This content has been generated for SALG by the Difficult Airway Society

A young adult was admitted for elective foramen magnum decompression. The patient had a rare congenital syndrome associated with a high likelihood of a difficult airway. Awake fibreoptic intubation with maxillofacial team support was planned. Attempts at intubation however were unsuccessful and the decision was taken to stop and send the patient to the High Dependency Unit (HDU). The following day the patient was returned to theatres where an ear nose and throat (ENT) surgeon from a tertiary centre attempted fibreoptic intubation which was also unsuccessful. The ENT team then proceeded with surgical tracheostomy under local anaesthetic.  After the procedure, sedation was allowed to wear off whilst still in theatre.  This was followed by intermittent obstruction of the tracheostomy with high airway pressures and acute desaturation on movement of the patient’s head. The patient was re-sedated and admitted to ICU. Deep sedation was required to minimise movement which was associated with intermittent obstruction and distress to the patient.  Surgery planned for two days later was cancelled due to unavailability of necessary equipment. It was then decided to allow more time for the tracheostomy tract to become established, before surgery was attempted.   Over the next 6 weeks the patient remained in ICU and suffered repeated episodes of airway obstruction requiring re-sedation. During the 7th week on ICU, despite re-positioning under direct bronchoscopy, a satisfactory airway could not be established. Granulation tissue was found to be encroaching on the airway, preventing effective ventilation. Finally, a size 5.5 reinforced endotracheal tube was inserted, and the patient was transferred to a tertiary centre for definitive airway management. Revision of the tracheostomy, microlaryngobronchoscopy and excision of granulation tissue was undertaken. Further episodes of intermittent obstruction were managed by a multidisciplinary team including critical care, maxillofacial ENT surgeons.

Commentary

The HSSIB report: ‘Advanced airway management in patients with a known complex disease’,¹ highlighted that there are no national guidelines for managing patients with an anticipated difficult airway. The Royal College of Anaesthetists are working with the Difficult Airway Society and other stakeholders to produce a framework for caring for patients who have a known or suspected difficult airway who may require advanced airway management.

The Difficult Airway Society Awake Tracheal Intubation (ATI) guide² gives useful information on how to plan for an ATI, including using a checklist, ensuring availability of ENT colleagues and planning ahead for what to do should a problem occur. 

1. Health Services Safety Investigations Body. Report: Advanced airway management in patients with a known complex disease. January, 2024
2. Ahmad, I; El-Boghdadly, K et al. Difficult airway society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia, 2020; 75: 442-6