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Loss of Secure Airway after Fiberoptic Intubation in Patient with Osteogenesis Imperfecta
Abstract Number: F5D-5
Abstract Type: Case Report/Case Series
Osteogenesis imperfecta (OI) is an inherited connective tissue disorder with multiple manifestations affecting anesthetic management, including skeletal deformities, respiratory compromise, platelet dysfunction, and airway abnormalities.(1) The anatomic and physiologic changes associated with pregnancy can render airway management of a patient with pre-existing difficult airway even more tenuous.(2) We present the case of a pregnant patient with OI whose delivery was complicated by loss of secured airway after difficult awake fiberoptic intubation (FOI).
A 34-year-old G2P0 with history of OI type III was admitted to the antepartum unit with progressive shortness of breath at 31 weeks’ gestation. Her OI was complicated by multiple compression fractures of the spine, severe scoliosis, and chronic pain managed with methadone. Physical exam revealed high-pitched phonation. Initial airway exam at 31 weeks revealed a very short neck and mildly restricted neck extension. Ultrasound of the spine revealed severe loss of height with poor visualization of interspaces.
Pre-delivery planning included maternal-fetal medicine and anesthesiology services, as well as bedside nasal laryngoscopy by ENT. All parties agreed upon cesarean delivery (CD) due to fetal diagnosis of OI, with general anesthesia (GA) after awake FOI. At 34 weeks’ gestation, the decision was made to proceed with CD given the patient’s progressive respiratory compromise.
After sedation and airway topicalization, initial attempt at awake FOI revealed uvula extending into larynx at level of epiglottis, obscuring the view of vocal cords. Awake laryngoscopy with glidescope revealed a similar view. After approximately 1 hour, ENT was called and advanced the scope and endotracheal tube through the vocal cords with visualization of tracheal rings.
After confirmation of end tidal CO2 (ETCO2), GA was induced with propofol and rocuronium. ETCO2 was then abruptly lost. A size 2.5 laryngeal mask airway was placed with good seal and ETCO2 was again confirmed. Oxygen saturation returned to 100% from nadir of 39%. Surgeons were instructed to proceed, and delivered the baby en caul 1 minute after intubation with Apgars of 8 and 9.
Upon delivery, ventilation improved with peak pressures decreased from 45 to 25cm H2O and tidal volumes increased from 150cc to 600cc. The decision was made to proceed through the CD with LMA in place. After reversal of neuromuscular blockade with sugammadex, the LMA was removed once the patient was fully awake.
The management of the pregnant patient with OI requires a multidisciplinary approach, with clear communication during the dynamic situations that may arise in the care of these complex patients. The use of a supraglottic airway device can be life-saving in the setting of loss of secured difficult airway during CD under GA.
1. Int J Obstet Anesth 2015, 24, 64-68
2. Curr Opin Anesth 2011, 4:249-254