Worst Case Scenario

An obese patient with obstructive sleep apnea presents for OSA surgery. He will have much of the soft tissues in his upper airway resected - a tonsillectomy, removal of part of his tongue, and resection of his uvula and soft palate. Hopefully, this will allow him to sleep better without obstructing and snoring as much. The anesthesia for these cases can be tricky though; because patients are often obese, their oxygen desaturates quickly and their pulmonary reserve is poor. Obesity and obstructive sleep apnea can make intubation challenging. Post-operative pain must be managed appropriately because too much sedative can lead to further obstruction and oxygen desaturation.

The case begins smoothly enough; I use a video laryngoscope, see a good view of the cords, and place a small oral tube. The patient's glottis is surprisingly deep and the tube is a little deeper than I would have expected. I secure it, but because the surgeons are working in the mouth, they request a little slack on the tape so they can move the endotracheal tube as needed. We turn the bed 180 degrees so that the head is facing the surgeons and away from the ventilator. The surgeons begin working on the tonsils.

After half an hour, I have an abrupt loss of the ability to ventilate. There is a large air leak around the endotracheal tube, and I have a strong suspicion that the tube has slipped out of the windpipe. I alert the surgeons and go take a look, and see that the tube has come out of place. This is one of the anesthesiologist's worst nightmares; I've lost the airway after the surgeons have started on a fairly bloody procedure, I'm turned away from my ventilator and supplies, and this patient will desaturate quickly and be difficult to intubate. I grab a conventional laryngoscope but can only see blood and uvula. I simply cannot see the vocal cords. I calm myself and remember to start with the basics. I am able to mask ventilate the patient; he never desaturates. Then, I optimize my positioning, give additional anesthetic and muscle relaxant, suction out the blood, and take a look with the technique that worked the first time, a fiberoptic laryngoscope. After reintubating the patient, I make sure I secured the tube tighter. The rest of the case goes just fine.