Airway & Respiratory, Cardiac & Resuscitation, Patient Care

Complex Airway Case Puts Providers’ Skills to the Test

Issue 12 and Volume 36.

American Medical Response and Clark County (Nev.) Fire Department are summoned to assist a 46-year-old male with difficulty breathing. The patient is located in an apartment just west of the famous Las Vegas Strip. Little additional information is available to arriving crews. The apartment complex is well known to rescuers because of its disrepair and reputation for crime.

Prehospital Care
Paramedics arrive to find the patient extremely short of breath and seated in an overstuffed chair. He is morbidly obese with body weight in excess of 350 pounds. The patient is barely 5 feet tall. The only history available is that he’s had difficulty breathing for the past three days. He is alert and oriented.

Paramedics complete the primary survey and find that the patient has stridor and is speaking in short sentences. They immediately place a non-rebreather mask and administer supplemental oxygen. Their secondary assessment reveals the patient to be in significant distress. Upper airway stridor is clearly present, and auscultation of the chest reveals bilateral wheezes and rhonchi. The abdomen is obese and soft.

The extremities exhibit 2+ edema, and the patient’s pulses are diminished throughout. The patient is alert but sluggish in response to questioning. No family members are present. His blood pressure is 88/50 mmHg; his pulse is 110, and his respirations are 30. His pulse oximetry (SpO2 ) is 89% on a non-rebreather mask. An ECG reveals a sinus tachycardia. End-tidal carbon dioxide is 44 mmHg.

A quick search of the apartment turns up prescription bottles for azithromycin (antibiotic) and lisinopril (antihypertensive). The crew provides a nebulizer treatment with albuterol and then carefully moves the patient to the ambulance. It takes several minutes to move him because of his body habitus and condition, as well as steep stairs and clutter.

Once they’re in the ambulance, paramedics apply continuous positive airway pressure (CPAP). The patient improves somewhat, but won’t tolerate the mask, so CPAP is discontinued. The trip to University Medical Center (UMC) Las Vegas is brief and uneventful. However, the patient’s vital signs and general appearance do not improve with the nebulizer treatment. On hospital arrival, paramedics provide a report and release the patient to the awaiting hospital team.

Hospital Course
At UMC, the patient remains hypotensive, tachycardic and tachypnic. He is afebrile with a temperature of 96.3° F. An ECG reveals a sinus tachycardia with right-ventricular strain. All of the findings are consistent with sepsis and the hospital’s sepsis protocol is initiated.1 The patient receives standard lab tests and empiric antibiotics. A fluid bolus is administered. The patient remains alert.

The stridor detected by paramedics is now becoming louder. A soft-tissue X-ray of the neck fails to reveal any evidence of epiglottitis or tracheitis. A continuous one-hour nebulizer treatment is provided with levalbuterol. Bilevel positive airway pressure (BiPAP) is attempted after the patient receives a small dose of lorazepam for anxiety and claustrophobia.

His chest X-ray reveals massive pulmonary congestion consistent with pneumonia. To make matters worse, the patient is found to be in renal failure. However, despite these findings, the primary concern remains the worsening airway stridor and respiratory fatigue.

The patient’s mental status is also declining. Because of this, the emergency department (ED) physician decides to proceed with rapid sequence intubation (RSI) and mechanical ventilation.

Examination of the oropharynx reveals massive upper airway swelling and secretions. The airway is suctioned, and multiple food products are detected. The pre-intubation assessment reveals the airway to clearly be a Mallampati Grade IV.

The patient receives etomidate and a neuromuscular blocker. He is placed in the “ramp” position with the external auditory canal aligned horizontally with the sternal notch.2–3 Mechanical ventilation with a bag-valve mask (BVM) is started. When the laryngoscope is inserted, all that can be seen are edematous tissues and food. The airway is again suctioned, and food particles are removed with McGill forceps.

The airway tissues are friable and start to bleed. BVM ventilation is resumed, but the patient is more difficult to ventilate. His head is repositioned, and the airway is repeatedly suctioned. A second attempt to intubate is made with a video laryngoscope. However, only blood, food and edematous tissues are seen. The airway structures are virtually unrecognizable. (The glottis can’t be seen, and a gum elastic bougie can’t be passed.)

An extraglottic airway cannot be inserted because of the massive edema. BVM ventilation is resumed. One physician holds the patient’s head in the sniffing position to allow BVM ventilation while a third and fourth physician come to assist. None can visualize the glottis.

An attempt is made to perform a retrograde intubation. The cricothyroid membrane is punctured and the wire inserted. However, the wire can’t be advanced because of the upper airway obstruction. Subsequently, the retrograde attempt is converted to a cricothyrotomy, and mechanical ventilation is resumed.

Otorhinolaryngology is consulted to convert the cricothyrotomy to a tracheostomy. The patient remained unstable. His airway pressures began to increase, and he became more difficult to ventilate. Tracheal suctioning was frequently required. A repeat X-ray revealed no evidence of pneumothorax.

The patient was taken emergently to the operating room for a tracheostomy. While there, he suffered a cardiac arrest and couldn’t be resuscitated. An autopsy confirmed the diagnosis of sepsis and renal failure. The pulmonary issue and airway obstruction was due to the aspiration of food with resultant aspiration pneumonia and massive tissue edema. Retrospective quality improvement review determined that the death was non-preventable.

This was an extremely complicated and unfortunate case. The patient suffered from several serious medical problems, including obesity, that ultimately contributed to his death. There wasn’t a rush to intubate this patient because, initially, he was maintaining acceptable ventilation. However, continuous reevaluation finally determined that the patient was fatigued and would probably die without a definitive airway.

Despite the experience of all providers in this case, and access to numerous airway management tools, the only obtainable airway was a cricothyrotomy. The patient’s death was due to sepsis and aspiration pneumonia complicated by acute renal failure.

Teaching Points
At some point in your career you’ll encounter a difficult airway. Hopefully, it won’t be as difficult as the one detailed here. It is important to always assess the airway prior to airway management.4 Although this certainly occurs during the primary assessment, additional assessment must occur prior to advanced airway management.

Numerous airway scoring systems can help determine potential airway difficulty. In this case, the Mallampati scoring system was used, but there are others in existence. Any time you approach an airway management issue, you should always formulate a back-up plan.

Determine what you will do if the initial airway fails and ensure you have all the necessary equipment and assistance. Extraglottic airways are the primary backup to endotracheal intubation (ETI), and, in some cases, they are an adequate substitute for ETI.

However, in rare cases such as this one, the only alternative is a surgical airway. A difficult airway is a predictable event and generally affords the paramedic adequate time to prepare necessary equipment and assistance. The less one uses a particular skill (such as a surgical airway), the more often that skill must be reviewed and practiced. Numerous airway management courses are available, all of which provide an excellent foundation for advanced airway management.
Paramedics should consider taking these—especially several years out from their initial education.

Establishment and maintenance of the airway is a fundamental tenet of emergency medicine. However, there are instances where simple positioning may be ineffective. Also, there are instances for which placing an advanced airway is difficult or, as discussed here, impossible. It’s important to always have a back-up plan and to be prepared to move to it if your initial plan fails. Remember, there is no shame in asking for help. JEMS

1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377.
2. Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: A comparison of the “sniff” and “ramped” positions. Obes Surg. 2004;14(9):1171–1175.
3. Rao SL, Kunselman AR, Schuler HG, et al. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: A randomized, controlled, equivalence trial. Anesth Analg. 2008;107(6):1912–1918.
4. Loder WA. Airway management in the obese patient. Crit Care Clin. 2010;26(4):641–646.

This article originally appeared in December 2011 JEMS as “Any Port in a Storm: Complex Airway Case Puts Providers’ Skills to the Test.”