Complex airway management of a patient with advanced upper airway obstruction and BiPAP-dependent acute respiratory failure (Preview)

Management of a difficult airway in the ICU is challenging and associated with high morbidity and mortality.¹ We describe complex airway management of a patient with a severely obstructed airway and acute, BiPAP dependent respiratory failure when a surgical airway could not be performed. No patient-specific photographs have been included in this report, and the Stanford Institutional Review Board has deemed the publication of this case report acceptible.

Case Description

A middle aged, morbidly obese patient with a remote history of tracheostomy and subsequent laryngeal reconstruction was transferred to the Stanford medical intensive care unit for management of acute pancreatitis. The details of the prior laryngeal surgery were not available. The patient endorsed generally good health but described the development of progressive stridor over the past year. Shortly after ICU admission, the patient developed sepsis and acute hypercapnic, BiPAPdependent respiratory failure that required emergent tracheal intubation.

Examination revealed a morbidly obese, obtunded patient with severe inspiratory stridor and acute respiratory distress, sitting up straight in bed in the high Fowler's position...