Difficult Airway in the ICU

I've had my share of difficult airways in residency, but the difference now is that I ought to be fully independent with airway management. Of course there is an ICU attending, but that attending isn't always an anesthesiologist, and in those circumstances, I am the go-to airway person in the ICU.

The Palo Alto VA has a pretty amazing spinal cord unit; we have patients transferred from all over to get our expertise in management of spinal injuries. A middle-aged vet with a longstanding cervical spine injury and fusion has subacute respiratory failure. His mouth opening is poor and his large face and prominent beard would make mask delivery of oxygen challenging. After talking it over with the patient and his sister, we decide to intubate him to get him through his pneumonia. How do I proceed?

Normally, I would come up with a plan and then discuss it with my anesthesia attending, but here, I had the role of "airway." Most of my co-residents who are now attendings talk about becoming a little more conservative now that they are on their own. I did the same. With the difficult airway cart in place, I decided to induce anesthesia, put in a laryngeal mask airway, and ventilate through the airway. After I knew I could deliver oxygen, I proceeded to use a fiberoptic bronchoscope, visualize the vocal cords and windpipe, put a catheter there, and then use the catheter as a guide to place an endotracheal tube. I was sweating a little bit, but it went easily, and his lowest oxygen saturation was 99%.

A week later, we tried to extubate him, but unfortunately, he failed to maintain his airway on his own. I had to put the breathing tube back in. This time, though, I had a resident. I knew what worked for me last time and I was confident I could reintubate him if necessary, so I asked the resident what she wanted to do to put the breathing tube in. She decided to go with a throwback to the 1990s with a Patil-Syracuse mask. I had only used this once or twice, but I trusted her judgment. The seldom-used Patil mask is designed to allow delivery of positive pressure ventilation while the anesthesiologists secure the airway with a fiberoptic scope. We used it with our BIPAP machine and ensured that it had adequate oxygen delivery and ventilation prior to putting the patient to sleep. Since we could continuously breathe for the patient while guiding the flexible camera into the windpipe, we had all the time we needed. The anesthesia resident, one of the best ones I've ever worked with, did everything independently. This taught me a lot as an attending, to trust my resident's skills, to appreciate judgement decisions, and to have confidence that I could rescue the patient if things went wrong. Now that I'm an ICU fellow, I don't intubate all that much, but occasions like these are ever so exciting.