Unanticipated Difficult Airway Consistent With Suspected Subglottic Obstruction in an Asthmatic Patient

Unexpected difficult airway during elective surgery under general anesthesia is one of the most critical problems in perioperative medicine. We report the case of a 68-year-old female patient of Somali origin (body mass index 31.2 kg/m²), with type 2 diabetes mellitus controlled with insulin, hypercholesterolemia, and mild persistent asthma, who was scheduled for elective incisional hernia repair. The patient underwent preoperative airway assessment involving Mallampati Class II; clinically normal mouth opening and unrestricted neck mobility did not predict difficulty. Previously, a history of severe, prolonged cough and sore throat that lasted for around 12 hours after she underwent cholecystectomy in Somalia five years ago was reported but not interpreted as an airway predictor. After administering midazolam 2 mg, fentanyl 150 ug, propofol 200 mg, and rocuronium 70 mg, video laryngoscopy was used to find the vocal cords, but it was unsuccessful. Respectively, attempts to intubate using two bougie-assisted 7.5 and 7.0 mm endotracheal tubes were unsuccessful twice because of subglottic resistance. Ultimately, the senior anesthetist succeeded in intubation using a size 7.0 mm endotracheal tube with a controlled clockwise-to-anticlockwise rotational tube technique, consistent with the underlying subglottic narrowing of the trachea. Peripheral capillary oxygen saturation (SpO₂) was maintained at 97% and above, and total time to confirmed intubation from start of induction was around nine minutes. Sugammadex 200 mg was administered at the end of surgery; quantitative neuromuscular monitoring was not performed, and the patient was extubated fully awake, meeting clinical extubation criteria (fully awake, obeying commands, SpO₂ >97% on spontaneous ventilation) without the development of any airway-related complications.