Failed airway in the emergency department; what’s next?

Abstract

A failed airway is defined as an unsuccessful intubation. It is a rare occurrence in the emergency department (ED) and always poses a challenge to emergency physicians. The ‘can’t intubate, can ventilate’ situation is one of the two ways a failed airway can occur in ED. Here, we present a case of failed emergency endotracheal intubation due to unanticipated subglottic stenosis. An elderly presented to a district hospital (without specialist) with acute bronchospasm, in which he was treated as severe exacerbation of chronic obstructive pulmonary disease (COPD). Despite maximal medical therapy, symptoms worsen, requiring intubation for airway protection. Standard rapid sequence intubation (RSI) was performed, with a good view of glottic opening; however endotracheal tube (ETT) size 7.5 could not be passed beyond the larynx. Several attempts using smaller-size ETTs still failed. A laryngeal mask airway (LMA) was inserted as a rescue device for ventilation. The patient was then sent to our centre for further evaluation and treatment. Initial examination in our ED revealed an elderly that was sedated and ventilated through LMA. Ventilation and oxygenation via the LMA were adequate. Diagnostic endoscopy was performed through LMA using flexible intubating scope which showed subglottic stenosis around 2cm below the vocal cord. The patient was referred to the Ear, Nose and Throat (ENT) team, where emergency tracheostomy was then performed in operating theatre. He was discharged well after 14 days of admission and given follow-up for his COPD and tracheostomy care.