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Acromegaly for laparoscopic cholecystectomy: the difficult airway49-year-old man, 112 kg, for elective laparoscopic cholecystectomy for recurrent biliary colic

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Know this first

  • Overgrowth of tongue, epiglottis and cords makes mask ventilation and laryngoscopy hard; a smaller tube is often needed.
  • A hoarse voice, stridor or breathlessness means the larynx may be involved; look at it before surgery.
  • DAS: three intubation attempts at most, a fourth only by a senior colleague, then a second-generation SAD.
  • OSA patients stay on continuous oximetry until no longer at risk, with their CPAP continued.

The patient

49-year-old man, 112 kg, for elective laparoscopic cholecystectomy for recurrent biliary colic. Active acromegaly: coarse features, large tongue and jaw, deep voice, loud snoring and daytime sleepiness; hypertension and impaired glucose tolerance. Drugs: monthly octreotide injections, amlodipine. Vitals: BP 152/94, HR 72, SpO2 95% on air, RR 14, glucose 148 mg/dL.

The examiner asks

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  1. Consider

    What are your concerns?

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    • A 49-year-old with active acromegaly, probable sleep apnoea and hypertension, for elective laparoscopic cholecystectomy. Patient
    • Overgrown tongue, epiglottis and cords: a hard mask, hard laryngoscopy and a smaller tube. Airway
    • His long jaw adds distance from lips to cords; big turbinates may block nasal airways.
    • Growth hormone excess also brings cardiomyopathy, valve disease, diabetes and sleep apnoea. Disease
    • Collateral flow at his wrist may be poor; a brachial or femoral line is safer.

  2. Prepare

    How will you assess him?

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    • I ask about voice change, stridor or breathlessness on exertion, which suggest laryngeal involvement. Airway
    • With his deep voice, nasendoscopy to see his cords and glottic size.
    • Neck imaging if subglottic narrowing is suspected.
    • Sleep study; if his OSA is severe, CPAP starts before surgery. Disease
    • ECG and echo for cardiomyopathy and valve disease; his glucose optimised.

  3. Plan

    What is your airway plan?

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    • If nasendoscopy shows laryngeal narrowing or he has stridor, awake fibreoptic intubation. Airway
    • Otherwise asleep: ramped, preoxygenated, videolaryngoscope with a stylet or bougie, smaller tubes ready.
    • Three attempts at most, plus one by a more experienced colleague.
    • Second-generation SAD and front-of-neck kit ready before induction.
    • Opioid-sparing analgesia, full reversal checked, and extubation awake and sitting up. After surgery

  4. Crisis

    After induction and rocuronium, two videolaryngoscope attempts fail. Two-handed mask ventilation is easy and SpO2 is 97%. What now?

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    • DAS unanticipated difficult intubation: I call for help; Plan A is failing, but mask oxygenation works. Crisis
    • Mask oxygenation between attempts; he stays anaesthetised and fully paralysed.
    • A third attempt only with a change: bougie, smaller tube, laryngeal manipulation or a senior operator. Airway
    • If 3+1 fail: declare failed intubation; front-of-neck kit opened and primed. Crisis
    • Plan B: second-generation SAD, up to three insertions, confirmed with capnography.
    • Stop, think, communicate: his gallbladder can wait, so I wake him with full reversal.
    • Rebooked for awake fibreoptic intubation, and the event documented and told to him. After surgery

  5. Crisis

    He's rebooked and intubated awake, and surgery goes well. In recovery, ten minutes after the tube comes out, he obstructs and SpO2 is 84%. What do you do?

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    • Upper airway obstruction in severe sleep apnoea, perhaps made worse by opioid. Crisis
    • Sit him up, jaw thrust and CPAP at 5–15 cmH2O.
    • If CPAP fails, an oral airway or SAD; his nose may not take a nasal airway.
    • Opioid suspected: naloxone 40 mcg at 2-minute intervals, to a 200 mcg total.
    • His own CPAP back on, and continuous oximetry in a monitored bed, not a general ward. After surgery

Fatal mistakes

  • Repeated laryngoscopy beyond the 3+1 limit.
  • Inducing a predicted difficult airway with no plan or rescue kit.
  • Sending untreated sleep apnoea to an unmonitored ward.

Checked against: Stoelting 8e · Miller 10e · DAS 2025 · Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea: An Updated Report (2014)

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