38.6  kg·m−2.  She  denies  reflux.  On  physical  examination,  she  has  a  Mallampati  Class  II  airway,  has  4  cm  mouth  opening,  and  a  good  neck  extension.  On  the  3-3-2  examination  she  is  just  less  than  3  on  mouth,  just  less  than  3  from  mandibular  to  hyoid,  and  2  on  hyoid  to  thyroid  notch.  She  has  no  past  surgical  history  except  for  a  cesarean  section  under  epidural.  The  patient  is  placed  on  standard  monitors.  Following  denitrogenation  and  induction  of  anesthesia  with  200  mg  of  propofol,  it  is  determined  that  she  can  easily  be  ventilated  by  a  bag-mask.  Rocuronium  (40  mg)  is  administered  for  muscle  relaxation.  Direct  laryngoscopy  is  attempted  with  #3  Macintosh  blade.  Only  a  large  epiglottis  is  seen  without  any  change  following  the  application  of  laryngeal  pressure.  A  #3  Miller  blade  is  then  used  to  lift  the  epiglottis.  But,  still  no  vocal  cords  are  seen.  An  Eschmann  Tracheal  Introducer  (bougie)  is  attempted,  but  passes  repeatedly  into  the  esophagus.  Bag-mask-ventilation  (BMV)  remains  adequate.  Help  and  the  difficult  airway  cart  are  summoned.  A  #3  Intubating  Laryngeal  Mask  Airway  (ILMA)  is  placed,  resulting  in  adequate  ventilation.  An  attempt  at  blind  intubation  through  the  ILMA  is  unsuccessful.  So,  a  7.0-mm  ID  endotracheal  tube  (ETT)  is  loaded  onto  the  FAST  (Foley  fiberoptic  airway  stylet,  Clarus  Medical  LLC,  Minneapolis,  MN)  and  placed  through  the  ILMA.  The  ILMA  is  manipulated  till  vocal  cords  are  visualized  and  the  ETT  is  placed  into  trachea  without  difficulty.