Airway management
This content has been generated for SALG by Dr Sandeep Sudan on behalf of the Difficult Airway Society
A patient of short stature, with a history of vocal cord palsy (with no shortness of breath or stridor), was scheduled for a renal transplant.. On laryngoscopy, the vocal cords were adducted. Two unsuccessful attempts were made to intubate the trachea using a size 6 tube. A third attempt using a size 5 tube was also unsuccessful. The patient became impossible to ventilate or oxygenate and began to desaturate. Attempts to gain front-of-neck access were also unsuccessful. Eventually, oral intubation using a size 6 tube was achieved. A tracheostomy was performed by ENT, and the transplant procedure was abandoned.
Commentary:
A history of known vocal cord palsy (VCP) should be regarded as a red flag for airway management. A difficult airway should be anticipated and there should be a multidisciplinary plan (including ENT) for airway management. When the case is elective there should almost always be sufficient time for this planning to occur.
Preoperative considerations
The airway history should include:
- Whether the palsy is unilateral or bilateral
- The underlying cause
- The degree of airway narrowing
- Associated symptoms
Fibreoptic nasendoscopy (FNE), to provide ‘awake airway visualisation’, should be performed preoperatively – either an ENT clinic or an anaesthetic airway clinic. Early review and planning allows for discussion around airway risks and the possible need for tracheostomy.
Intraoperative management
ENT colleagues should be present.
High-flow nasal oxygen (HFNO) should be considered for per-oxygenation. The equipment for front-of-neck access (eFONA) must be immediately available. The cricothyroid membrane (CTM) should be assessed, the incision technique and who the operator will be should be decided beforehand.
Ultrasound is recommended if the CTM is not palpable and can be used to assess vocal cord movement.
Awake techniques should be considered, including awake tracheal intubation or a surgical tracheostomy performed in theatre.
In this case, repeated attempts at intubation suggest obstruction at the level of the vocal cords. Smaller tubes were used, but it is unclear whether videolaryngoscopy (VL) was attempted. VL should be used as first-line whenever available, in line with DAS 2025 guidelines. In this situation the issue is with passing the tube (more so than obtaining the view). VL should provide a more enhanced/magnified view of the larynx and also allow for more than one person to visualise what the issue with intubation is. Both are useful when difficulty is expected.
If one airway strategy fails there should be no delay in moving on to the next. Formal conversion to a surgical tracheostomy should be undertaken by ENT.
Postoperative care
Postoperative management should be in HDU/ICU, or on a specialist ward depending on local practice. Extubation will be high-risk, requiring careful planning and monitoring for airway obstruction.
Finally, it is important to acknowledge the considerable psychological impact associated with any eFONA event. Teams involved should be offered appropriate support.
References:
- Ahmad I, El‑Boghdadly K, Iliff H, Patel A, Rivett K, McNarry AF, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth 2026;136:283–307. doi: 10.1016/j.bja.2025.10.006
- Lohse R, Teoh WH, Kristensen MS. Airway ultrasound. BJA Educ 2025;25:1–9.