CASE PRESENTATION
A 49-year-old woman (144 cm; 60 kg) experienced spontaneous, upper leg pain. She was bedridden with gradually worsening of dyspnea and finally called an ambulance.
In early childhood the patient was diagnosed with severe juvenile idiopathic arthritis. She had undergone multiple previous surgeries all of which were performed with ATI-FB. At one occasion, after securing the airway, inducing unconsciousness and neuromuscular relaxation, attempts at introducing a HA-VL (McGrath-MAC X-BladeTM, Medtronic, MN, USA) were unsuccessful due to severely limited mouth opening.
In the emergency department the patient was diagnosed with a femoral fracture and pneumonia (Fig. 1). She deteriorated and was transferred to the intensive care unit. The respiratory rate was 40 breaths/min, peripheral oxygen saturation was 88-95% (with 5 L/min oxygen delivered via nasal cannula), heart rate was 120 beats/min, and blood pressure was 130/70 mmHg. Intermittently, the patient could still follow commands (such as squeezing a hand), but no longer opened her eyes or responded verbally. After Non-invasive Ventilation (NIV) on maximal settings, her arterial gas showed pO2 at 8.2 kPa, pCO2 at 12.8 kPa, pH at 7.30, lactate at 0.6 mmol/L, and base excess at 13.1 mmol/L. Airway examination revealed a mouth opening of 13 mm, severely limited neck movement (< 80º), severe retrognathia, and a short neck that was difficult to palpate (Fig. 1).
The patient was positioned upright sitting and preoxygenated with NIV, followed by high-flow nasal oxygen (HFNO) for the intubation itself. Glycopyrrolate 0.2 mg (Meda, Solna, Sweden) was administered slowly intravenously. The cricothyroid membrane was identified and marked. Sedation was achieved with midazolam 0.25 mg (Hameln, Hameln, Germany) and s-ketamine 5 mg (Pfizer, Ixelles, Belgium), which were both titrated slowly and administered intravenously. For the sake of speed and simplicity, lidocaine 2% with epinephrine 5µg/ml (Amgros, Copenhagen, Denmark) was used for topicalisation supplemented with spray application of lidocaine 10% (Xylocaine Pump Spray 100 mg/ml, AstraZeneca, Södertälje, Sweden). Nebulisation on the NIV machine (5 ml ×2), spray application (3 puffs ×2), transtracheal injection (2 ml ×1), infiltration superficially to the cricothyroid membrane (3 ml ×1), nasal atomising (MAD NasalTM, Teleflex, Waine, PA, USA), and direct nasal application with a local anaesthetic soaked ribbon gauze (1 ml ×2 and 5 ml ×1, respectively) were applied. Intubation was then performed with an FB (Ambu®aScope™ Regular, Ambu, Ballerup, Denmark), a Portex®Soft Seal® tracheal tube with an internal diameter of 7.0 mm (Smiths Medical, Minneapolis, MN, USA) and a size 8-cm Berman Intubating Airway (Vital Signs, Totowa, NJ, USA), which maximally compressed could just be inserted between the teeth. The flashing bright light from the IRRIS momentarily allowed identification of the relevant structures. During the procedure (see Supplemental Video S1), vital signs remained stable including peripheral saturations at 85-95%. Total time from initiation of topicalisation to successful intubation was 13 minutes, whereas the intubation itself took less than 2 minutes. Visual confirmation of tube placement, gentle cuff inflation and immediate capnography were followed by propofol infusion and initiation of mechanical ventilation.