Unexpected difficult airway management, although rare, may occur after induction of anesthesia. In such cases, appropriate airway management is required to prevent life-threatening hypoxia. In a 44-year-old woman without predicted difficult airway, after induction of general anesthesia, repeated attempts at tracheal intubation using videolaryngoscopes had failed, and ventilation using both a facemask and a supraglottic airway became difficult; the patient was awakened and the surgery cancelled. One week later, awake nasotracheal intubation using a flexible bronchoscope was attempted under high-flow nasal oxygenation. A clear view of the glottis was obtained by bronchoscopy and the trachea was intubated successfully without hypoxia. In patients with unexpected difficult airway management, appropriate airway management (including awakening the patient) is required to prevent life-threatening hypoxia. High-flow nasal oxygenation would be useful for awake fiberoptic intubation, by providing a clear view of the glottis and by preventing hypoxia.
Arai et al. (2026) studied this question.