“Can’t Intubate Can’t Oxygenate” Situation in an Elective Patient in Suspected Sarcoidosis: A Case Report

Anaesthetists and pulmonologists are well trained to follow the “can’t intubate, can’t oxygenate” (CICO) protocol but the procedure is rarely practised. This case report concerns an elective patient scheduled for endobronchial ultrasound bronchoscopy (EBUS) because of suspected sarcoidosis. Based on known medical history, anaesthesia for EBUS procedure was initiated with a laryngeal mask. The airway turned out to be difficult and the patient was not ventilable despite several efforts including curarization and orotracheal intubation. Rapid desaturation imposed to apply the CICO protocol with emergency cricothyroidotomy as extreme measure but also failed. 6-handed face mask ventilation was continued. Eventually, introduction of a microlaryngeal tube of the 3(rd) generation laryngeal mask, placed on the fibrescope, allowed endotracheal intubation. The patient fell into pulseless electrical activity, and the CICO protocol was started. Immediate cardiopulmonary resuscitation totally recovered vital functions. In the post-operative follow-up, no temporary or permanent cardiological and neurological sequels were found, but new medical history such as inconstant use of C-PAP (Continuous Positive Airway Pressure) and a significant weight gain since the last notable difficult intubation were uncovered, which explained the patient’s compromised airways. Had this information been available prior to the scheduled operation, it would have indicated awake intubation with a local anaesthesia of the oropharynx and appropriate sedation of the patient. LEARNING POINTS: The CICO protocol was effective to manage an unanticipated difficult airway. The patient was resuscitated with the use of a microlaryngeal endotracheal tube of the 3(rd) generation laryngeal mask, placed on the fibrescope. The patient’s previous and current medical condition is of vital importance for the pre-operative anaesthetic assessment. Specific questioning during the pre-operative anaesthetic interview could detect events that seem to be insignificant to the patient but are significant for a diagnostic intervention in a new situation.