Awake intubation

A middle-aged ASA II patient with obstructive sleep apnoea and a BMI of 35 kg.m required a total thyroidectomy. The patient had limited cervical spine mobility, tracheal deviation and it was noted that a surgical airway would be difficult. A spontaneously breathing general anaesthetic was performed using propofol and remifentanil. Direct laryngoscopy showed a grade 3 view and during repositioning complete airway obstruction followed with inability to mask ventilate despite six-handed ventilation. Several unsuccessful attempts at needle cricothyroidotomy, both fine and large bore, were made and the airway was finally secured after a difficult tracheostomy. The patient spent 20 minutes with oxygen saturations of less than 50% and received elective ventilation to manage cerebral hypoxia. A full recovery was reported. NAP4—Major Complications of Airway Management in the UK.