“By The Way, Doc, I’m a Difficult Intubation.”

| November 28, 2012 | 23 Comments

I’d like to to tell you about a recent experience I had taking care of a patient. I won’t get into specifics about the patient, the surgery, or where this took place as I do not want to violate any privacy laws.

But I do want to draw attention to a little known (in the public sphere), but extremely important, topic in anesthesia.

And that is the topic of the difficult airway or difficult intubation.

As I introduced myself to this patient prior to the surgery and began inquiring about his medical history, nothing seemed “out of the ordinary”. From the medical chart and my interview with him, there were a few, minor medical issues that came up. Nothing “big”.

Then, near the conclusion of my consultation, almost as an after-thought, the patient’s wife said:

“Oh yeah. The anesthesiologist that took care of him last time said he was a difficult intubation.”

Now that is “big”.

I can’t stress how important this information is, not only to the anesthesiologist, but to YOU, the prospective patient.

So I went back and asked more details about what happened the last time.

I got a hold of one of my partners, another anesthesiologist, let him know about the patient and asked him to give me a hand putting this patient to sleep. I also went and placed our difficult airway equipment in the operating room.

From my talk with the patient and his spouse, and my airway physical examination, I was able to deduce that although this patient was a difficult intubation in the past, he was NOT difficult to ventilate (exchanging oxygen and carbon dioxide via a face mask once the patient is “asleep”).

Once I put the patient to sleep, I was easily able to ventilate him. This is an important thing; if a patient can be ventilated, you can keep them alive by “breathing for them”.

Intubation (placing a breathing tube through the windpipe), however, was indeed challenging.

Using a regular laryngoscope blade that is normally used, I could not see the proper anatomy to intubate this patient. But because I was ready for this, I was able to quickly switch to another technique.

I ended up intubating this patient using a video laryngoscope, called a Glidescope. This laryngoscope has a camera at the end of it that allows anesthesiologists to see the airway anatomy better in these types of situations.

In the image below, the view on the screen is that of the vocal cords (through which the breathing tube must be placed), facilitated by the camera at the end of the laryngoscope.

Simulation of video laryngoscopy using a Glidescope

 

 

 

 

 

 

 

 

Even using such a tool, placing the breathing tube was not easy. This patient’s airway anatomy was such that this was just more challenging. But I got it placed properly and the rest of the case went smoothly as well.

And I was ready for any challenges that might arise because I was given this crucial piece of information.

I had difficult airway equipment immediately available. And I had another airway expert right there to give me hand, should I need it.

When the procedure was over, I let the patient and his spouse know about the difficulty I had encountered intubating him.

I also wrote a special note for him to take home that detailed exactly what I did, where the difficulty was encountered, and what I used to be able to intubate him and secure his airway.

I let him and his wife know how important it was that anytime he needed anesthesia in the future, he needed to provide this information to his anesthesiologist. And now he had a note to give to his future anesthesiologist that explained everything in “doctor speak”.

***

If you are a patient that has been told you are a difficult airway, or a difficult intubation, I can not stress how important it is to tell your anesthesiologist about this.

We over-use the term “life and death”, but this truly is one of those situations where it can be an issue of life and death.

By knowing this information and passing it along to your anesthesiologist, you give him/her the chance to have extra equipment ready and available in your operating room.

And depending on the individual circumstance, it may be safest to perform what is called an “awake intubation”. This may be the topic of another post if there’s interest from our readers, but in certain situations your anesthesiologist may have to place the breathing tube while you are still awake and breathing on your own.

As you might imagine, this can be somewhat uncomfortable for patients. And that’s why it’s important to understand that if your anesthesiologist is recommending this approach, it is because they have your safety in mind.

***

I’d love to hear your questions about this important topic in our forum.

And if you know you have a “difficult airway”, please share your experiences with our community.  Thanks for stopping by anesthesiamyths.com!

What General Anesthesia Side Effect have you experienced, if any?

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    Category: Anesthesia Topics, Day of surgery, General Anesthesia, The Operating Room

    Comments (23)

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    1. Wanda Snell says:

      I had surgery on my foot today and the Dr said there was trouble with the intubation. My throat was sore in 3 places. I had surgery just 6 months ago and nothing was said about there being trouble. Should I see a throat specialist to see if something has developed?

      • Wanda,

        Thanks for writing your question.

        Usually if you have been successfully intubated for a prior surgery, it means that the odds are good that it will not be difficult to intubate you the next time you have anesthesia. This is unless your surgery was on or near your head and neck or if your medical history has changed.

        If your throat was not sore after surgery six months ago and no mention was made of difficulty with intubation, there may a few details to work out. What type of surgery did you have 6 months ago? Was it foot surgery?

        Depending on the previous type of surgery, it is possible that you did not require intubation. And this may have been the reason why your throat was not sore.

        Also, one procedure may have required the use of a laryngeal mask airway (LMA) versus an endotracheal tube. Sometimes a LMA can cause a sore throat postoperatively as well.

        In any case, I would not hesitate to ask your surgeon the same question you asked here. Your surgeon will have communicated with the anesthesiologist especially if there were any troubles during the case.

        Also, I will mention that every procedure on a patient is a unique event. So even if you were easy to intubate before, anesthesiolgists are still vigilant about the possibility of a difficult intubation.

        Can you get back to us with a few more details when you get a chance? Talk to you soon.

    2. i have difficult intubation when i hed my thoirod taken out

      • David Draghinas says:

        Did your anesthesiologist give you any more information on the difficult intubation?

        Sometimes, if the thyroid is really big, it can cause problems with intubation.

    3. Louise Adair says:

      I had a breathing tube put up my nose for surgery last night as I couldn’t open my jaw very far can you tell me what this is called? Thanks

      • David Draghinas says:

        This is called a nasal intubation.

        Sometimes, a breathing tube is placed this way if the surgeon needs to work on the jaw or in the mouth.

        Can you tell us a little more about your experience? Was the tube placed after you were put to sleep?

        Dr Dave

    4. Brenda says:

      I had hernia surgery a year ago. ( I have had a few prior surgeries with very sore throats afterwards. I have a small airway, and I also have fairly large dental tori bones.)
      After my hernia surgery, I had terrible mouth pain on the bottom right side of my jaw a few days after wards. It got extremely infected and I needed penicillin to heal it.
      Since then, my dentist tells me there is scar tissue there. I feel bumps there. Recently, it started to both me again. One night, I felt something hard there, and pulled out what appears to be a small piece of white plastic.
      Could this be part of the intubation tubing? If not, what could it be? And, could I have it analyzed?

      • David Draghinas says:

        Thanks for your question. I’m sorry to hear about your sore throats.

        To get to your question, it would be very unlikely to have a piece of the breathing tube break off and lodge into your tissue.

        But I can’t give you any other suggestions as to what that might be.

        What you could consider is placing that object into a sealed plastic bag and showing it to your doctor.

        If they can’t tell you what it is by examining it, maybe they can tell you if it’s worth sending somewhere for analysis.

        Please come back and let us know what you find out.

    5. Sherrick says:

      I’ve had my tonsils removed about 7 years ago and I’ve been told I was hard to intubate twice. Is this from having my tonsils removed?

      • Sherrick,

        This is a difficult question to answer without more details. However, in general terms, if you no longer have your tonsils, this wouldnt make you more difficult to intubate (all things being equal). But there may be more to the story. Can you provide any details about the other two surgeries?

    6. liz kinnedy says:

      I recently had sucessful laparascopy surgery as a day case.I was given a letter for my doc and myself stating it was a difficult intubation and I should consider wearing a medialert bracelet. I have never had a problem with previous G.A.’s.
      I was not told what happened.I was was drowsy when I was handed letter by doc.A new experience for me, I did ask was it a congenital problem ans was told ‘no’. I am a healthcare professional, and want to know what the hell happened without having to contact a lawyer.There is no follow up visit scheduled.On the positive side I am no longer barking like a dog!

      • David Draghinas says:

        Hi Liz,

        Glad to hear everything ended up “ok”.

        What kind of information was provided in your “difficult intubation letter”? Hopefully it describes where your anesthesiologist had difficulties and what was done to remediate them.

        You can always get in touch with your anesthesiologist (often through either the hospital of the anesthesiologist’s group) so that he/she can explain to you what happened.

        Keep us updated so that we can all learn from your experiences.

        Dr Dave

        • liz kinnedy says:

          Both letters are the same.they say in layman’s terms
          ‘The anesthesiologist found it difficult to put a breathing tube in your windpipe.Although you were never in immediate danger,this letter is to make you aware of this fact because it could cause major problems for you during future surgery.
          You should inform any anesthesiologist who looks after you in the future that you were told you are a difficult intubation. You may also consider obtaining a Medical Alert bracelet, which states difficult intubation, and wearing it all the time.
          If you have any further questions,please feel to call or write to me.’
          Is seems to be a generic letter.At the time of the op all I saw of him was a disembodied hand holding a mask appearing around the side of my trolley and a voice instructing me to hold it to my face.He was standing behind my head, I could’nt see him, nor did he tell me who he was.His junior doc was facing me and put the cannula in my left hand. I do have a sense of humour, and I took the mask and leaned around to get a look at him and said “And you are??”
          Maybe he did’nt find it funny, and it took him out of the zone.I cannot see him talking to me as an equal.However I will contact him and give it a shot!

    7. Denise Z says:

      3 years ago I had a hysterectomy and when they pulled the tube out of my throat my throat got scratched. Yesterday I had my gall bladder removed, I spoke to the anesthesiologist about my past experience … I also told him I have GERD and experience issues of food particles or food getting stuck in my throat and said I had concerns that my throat may have inflammation and that it may be an issue getting the tube in or taking it out….I figured my throat woks be sore which it is and they’ve given me spray to use, but I also feel like I have something stuck on my pharynx, I first noticed it in recovery while sucking on ice chips… I mentioned it but when they looked at the back of my mouth they couldn’t find anything…when I swallow it feels like something that just won’t go down my throat and when I cough I can feel it against the top of my mouth at the back of my throat, I try to dislodge it with my tongue but it won’t budge, I’ve tried gargling but nothing helps…is it possible that there is an injury to my pharynx? Or maybe a tiny piece of tooth that is stuck there? At first it felt like the particle was stuck farther down my throat and when I coughed it seemed to move to where I’m now feeling it

    8. Patricia leale.. says:

      After general anaesthetic with tube last Monday my throat has been very painful,couldn,t eat etc,feeling ill….last night the climax came, from feeling like quinzy under tongue all week it seemed to go down into my throat.I felt it.I could then swallow more easily.but neck hurt badly and I felt so ill.sweating, upset stomach incessantly,I,d had headaches all week, felt so ill dialled 111 and was told if it got worse before I was seen to get ambulance.dr rang me within 5 mins. But I had to wait about 2 or 3 hours and I had to go to a health centre at 9.30pm.I hadn,t walked on my leg so it was very painful getting there. Very nice dr. Gave me local anaesthetic spray and antibiotics.I said this was not done in NHS hospital so why do you think this happened.she repled definately tube was yanked out.causing this.I feel dreadful today and am thinking I pay to go privately to hopefully ensure better treatment…..anything I can do? Thank you.

    9. Southsfinest says:

      I went in today to have an outpatient surgery and my health is good,labs was great; I was given anesthesia and went to sleep. I woke up in the recovery room with only my throat hurting instead my body. My doctor comes in and tells me my surgery couldn’t be performed because i couldn’t be intubated with none of the tubes they had; not even the smallest one.

      He then scheduled me another appointment to see him because he says if I still want him to do the surgery I will need to have it done in an hospital and I also need to get a medical bracelet indicating I’m hard to intibate. Now I’m just lost for words. What do you think?
      Thanks

    10. Brandi Haynes says:

      i had surgery in 2015 to remove a sebaceous cyst. From this procedure, I learned i had a “difficult or small” airway that caused it to be hard for the intubation process. My oxygen dropped down to 20% and they were moments away from having to give me a tracheotomy to keep me alive. You mentioned a letter the patient could provide for future procedures, is that something I may still be able to obtain from that doctor this far out?

      • David Draghinas says:

        Truly scary stuff, Brandi. I’m glad you are ok.

        You may still be able to get one of these letters. You could print a copy off of our site and have your anesthesiologist fill it out. Hopefully, you can still get in touch with her/him.

        If you can’t get a hold of your anesthesiologist, be sure to mention what happened (like you did in this comment) any time you need anesthesia again.

        Another option is to also buy a “medical alert” bracelet that says you’re a difficult intubation.

        Dr Dave

        • Brandi Haynes says:

          Thank you Dr. Dave. I will contact the surgeon and see if where we go from there. I’m also going to look into the medical bracelet.

    11. Dee says:

      Thank you for this information!! I had laparoscopic surgery last year, and I found by reading chart notes that there were 3 tries to entubate before the crna called in the anesthesiologist; everything went fine. Today my dentist asked if I’d ever had problems with intubation – I was surprised he would know, and he let me look in my throat. Yikes! He suggested seeing an ENT for confirmation and diagnosis, but said I was likely a Mallampati score of 3. I wasn’t sure if this was worth putting in my records, but from your article–seems like a Yes! It’s good to know that this health data should be shared and hopefully welcome knowledge for future anesthesia providers. (And I’m glad as a patient I keep copies of all records–I wouldn’t have known otherwise).

      • David Draghinas says:

        I’m glad to hear things ended up OK and that you found this information useful.

        Your Mallampati score is almost certainly on your anesthesia record (or preop record; sometimes a different sheet). Look for airway exam. Usually, you’ll find an “MP” with numbers 1-4 after it. The number circled is your mallampati score.

        Dr Dave

    12. Sarah says:

      Hi Dr. Dave,

      I was supposed to have a complete thyroidectomy due to thyroid cancer on April 18, but after 4 attempts to intubation me, they called it quits. Since obviously I was quite out of it as far as the explanations to my family (although could feel tremendous pain and could not speak), I have only the info second hand information to go by. They said my doctor was quite concerned and decided that since there was a lot of blood and he couldn’t see anything more through the scope from my nose they decided after the four tries to stop altogether since this was obviously not what they were expecting. I have been in so much pain sine, barely able to speak or eat and swallowing anything is terrible! I’ve had several surgeries before and this was never an issue. Now I’m so scared for them to try again but I have no choice, it’s cancer! Could this be because my thyroid is causing the problem? And what’s with all this blood that is scaring my surgeon?

      • David Draghinas says:

        If you’ve had a breathing tube placed before for surgery (especially if it’s been fairly recently), it could be that your thyroid is affecting your airway and making intubation more difficult now.

        It sounds like the blood that was concerning was coming from your throat/airway.

        With every intubation attempt, your airway gets a bit more traumatized (especially in a situation where there’s difficulty placing the breathing tube).

        There’s a danger, if your anesthesiologist continued attempting to intubate, that he/she could also no longer ventilate (breathe for you).

        In that situation, your life could be in jeopardy. That is likely why they chose to stop.

        When they try again, they may have to do an “awake” fiberoptic intubation to ensure your safety.

        Dr Dave

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