Long case — the predicted difficult airway in a morbidly obese man

Presentation

Candidate summary. Mr R, 58, BMI 43, severe obstructive sleep apnoea on home continuous positive airway pressure, a short recessed chin and a thick beard, admitted with right middle-lobe pneumonia. He is tiring — respiratory rate 32, using accessory muscles, SpO2 90% on high-flow oxygen at 50 L/min, and his arterial gas shows a rising PaCO2 with a falling pH. He is hypotensive at 92/58 mmHg. Intubation within the hour is likely, and this is a predicted difficult airway on both the anatomical and the physiological axes: the anatomy predicts a hard laryngoscopy and a hard mask ventilation, and the physiology (obesity, OSA, hypoxaemia, hypotension) predicts a rapid desaturation and a cardiovascular threat.

^[1]The task is to assemble a plan that predicts the difficulty, prepares for it, and secures the airway with the failed-intubation algorithm and front-of-neck access ready.