Orotracheal Intubation Challenges in an Anticipated Difficult Mask Ventilation, Preoxygenation, Tricky Laryngoscopy,...

With the advancement of technology, equipment, and airway management knowledge, anticipated difficult airway (DA) management has come a long way towards excellence. Usually, anticipated difficulties are related to bag-mask ventilation (BMV), laryngoscopy, intubation, or supraglottic airway placement; all in a single patient pose exceptionally challenging airway management. We may electively plan a surgical airway, but the option may not be available, especially when the patient provides tracheostomy permission only for emergency airway management, not for an elective. A 48-year-old male patient with a probable diagnosis of midline lethal granuloma presented with right-side nasal blockade, deformity, and near-total blockade of the left nasal cavity with right-sided mid-facial swelling, pain, and foul-smelling discharge and an ulcerated hard palate and was scheduled for an endoscopic biopsy. The airway examination predicted difficult bag-mask ventilation, pre-intubation oxygenation, risky laryngoscopy, and supraglottic airway insertion. Even airway topicalization, sedation, and preparation for awake intubation were challenging. Resource limitations and unexpected desaturation while attempting awake intubation led to an emergent situation; i-gel came as a rescue, and ultimately, the definitive airway was secured using a 6.5 mm cuffed endotracheal tube (ETT), railroaded over a fibreoptic bronchoscope (FOB), and inserted through i-gel. We present the case to highlight the challenges and discuss the possible remedies where our technique can be an alternative for cases with difficult mask ventilation, intubation, and supraglottic airway insertion.