Anatomy of an Airway Emergency

I walk into the intensive care unit as a "swing" fellow, a put-out-fires, go-where-I'm-most-needed fellow, and immediately, I'm called for an intubation in the unit. A rather obese man was extubated an hour ago but failed. He now has stridor, airway noises that suggest a critical obstruction. He looks in extremis, having visible trouble getting enough air. His oxygenation and vital signs are starting to decline. Another ICU fellow and an anesthesia resident have been at the bedside for the last ten minutes preparing to re-intubate him. I was called as I was the most senior airway expert available; I hear the story and the plan, and I tell them to go ahead.

I recognized several red flags for potential airway difficulty, especially stridor, an emergent intubation, the out-of-OR location, the borderline vital signs, obesity, and even the fact that I just came into the hospital and didn't know the patient's comprehensive history. Nevertheless, the role of the critical care anesthesiologist in this situation is to stabilize the patient. I pre-assigned tasks, putting myself in charge of managing the vital signs and plane of anesthesia. I put the other fellow and the anesthesia resident at the head of the bed.

Each of them took a look with direct laryngoscopy but couldn't get an adequate view. We went to our planned back-up plan, a video laryngoscope, with which we could obtain a suboptimal view of the vocal cords but simply could not get the endotracheal tube to pass. I then decided I needed to take over the airway and handed over the management of medications and vital signs to one of my colleagues.

Following the American Society of Anesthesiologists difficult airway algorithm, I planned for the next few steps. Even though I wanted to look with a laryngoscope myself, I knew that my role at this time was to follow my pre-determined back-up plans and call for more help and the difficult airway cart. I placed a laryngeal mask airway, something seldom done outside the operating room, but with my background, something I felt incredibly comfortable with. This freed up hands, and more importantly, allowed me to continue oxygenating and ventilating the patient during my intubation attempts. Thus, the vital signs during this half hour saga remained extremely stable. With a flexible fiberoptic bronchsocope, I saw significant edema and swelling around the airway, so much that even identifying the vocal cords was a real challenge.

Ultimately, I got the trauma surgeon to come and do a bedside tracheostomy. I couldn't get the tube through the glottic opening, and in fact, the patient had been evaluated for tracheostomy the previous day. With his neck circumference, even that was a real challenge, but the surgeon managed to access the airway. We brought the patient to the operating room to stabilize it. Despite this ordeal, the patient had no additional injuries and left the hospital a week later.

In an airway emergency, the role of the most senior airway expert is to lead a team, continually evaluate the situation, plan for the next several steps, and obtain other consultations as necessary to keep the patient safe. I tried hard not to get telescoped into tasks, and when I did, I assigned roles to make sure all aspects of care were addressed.

Image is in the public domain, from Wikipedia.