Unexpected difficult airway in a remote setting
You are the anaesthetist on call for a small district hospital. At 02:00 you are asked to anaesthetise a 68-year-old man (weight 120 kg, neck circumference large, beard, limited mouth opening, Mallampati 3, previous radiotherapy to the neck) for incision and drainage of a deep neck abscess with impending airway compromise. He is stridulous at rest, drooling, and has a voice change. He is sitting upright and refuses to lie flat. The hospital has one anaesthetic machine, a video laryngoscope, a fibreoptic scope, a size 5 and 6 ProSeal laryngeal mask, and no intensive care unit. The nearest tertiary centre is 2 hours by road; retrieval is available but will take at least 3 hours. The surgeon says he can do it 'quickly under a mask'.
1. Set out your airway strategy and justify why you would or would not proceed in this hospital.
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This is a predicted difficult airway with actual airway compromise: stridor at rest, drooling, voice change and inability to lie flat indicate a compromised, possibly narrowing upper airway. Forcing a supine position or inducing anaesthesia risks complete obstruction and a cannot-intubate cannot-oxygenate scenario in a hospital without ICU or surgical airway backup on site. The surgeon's suggestion of mask anaesthesia is unsafe: positive pressure in an obstructed airway can worsen oedema, and the patient cannot lie flat. My preferred strategy is to secure the airway awake, with the patient sitting, using topical anaesthesia and a flexible scope, with a tracheostomy set and an experienced surgeon scrubbed and ready for emergency front-of-neck access; the surgeon should be prepared to perform a tracheostomy under local anaesthesia if the airway deteriorates. I would not proceed with an inhalational or intravenous induction and paralysis in this setting. Given the absence of ICU and the complexity, I would strongly consider transfer to the tertiary centre after initial stabilisation, or at minimum call in the on-call ENT consultant and a second anaesthetist and discuss with the retrieval service. If transfer is not possible and the airway is deteriorating, awake fibreoptic intubation with surgical backup is the least bad option, with a clear plan for front-of-neck access if it fails. Document the discussion and the risks with the patient.
2. If awake fibreoptic intubation fails and the patient becomes hypoxic, outline your emergency sequence.
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Declare the emergency and call for help, including the surgeon for front-of-neck access. Maintain oxygenation: keep the patient sitting if possible, apply high-flow nasal oxygen, and attempt gentle bag-mask ventilation with an oropharyngeal airway and two-person technique; if ventilation is possible, keep the patient spontaneously breathing and consider a laryngeal mask while maintaining anaesthesia. If the airway is obstructed and ventilation is not possible, the priority is an emergency surgical airway: the surgeon performs a scalpel-bougie-tube cricothyroidotomy or tracheostomy, and I would continue oxygen delivery via the upper airway or the surgical airway. If intubation is possible but ventilation is not, consider a laryngeal mask and, if that fails, proceed to front-of-neck access. Throughout, avoid repeated traumatic attempts that worsen oedema and bleeding, limit each attempt, and keep the patient oxygenated. Once the airway is secured, proceed with surgery, then arrange transfer to a tertiary ICU for postoperative care, since this hospital has no ICU and the patient will need monitoring for airway oedema and sepsis. Debrief the team and complete an incident report.