Excitement

The dread terror of the difficult airway mellows out after a year of anesthesia training. An older gentleman with metastatic renal cell cancer presents for tumor debulking for palliation of symptoms. He is morbidly obese at 280 lbs while only 5'3". Along with hypertension, chronic pain, cervical spine stenosis, and gastroesophageal reflux disease, the patient has a thyroid goiter. The mass is 5cm large and compresses the trachea.

A year ago, this constellation of symptoms would strike the pit of my stomach with fear. He could be an airway disaster. If the patient goes off to sleep, his tracheal compression may get worse. The mass distorts normal anatomy and can make it difficult to pass an endotracheal tube even if the cords are visible. His cervical spine disease limits his neck extension. And his body habitus limits the oxygen reserve he has and the amount of time he can be apneic (not breathing) before his vital signs start crashing. Positioning a man this large is no small task. And his kidney disease may cause some to hesitate before giving muscle relaxants for intubation. The safest method is an awake fiberoptic intubation so that the patient is spontaneously breathing until the breathing tube is in the trachea, but this requires a lot of patient buy-in. And the patient was extremely anxious.

After discussing this case with the patient, a head and neck surgeon, an anesthesiologist who specializes in the difficult airway, and the oncology surgeon, we decided to proceed with putting the patient to sleep in a rapid fashion. After optimizing positioning, we introduced a fiberoptic laryngoscope while keeping the neck stable. Luckily the cords were immediately visible and the endotracheal tube passed smoothly. I cannot say I wasn't nervous the whole time, but I managed to stave off that dread terror I would have felt a year ago. My facility with the potentially difficult airway, my understanding of anatomy and available tools, and a year to build manual dexterity, speed, and confidence all helped. Nevertheless, I don't underestimate the potentially difficult intubation, and that's why I get consultation and input from all the available experts.