By: 10 June 2021
A case of a difficult airway in the ED with anterior neck swelling




Airway obstruction is an emergent, life-threatening condition and could contribute to the difficult airway[1]. A patient with upper airway obstruction can present with a complaint of cough, stridor, hoarseness of voice, and respiratory distress [2]. A well-rehearsed, clearly-led and protocolised airway management plan is crucial. In general, airway management is one of the fundamental skills of an emergency physician. We report a case describing the management of a patient with severe upper airway obstruction and altered mental status due to respiratory failure and impending respiratory arrest.


Case presentation

A 52-year-old gentleman was brought to our emergency department (ED) via emergency medical services (EMS) with a pre-alert notification of airway obstruction that might require intubation. On arrival to our ED, the patient was in severe distress with audible stridor. Vital signs were documented as showing a tachypnoea with a respiratory rate of 32/minute, heart rate of 107 beats per minute, and a blood pressure of 175/97 mmHg. His Glasgow coma score (GCS) was recorded as 5/15. He was receiving oxygen via a 15 l/min non-rebreather mask.

An arterial blood gas pre intubation showed a pH of 7:06, undetectable CO2, undetected HCO3 and O2 level of 326 mmHg.

Upon examination, an anterior firm neck mass was noted in the midline.

A decision was made to intubate the patient in view of imminent arrest due to airway obstruction. A plan consistent with the difficult airway society algorithm, as suggested by the Difficult Airway Society (DAS) was discussed.

Plan A – video laryngoscopy with sedation medication only

Plan B – Plan A with bougie If failed, plan B was bougie. Call for help

Plan C – Use Intubating LMA

Plan D – Front of neck access with cricothyroidotomy


Intubation was unsuccessful with video laryngoscopy and bougie assistance.

We called for help from the anaesthesia department. They were also unsuccessful intubating and recommended emergent ENT intervention. Throughout this process, we were able to ventilate the patient.

Eventually, the patient was intubated using a bougie and a smaller size endotracheal tube (size 5.0). A CT scan revealed a laryngeal mass from the glottic region with signs of necrosis and infiltration to the adjacent neck muscles. The patient underwent an emergent tracheostomy followed by a total laryngectomy and was commenced on chemotherapy.



The incidence of a difficult airway in the ED has been reported from 3-5.3% and failed intubation to be 0.5-1.2% [1] The difficult airway has been defined as an airway complicated by anatomical, physiological, or trauma related reasons. In contrast a failed airway has been variably defined and includes objective criteria like inability to achieve endotracheal intubation on 3 attempts by a skilled provider or a ‘cant intubate/cant oxygenate’ scenario. [1] Early recognition and intervention with a good airway plan is crucial in such cases. Indications for emergency airway management are less well-defined but broadly include airway obstruction, inability to maintain/protect an airway, and impending/established respiratory failure.

It is helpful to vocalise one’s mental model as part of preparation for the difficult airway. An intubation checklist list can help collate preparation including a plan for the ‘Can’t intubate, can’t ventilate’ scenario and serve as a cognitive aid. Despite the lack of high quality evidence for their use in ED, airway checklists have been shown to decrease complications from intubation related complications [2].

Preoxygenation is key in emergency airway management and has been demonstrated to prolong the time to desaturation [3]. Delayed sequence intubation has also been described though initially only the induction agent is administered. This follows a period of oxygenation, followed by administration of the paralytic agent [4]. Apneoic oxygenation relies on administration of high flow oxygen through a nasal cannula, sometimes, in addition to a face mask, and is shown to also delay desaturation during apnea following paralysis [5].

When the patient does not have a suspected cervical spine injury, positioning of the airway improves visualisation of the glottis. The ‘Head Elevated Laryngoscopy (HELP)’ – or the ramp position – are one such example where access to the laryngeal inlet can be improved.

Ketamine, etomidate, and midazolam are known to have a lower negative hemodynamic effect compared to other drugs. However, it is acknowledged, an ideal induction agent for the difficult airway does not exist [1].

It should be mentioned here that awake intubation using topical local anesthetics on the airway followed by fibre-optic intubation is usefully indicated in the ‘Can’t intubate, can’t ventilate’ scenario [6].

The commonest paralytic agents used in the difficult airway include succinyl choline and rocuronium. Historically, succinyl choline has been correlated with better intubating conditions, however, rocuronium at dose of 1.2 mg/kg offers comparable results [7].

Direct laryngoscopy has been used for tracheal intubation since the late 19th century. It is worth remembering external laryngeal manipulation using the ‘Backwards Upwards Right side Pressure’ (BURP) technique can improve glottis visualisation. The bougie remains one of the most trusted devices when the vocal cords cannot be visualised and is commonly part of all difficult airway algorithms [8]. Stylets are another type of intubation assistance device often malleable, and sometimes include a light source. Difficult airway guidelines have incorporated the laryngeal mask airway (LMA) since the 1990s and video laryngoscopy a decade later [9]. It is paramount to remember ventilation of a patient is a priority when faced with a difficult airway, either by a supraglottic device, invasive intervention, or where applicable, by waking the patient up [9]. Video laryngoscopy allows better visualisation of the glottis and real time confirmation of tube placement. These devices should be readily available but should only be used by staff trained and accredited in their use [9]. Suction is very important as blood and secretions make visualisation difficult.

‘Front of Neck Access’ is a procedure where a surgical opening is created in the cricothyroid membrane followed by placement of a endotracheal tube, often via bougie. It would be strongly recommended a trained healthcare provider skilled in performing emergency front of neck access is always available when attempting to intubate a difficult airway . This is the final time critical step and lifesaving intervention to reverse hypoxia and prevent brain, cardiac arrest, and death [10]. Although there are many methods for performing a surgical airway, scalpel cricothyroidotomy is the preferred method using scalpel, bougie, and endotracheal tube [7,10].

Early involvement of ENT and critical care can allow time critical interventions like tracheostomy to be performed in an emergent manner.

It is worth noting, regular training around technical aspects and human factors have been shown to improve safety when dealing with the difficult airway. The NAP4 audit identified poor training and education as the commonest causes of adverse airway events requiring emergency front of neck access [11].

Regular simulation sessions for High Acuity Low Occurrence (HALO) scenarios like the surgical airway with multi-disciplinary team involvement like emergency department staff, anaesthesia, ENT, and respiratory technicians would encourage crisis resource management and address technical and human factor challenges often faced in such scenarios.



This case highlights the importance of having a protocolised structured approach to the unanticipated difficult airway. Familiarity with difficult airway management guidance similar to the DAS algorithm and equipment familiarisation with your workplace difficult airway guideline allows us to be more prepared when we face unanticipated difficult intubation. The importance of hands-on training sessions at regular intervals for rehearsing the difficult airway management is crucial for better team working, translating to safer patient outcomes.




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Ibraheem AlZaabi1 , Emergency Medicine Resident, Emergency Department, Sheikh Shakbout Medical City, Abu Dhabi, UAE email:

Amna Saeed Al Bairaq1 , Emergency Medicine Resident, Emergency Department, Sheikh Shakbout Medical City, Abu Dhabi, UAE email:

Dr Sher Mohamed1 , Consultant Anaesthetist, Royal Hallamshire Hospital, Sheffield, UK Email:

Hasan Qayyum 2 , Consultant Emergency Department, Sheikh Shakhbout Medical City, Abu Dhabi, UAE email: