2) Buy time - The patient could be anticipated to have little respiratory reserve due to his compromised respiratory starting point, and thus to tolerate apnea poorly. He also could be anticipated to respond poorly to an EGD or bagging, when his age and the compliance of his lungs were considered. In fact, he responded well to bagging…with optimal technique. This means, two hands on the mask, thenar grip, a good mask seal, an oral airway +/- a nasal trumpet in place. He was preoxygenated as well as he could be, but he had a shorter distance to skid before he fell. Remember, the fall from 100% to 90% is slow and flat, but the fall from <90% to venous sat is fast and steep. Anticipate this.

3) Diagnose the problem, and take specific action - This man was already positioned well, but positioning can slip, so reposition. Given the view, BURP/OLEM would likely not solve the problem…the issue was not that the airway was too high or anterior to see, but that the tongue and epiglottis were too posterior to permit a view of the cords. Once this diagnosis is made, the solution becomes evident; we either have to move the tongue and epiglottis out of the way (bigger Mac, or change to a Miller), get an eyeball past the tongue and epiglottis (video, optical or fiberoptic adjunct), or settle for a blind method (bougie…a VERY distant third). The order in which I listed these is no accident.

4) Deploy a toy - The change of blade size was a good idea but did not solve the problem. Change to a Miller also would be a good idea, and might have solved it, but might not have…it is worth a try. However, he required an interruption in laryngoscopy to be bagged, but responded, giving us time to think. Time to deploy an eyeball. This could be an eyeball on a blade (C-Mac or Berci-Kaplan), an eyeball on a directable wand (intubating scope), or an eyeball at the tip of the ETT (Bonfils stylet). But, to deploy an eyeball takes time. Anticipate this, and have the tools out and ready to minimize the delay. This case was solved with the C-Mac, though multiple attempts were required. My second choice would have been the Bonfils. With regard to a bougie, these have the virtue of being quick to deploy, but their intended role is to help with a partial laryngoscopic view, not an absent view.

Remember, visualizing adjuncts are not rescue devices. Because of the time required to use most of them, they are not sufficient to the task of rescuing a patient who is already crashing. The crashing patient requires either bagging or an EGD to buy time to deploy the visualizing adjunct. Among the adjuncts, the video laryngoscopes are probably the quickest to implement - if they are in the room. So prepare! I am not suggesting that we hook up all of the gadgets every time we do an intubation, but we should at least have the one(s) we would likely want for the most likely challenges that might arise, locate them, and place them within easy reach.

Update: In the interval between the original submission of this case and the present, my feelings about DL as a first step have changed. DL is, simply, inferior to VL in all respects. There may be an extraordinarily rare exception to this (excessively goopy airway), but not in the main. The Berci-Kaplan is a nice compromise to retain the skill [DL], but not harm the patient. In the near future, retaining this skill may not be sufficient justification for continuing DL in any form.

Best,

I.C.