# Successfully Anticipated Difficult Airway Management of a “Can Ventilate, but Cannot Intubate” Situation for Urgent Laparoscopic Appendectomy in a Patient with Duchenne Muscular Dystrophy

## TL;DR

This case study describes the successful management of a difficult airway in a Duchenne patient during urgent surgery.

## Contribution

The paper highlights a real-world application of the Difficult Airway Society algorithm in a Duchenne patient with a 'can ventilate, but cannot intubate' situation.

## Key findings

- Three failed intubation attempts were managed by awakening the patient and waiting for swelling to subside.
- Fiberoptic-guided intubation via a supraglottic device was successfully performed after using reversible agents.
- Adherence to the DAS guidelines and team communication were critical for safe airway management.

## Abstract

Background: Airway management in Duchenne patients can be challenging. We present a case of an anticipated difficult airway in a 24-year-old Duchenne patient that was managed by planning different suitable strategies based on the unanticipated difficult airway algorithm of the Difficult Airway Society (DAS). Case presentation: The patient initially presented with appendicitis, requiring a laparoscopic appendectomy within 6 h. Due to the underlying condition and a known difficult airway, we anticipated potential airway problems and successfully managed the “can ventilate but cannot intubate” situation using the algorithm. The difficult airway was attributed to reduced mandibular mobility, limited inclination or reclination, a large tongue, prominent incisors, and a posteriorly positioned epiglottis. Despite thorough preparation and team briefing, we experienced three failed intubation attempts. Considering limited nighttime resources, the urgency of the surgery, the need for a tube for laparoscopy, and the risk of exacerbating airway issues, we made the decision to awaken the patient and wait for a second attempt after the epiglottis swelling had subsided. We used reversible, short-acting agents for induction, enabling us to continue with the algorithm within the allotted timeframe. In a second stage, we successfully performed fiberoptic-guided intubation via a supraglottic airway device using the Aintree intubation catheter, utilizing more favorable resources. Conclusions: For a patient with Duchenne muscular dystrophy and a difficult airway, advanced expertise is critical. Detailed anesthesia planning, clear team communication, and the use of reversible, short-acting agents are crucial. Adherence to the Difficult Airway Society guidelines is essential for safe airway management.