Anticipated Difficult Airway: A Nightmare When Resources Are Limited

Inability to manage a difficult airway is the cause of thirty to forty percent of all anaesthesia related deaths. A 31year old man scheduled for a debulking cheiloplasty following a vascular malformation involving the lower lip, tongue and facial skin. Examination showed a grossly enlarged lower lip and tongue. The primary anaesthetic concerns were anticipated difficult mask ventilation from poorly fitted face mask and surgical site bleeding. Therefore, our plan was to do a ’test laryngoscopy’ under general anaesthesia with spontaneous breathing, and if intubation was deemed easy then proceed with nasotracheal intubation. Conversely, if intubation was deemed difficult, we planned to allow the patient to recover. The patient was pre-oxygenated with the available poorly fitted size 5 face mask. Anaesthesia was induced with Atropine 0.6mg, sodium thiopentone 350mg and halothane at 1-2 volume percent. The patient was mask ventilated with difficulty by two operators. A ’test laryngoscopy’ was performed which showed Cormack-Lehane laryngoscopy grade 2. The laryngoscope was withdrawn, spontaneous ventilation with 100% oxygen continued, suxamethonium 100mg was given and laryngoscopy repeated after fasciculation which revealed grade 1 view with external laryngeal manipulation. A nasotracheal intubation with size 7 mm endotracheal tube was achieved and anaesthesia maintained with halothane, pancuronium and fentanyl till the end of surgery, and reversed with atropine/neostigmine combination. The patient was subsequently extubated and transferred to the ward. In difficult airway situations, where resources are inadequate, some unconventional strategies may be adopted provided the patient’s safety is not compromised.