would you approach the airway management in this patient?
Airway assessment begins with careful
history-taking and physical examination. A recent history of an unevent-ful
intubation may be reassuring; however, anatomic and physiologic changes over
the course of 1–5 years may affect one’s ability to manage the airway
successfully. Patients without hoarseness or dyspnea and with adequate mouth
opening may be approached in the routine manner. Only oral intubation or
tracheostomy can be considered for transsphenoidal surgery because a nasal
endotracheal tube would obstruct the surgical field. Patients are instructed
preoperatively that mouth-breathing will be required in the postoperative
period because of bilateral nasal packs. Typical features such as large tongue,
large epiglottis, dis-tortion of the larynx, and soft tissue swelling complicate
visualization of the larynx in acromegalic patients.
The American Society of Anesthesiologists’
algorithm should be followed in the event of failed intubation and dif-ficult
ventilation. If difficulties with the airway are suspected after a careful evaluation,
it may be prudent to secure the air-way with the patient awake, either by
fiberoptic-guided intu-bation or alternative techniques. Anticipation of the
possible need to insert a smaller diameter tracheal tube and minimiz-ing
mechanical trauma to the upper airway and vocal cords are important
considerations, as additional edema can result in airway obstruction after the
tracheal tube is removed.