“By The Way, Doc, I’m a Difficult Intubation.”

I’d like to to tell you about a recent experience I had taking care of a patient. I won’t get into specifics about the patient, the surgery, or where this took place as I do not want to violate any privacy laws.

But I do want to draw attention to a little known (in the public sphere), but extremely important, topic in anesthesia.

And that is the topic of the difficult airway or difficult intubation.

As I introduced myself to this patient prior to the surgery and began inquiring about his medical history, nothing seemed “out of the ordinary”. From the medical chart and my interview with him, there were a few, minor medical issues that came up. Nothing “big”.

Then, near the conclusion of my consultation, almost as an after-thought, the patient’s wife said:

“Oh yeah. The anesthesiologist that took care of him last time said he was a difficult intubation.”

Now that is “big”.

I can’t stress how important this information is, not only to the anesthesiologist, but to YOU, the prospective patient.

So I went back and asked more details about what happened the last time.

I got a hold of one of my partners, another anesthesiologist, let him know about the patient and asked him to give me a hand putting this patient to sleep. I also went and placed our difficult airway equipment in the operating room.

From my talk with the patient and his spouse, and my airway physical examination, I was able to deduce that although this patient was a difficult intubation in the past, he was NOT difficult to ventilate (exchanging oxygen and carbon dioxide via a face mask once the patient is “asleep”).

Once I put the patient to sleep, I was easily able to ventilate him. This is an important thing; if a patient can be ventilated, you can keep them alive by “breathing for them”.

Intubation (placing a breathing tube through the windpipe), however, was indeed challenging.

Using a regular laryngoscope blade that is normally used, I could not see the proper anatomy to intubate this patient. But because I was ready for this, I was able to quickly switch to another technique.

I ended up intubating this patient using a video laryngoscope, called a Glidescope. This laryngoscope has a camera at the end of it that allows anesthesiologists to see the airway anatomy better in these types of situations.

In the image below, the view on the screen is that of the vocal cords (through which the breathing tube must be placed), facilitated by the camera at the end of the laryngoscope.

Even using such a tool, placing the breathing tube was not easy. This patient’s airway anatomy was such that this was just more challenging. But I got it placed properly and the rest of the case went smoothly as well.

And I was ready for any challenges that might arise because I was given this crucial piece of information.

I had difficult airway equipment immediately available. And I had another airway expert right there to give me hand, should I need it.

When the procedure was over, I let the patient and his spouse know about the difficulty I had encountered intubating him.

I also wrote a special note for him to take home that detailed exactly what I did, where the difficulty was encountered, and what I used to be able to intubate him and secure his airway.

I let him and his wife know how important it was that anytime he needed anesthesia in the future, he needed to provide this information to his anesthesiologist. And now he had a note to give to his future anesthesiologist that explained everything in “doctor speak”.

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If you are a patient that has been told you are a difficult airway, or a difficult intubation, I can not stress how important it is to tell your anesthesiologist about this.

We over-use the term “life and death”, but this truly is one of those situations where it can be an issue of life and death.

By knowing this information and passing it along to your anesthesiologist, you give him/her the chance to have extra equipment ready and available in your operating room.

And depending on the individual circumstance, it may be safest to perform what is called an “awake intubation”. This may be the topic of another post if there’s interest from our readers, but in certain situations your anesthesiologist may have to place the breathing tube while you are still awake and breathing on your own.

As you might imagine, this can be somewhat uncomfortable for patients. And that’s why it’s important to understand that if your anesthesiologist is recommending this approach, it is because they have your safety in mind.

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I’d love to hear your questions about this important topic in our forum.

And if you know you have a “difficult airway”, please share your experiences with our community.  Thanks for stopping by anesthesiamyths.com!