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Airway and respiratory · Core09 / 12

Ludwig angina with trismus: awake tracheal intubation44-year-old man, 86 kg, for urgent incision and drainage of a deep neck abscess (Ludwig angina) from a lower molar

Anticipated difficult airway: awake tracheal intubation step by step

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Sublingual spread pushes the tongue up and back and can obstruct the airway, worse when supine.
  • Trismus from infection may not open under relaxant once the muscles are swollen.
  • ATI: sTOP; topical lidocaine capped at 9 mg/kg of lean weight; maximum 3 + 1 attempts.
  • Failed ATI: stop sedation, 100% oxygen, help; awake front-of-neck access if the airway is essential.
  • eFONA kit: number 10 scalpel, bougie, size 6.0 cuffed tube.

The patient

44-year-old man, 86 kg, for urgent incision and drainage of a deep neck abscess (Ludwig angina) from a lower molar. Floor-of-mouth swelling, tongue pushed up, drooling, muffled voice; mouth opening 1.5 cm. Poorly controlled type 2 diabetes. Drugs: metformin, gliclazide; IV antibiotics started in the emergency department. Vitals: BP 138/84, HR 118, SpO2 95% on air, RR 24, temperature 38.9 °C. Glucose 290 mg/dL.

The examiner asks

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  1. Consider

    What are the key issues?

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    • A septic 44-year-old diabetic with Ludwig angina and trismus, needing urgent drainage. Patient
    • The infection pushes his tongue up and back, so he can suddenly obstruct. Disease
    • Drooling and a muffled voice tell me his airway is already narrowing. Airway
    • His trismus may not ease with relaxant, because the infected muscles are swollen.
    • The abscess can burst into his pharynx with laryngoscopy and soil his lungs.
    • Sepsis: antibiotics within the hour; drainage is his source control. Disease

  2. Prepare

    What do you do before you touch his airway?

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    • He stays sitting up; lying flat worsens his obstruction, so CT only if he can tolerate it with me there. Airway
    • ENT nasendoscopy to see how much laryngeal space he has left.
    • Insulin infusion to bring his glucose of 290 toward 140–180 mg/dL. Disease
    • ENT scrubbed, neck cleaned and marked, before I touch his airway. Airway
    • Awake tracheostomy under local is a valid first choice; we agree which plan first.

  3. Plan

    How will you secure his airway?

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    • Awake tracheal intubation, nasal flexible bronchoscope, because his trismus blocks the mouth. (Airway)
    • High-flow nasal oxygen throughout; his narrowed airway makes it strongly advised.
    • Co-phenylcaine 2.5 mL to the nose; total lidocaine under 9 mg/kg lean weight.
    • Little or no sedation; over-sedating him obstructs his airway and stops him breathing.
    • A smaller tube, the most experienced operator, and FONA primed.
    • Two-point check, bronchoscope view and capnography, before induction.

  4. Crisis

    During topicalisation he becomes agitated and his stridor worsens. SpO2 82%, BP 165/95, HR 128. What do you do?

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    • DAS awake intubation, failed: near-complete obstruction during topicalisation; stop, help, 100% oxygen. (Crisis)
    • Sit him fully upright and stop or reverse any sedative.
    • Laryngospasm is a risk with stridor; I switch to lower-strength or nebulised lidocaine only if he recovers.
    • If he doesn't settle at once, the surgeon performs awake front-of-neck access now.
    • I do not induce anaesthesia to take control of this airway.

  5. Crisis

    He goes apnoeic before the surgeon is through. Mask ventilation fails; SpO2 70%, BP 80/40, HR 45. What do you do?

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    • DAS Plan D: cannot intubate, cannot oxygenate, in a swollen septic neck. (Crisis)
    • Declare CICO, allocate roles; full neuromuscular block, neck extended as far as the swelling allows.
    • Oxygen kept on the upper airway throughout.
    • Surgeon completes the front-of-neck airway now, or I do scalpel–bougie–tube, vertical incision.
    • Cuff up, ventilate 100% oxygen, confirm with capnography.
    • His bradycardia is hypoxic; oxygen through the new airway treats it. Pulse lost: CPR, adult arrest algorithm.
    • Then exclude bronchial intubation and pneumothorax; ICU, ventilated until his swelling settles.

Fatal mistakes

  • Inducing general anaesthesia before the airway is secure.
  • Heavy sedation for an awake technique.
  • No surgeon ready for front-of-neck access.
  • Blind nasal attempts through an infected pharynx.

Checked against: Barash 9e · Miller 10e · Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults (2020) · DAS 2025

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Same topic, another patient

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Another patient · Intra-operative crises. Can't intubate, can't oxygenate in floor-of-mouth infection. Same infection: sedation during topicalisation leads to CICO and eFONA

Know this first

  • Sedatives or relaxants can turn a narrowed airway into a complete obstruction.
  • Awake intubation: topical lidocaine capped at 9 mg/kg by lean body mass; two-point check before induction.
  • Trismus: nasal flexible-scope approach; stridor: high-flow nasal oxygen and a primed front-of-neck plan.
  • DAS 2025: Plan A tube, B supraglottic airway, C facemask, D front-of-neck access.
  • eFONA: full neuromuscular block, scalpel–bougie–tube, size 6.0 cuffed tube.

The patient

54-year-old man, 96 kg, insulin-treated diabetes; three days of floor-of-mouth swelling. Trismus with 1.5 cm mouth opening, drooling, muffled voice and soft inspiratory stridor; CT shows bilateral submandibular collections narrowing his airway. Emergency incision and drainage of the neck. Vitals: BP 148/88, HR 116, SpO2 94% on air, RR 24, temperature 38.9 °C, glucose 16 mmol/L.

The examiner asks

Answer aloud, then press Show.

  1. Consider

    What are your concerns?

    Show the answerHide the answer
    • A 54-year-old diabetic with floor-of-mouth sepsis, trismus and stridor, for emergency neck drainage. Patient
    • Trismus, drooling and stridor: a narrowed airway I can barely reach through his mouth. Airway
    • Sedation or relaxants could turn his partial obstruction complete.
    • One traumatic attempt can close his marginal airway entirely.
    • Sepsis and glucose of 16 need treating, but his airway comes first. Disease

  2. Prepare

    How will you prepare?

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    • Senior anaesthetist and ENT both present, ENT scrubbed for a surgical airway. (Airway)
    • Cricothyroid membrane found by ultrasound and marked before we start.
    • High-flow nasal oxygen throughout, as advised with stridor.
    • Smaller tubes and a flexible scope ready; his narrowed airway may not take a standard tube.
    • Plan said aloud: awake intubation first, then awake tracheostomy under local if it fails.

  3. Plan

    What is your airway plan?

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    • Awake intubation through the nose with a flexible scope, since trismus blocks his mouth. (Airway)
    • Topical lidocaine capped at 9 mg/kg by lean body mass; co-phenylcaine 2.5 mL to the nose.
    • Minimal sedation or none: over-sedation is dangerous with his stridor.
    • Two-point check, tube seen in trachea plus sustained capnography, before I induce.
    • Scope won't pass: ENT does an awake tracheostomy under local.

  4. Crisis

    During topicalisation a colleague gives midazolam 2 mg and fentanyl 100 mcg. He stops breathing; SpO2 82% and falling; facemask ventilation is failing. What do you do?

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    • DAS failed airway: obstruction after sedation, SpO2 82%; help called, ENT to the neck. Crisis
    • Two-person facemask with nasal airways and 100% oxygen while help arrives. Airway
    • Naloxone and flumazenil given, but the airway steps don't wait for them. Crisis
    • Plan B: supraglottic airway, three attempts maximum; his trismus will likely defeat it. Airway
    • Failed SAD: front-of-neck kit opened as I move to Plan C. Crisis
    • Plan C: final facemask attempt after rocuronium 1.2 mg/kg, two-person, with adjuncts.

  5. Crisis

    No supraglottic airway will pass and the final facemask attempt fails, even paralysed. SpO2 64%, HR 52. What now?

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    • Plan C failed: CICO declared aloud; Plan D is eFONA, now, by ENT or me. Crisis
    • He is already fully paralysed from Plan C, as eFONA requires.
    • Neck extended over a pillow; oxygen to the upper airway continues.
    • His swollen neck hides the membrane, so a vertical incision, then a transverse stab.
    • Bougie in, size 6.0 cuffed tube railroaded over it, cuff up, capnography confirms.
    • Then exclude bronchial intubation and pneumothorax; ENT converts to tracheostomy; ICU after. After surgery

Fatal mistakes

  • Deep sedation in a stridulous, obstructed airway.
  • Delaying front-of-neck access after CICO is declared.
  • Starting without ENT and a surgical airway plan.
  • Attempting front-of-neck access without full neuromuscular block.

Checked against: Barash 9e · Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults (2020) · DAS 2025

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