Rapid Sequence Induction And An Unanticipated Difficult Airway

Proposal Number:


Proposal Type:

Medically Challenging Case Report Poster 


Grace Cunningham  
Mayo Clinic


Thomas Stewart  
Mayo Clinic
Timothy Long  
Mayo Clinic
Xun Zhu  
Mayo Clinic


67-year-old woman with end-stage Parkinson's and chronic aspiration pneumonia presented for percutaneous endoscopic gastrostomy tube revision.

Rapid sequence induction was performed with propofol, fentanyl and rocuronium. The glottis was easily viewed but placement of a 6.5mm endotracheal tube (ETT) was unsuccessful. Desaturation required attempts at mask ventilation, which proved difficult. Ventilation improved with release of cricoid pressure. A laryngeal mask airway (LMA) was placed and muscle relaxation was reversed with sugammadex 16mg/kg. Placement of an ETT through the LMA with an exchange catheter was unsuccessful. At this time, the patient resumed spontaneous ventilation; awake fiberoptic intubation was successfully performed without obvious aspiration on subsequent examination.

This case demonstrates a difficult scenario in which the ASA difficult airway algorithm was utilized for safe management of an unanticipated difficult airway (1). Despite the comorbid conditions contraindicating supraglottic airway use, utilization of an LMA likely reduced the aspiration risk given higher likelihood of gastric insufflation with continued attempts at mask ventilation (2).

Learning Objectives:
1. Enhance understanding of the difficult airway algorithm as a standard of care.
2. Evaluate scenarios in which patient comorbidities potentially complicate certain steps within the difficult airway algorithm.
3. Enhance understanding of the need for and ability to tailor the difficult airway algorithm for patient and circumstance-specific situations.

Professional Category:



Other - Airway

Enter up to two references.

1. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251-270.
2. Ho-Tai LM, Devitt JH, Noel AG, O'Donnell MP. Gas leak and gastric insufflation during controlled ventilation: face mask versus laryngeal mask airway. Can J Anaesth. 1998;45(3):206-211.