[Airway obstruction during attempts at fiberoptic intubation in an awake patient]

A 67-year-old woman with rheumatoid arthritis was scheduled for lumbar anterior fusion (L5-S1). The patient had undergone several major operations on the cervical to the lumbar spine. Cervical spine movement was severely restricted, the mouth opening was limited (inter-incisor distance 3 cm), and the jaw was small (thyro-mental distance 2 cm). During previous anesthesia tracheal intubation was always difficult. Fiberoptic nasotracheal intubation while the patient was sedated was planned. After bilateral superior laryngeal nerves had been blocked using 1% lidocaine, sedation was achieved using midazolam 1.4 mg and fentanyl 0.025 mg. Fiberscopy showed an edematous larynx, due probably to rheumatoid arthritis and to a long-term steroid therapy. It was possible to insert a fiberscope into the trachea, but it was difficult to pass a reinforced tube (6.0 mmID) and the procedure led to airway obstruction with a decreased arterial hemoglobin oxygen saturation. At the second attempt at fiberoptic intubation a rapidly swollen larynx was observed and awake intubation was abandoned. Fiberoptic intubation could be perfomed after induction of general anesthesia. This case indicates that, although awake fiberoptic intubation is regarded as the safest and the most reliable method, this may also be associated with severe airway obstruction.