Observations: Take a Deep Breath

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September 1, 2013 Volume 77, Number 9
Observations: Take a Deep Breath N. Martin Giesecke, M.D.

As an anesthesiologist, I consider myself an expert on management of the airway. This statement in no way contradicts the fact that there certainly are other anesthesiologists who are more adept at certain airway skills than am I. Nevertheless, in the 28 years I have been studying anesthesiology, I have seen my fair share of airway adventures.

One of the first I recall occurred when I was an anesthesiology resident in Galveston, Texas. I was called to intubate a woman in her late 50s or early 60s. The woman’s medicine team called me, stating that she was in status asthmaticus. Upon my arrival, she was sitting straight up in bed, using all her accessory muscles of respiration, and her wheezing was audible throughout the room. It was my request that we move the patient to the MICU for the procedure. The team told me the patient could not be admitted to the MICU unless she was intubated.

My first approach was a blind nasal with a BAAM whistle. The tube easily entered the trachea and the cuff was inflated. However, as soon as an ambu bag was attached, the cuff herniated out of the vocal cords. I tried once again to pass the tube blindly with the whistle. Again, the trachea was easily intubated, but the same thing occurred when the ambu bag was connected. By now, the patient was obtunded, so I flattened the bed and looked with a laryngoscope. After deflating the cuff, I easily passed the tube into the glottis. A third time at connecting the ambu bag resulted in herniation of the cuff above the vocal cords.

Three strikes had called out my attempts at nasal intubation. Under direct vision with the laryngoscope, I removed the nasal tube and placed an oral endotracheal tube. There was a bit of resistance as I advanced the tube below the vocal cords, but not so much that it concerned me at the time. And this time, as soon as the ambu bag was connected, the patient’s abdomen began to enlarge. The medicine team accused me of intubating the esophagus, but repeat laryngoscopy revealed the tube going between the vocal cords and into the glottis.

Sadly, this woman went into cardiac arrest and the medicine team stopped resuscitation efforts after only a short period of time. I was quite shaken by this outcome, as it was a first for me (not the death, per se, but rather the death after an intubation attempt).

The autopsy revealed that the woman had a tracheal stenosis below the vocal cords. At the stenosis, the trachea was only four millimeters in internal diameter. The first three times I had gently placed the endotracheal tube via the nasal approach, it had stopped at that stricture. However, inflation of the cuff had caused the cuff to herniate above the vocal cords, thus leading to an airway leak. The time I intubated orally, I felt a bit of resistance. The autopsy showed that that resistance had fractured the trachea. Oxygen then traveled through the mediastinum and through the crux of the diaphragm, where it entered the abdomen as free gas. Had I known about her tracheal stenosis, I would have insisted on a different approach, perhaps a controlled tracheostomy. Such is the wisdom of hindsight.

A second patient incident that took place shortly after I entered my first private practice underscores a process failure that has been shown by the ASA’s Closed Claims Project to lead to permanent injury (brain damage, death).1 This process failure is the continued use of an unsuccessful technique, over and over, until the airway is lost, ventilation becomes impossible and the patient arrests from hypoxia. My patient was a woman in her mid-30s. She had presented to an outside hospital for an elective cholecystectomy via the upper-abdominal incision common to pre-laparoscopic procedures. The patient never had her cholecystectomy because the anesthesia caregiver was never able to place an endotracheal tube. This was despite 45 minutes using the same two laryngoscope blades.

The patient was awakened and discharged from the hospital. However, five days later she presented to my hospital’s emergency room with a massive, fluctuant parapharyngeal abscess. The otolaryngologist on duty called me in to do the case. There was no way I was going to attempt this intubation except by using the fiberoptic bronchoscope. However, the situation was complicated by the giant abscess. No superior laryngeal nerve blocks could be given, nor could a transtracheal block be placed. And the abscess extended from the angle of the chin to the sternum, so there was no way the surgeon would consider a tracheostomy – there was just too much purulent material in between the skin and the trachea. In addition, she too was sitting straight up to breath, and she was unable to swallow her secretions. This latter issue precluded my use of nebulized lidocaine, as I did not want to anesthetize her reflexes and have her aspirate those oral secretions.

So I anesthetized her nose and used the nasal approach. My view through the fiberoptic scope was impressive. The entire pharynx was filled with erythematous, edematous tissue. The only time I saw anything was when the patient exhaled. Then, there was a small, inverted black triangle at the base of all this edema. No normal anatomy was seen. I never did see her epiglottis. My plan was to move the bronchoscope as close to this opening that occurred during exhalation, inject a bit of lidocaine through the suction port, and hopefully continue advancing the scope until I could see tracheal rings.

It took me 45 to intubate the woman in this manner. I lost about three kilos from sweating, but this time the patient was saved. The surgery proceeded without incident. I kept the patient intubated and on mechanical ventilation for about eight days postop until there was a resolution of her inflammation and edema. On that day, she finally had a leak around the deflated cuff of the endotracheal tube. She was extubated without incident.

As anesthesiologists, we have continued to evolve our techniques to provide better, multiple options at airway instrumentation. When I trained, we had the typical laryngoscope blades (Millers, Macintoshes, Sikers and Wis-Hipples) as well as blades with an optical prism and laryngoscopic attachments that allowed a different blade angle than the typical 90 degrees. Lighted stylets and Bullard laryngoscopes were just appearing. And though we have several different video laryngoscopes from which to choose, the go-to scope for the difficult airway remains now, as it was when I trained, the fiberoptic bronchoscope.

Enjoy the articles on airway management in this issue of the NEWSLETTER. There is always something new for us to learn – another understanding of airway patho-physiology, another trick or technique to add to our armamentarium.


1.Miller CG. Management of the difficult intubation in closed malpractice claims. ASA Newsl. 2000;64(6):13-16, 19.