Unanticipated

For me, the most useful predictor of whether someone will be a difficult intubation is whether he was a difficult intubation in the past. If I trust the proceduralist (or if I had previously intubated the patient), then I usually assume the airway has not changed significantly and the past experience will be replicated. Recently, however, I found that this is not always the case.

I am called to intubate a patient in the emergency department with altered mental status of unclear etiology. He is completely obtunded and unarousable. Because he cannot protect his airway - that is, he is at risk for aspirating and choking - we place a breathing tube. This is easy and there are no problems. Five hours later, I am called to the intensive care unit for a stat airway, and I am surprised to see it's the same patient. He awoke and began to undergo alcohol withdrawal. Confused and violent, he pulled out his endotracheal tube with the balloon still inflated. He was hoarse and the ICU team wanted to sedate him and secure the airway again. This time, when I looked, everything was swollen. His vocal cords were large and edematous, his airway was angry and inflamed. I couldn't intubate him with a regular laryngoscope like I did several hours ago, and eventually had to call for a video laryngoscope to aid me.

Similarly, airways change in the operating room. For many of our thoracic surgery patients, we start by placing a single lumen endotracheal tube which facilitates bronchoscopy. When the surgeons begin the thoracic portion of the surgery, however, they want the single lumen tube changed to a double lumen endotracheal tube. Even if placing the single tube initially was easy, sometimes I find it much more difficult to get a good view and place a stiff, large double lumen endotracheal tube. These experiences remind me to approach each intubation with caution, even if I expect things to go smoothly and easily.