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An 88-year-old woman presented with acute airway obstruction caused by a large retrothyroid bleed following anterior neck trauma. Her airway was secured in the operating theatre with an awake nasal flexible optical bronchoscope tracheal intubation using an Intubating Laryngeal Mask Airway tracheal tube. Haemostasis was achieved following surgical ligation and the patient was transferred to the critical care unit. Postoperatively, a large leak around the tracheal tube was noted and a decision was made to change to an orotracheal tube with a subglottic drainage port. Our exchange technique required two experienced operators. The first operator used videolaryngoscopy with a hyperangulated blade to establish an optimal view of the larynx. The second operator placed an airway exchange catheter through the existing nasal tracheal tube to ensure airway control. The trachea was then intubated orally using a flexible optical bronchoscope observed under direct vision using the videolaryngoscope. The technique combined several simple and well-documented approaches, but importantly, the airway remained secure and visible throughout the procedure.

For patients with epilepsy refractory to medical management, vagal nerve stimulator implantation may reduce the number of seizures and/or reduce their severity. A 34-year-old woman with epilepsy underwent a change in vagal nerve stimulator battery under general anaesthesia with a supraglottic airway device and total intravenous anaesthesia. During the procedure, she developed clinically significant airway obstruction, which resolved only when the device was disabled. We recommend that anaesthetists and others providing peri-operative care for patients with a vagal nerve stimulator remain vigilant to the possibility of device-related airway obstruction, which may occur even in asymptomatic patients. All patients with a vagal nerve stimulator are provided with a magnet that will disable the device, should complications arise. There is a need to establish a standard approach to the peri-operative care of these patients, including the identification and management of devicerelated airway obstruction.

Deciding on the techniques and equipment to use when managing a patient’s airway during anaesthesia is a complex process. It is influenced by many factors, including the type of surgery being undertaken, patient co-morbidities, perceived risk of airway difficulty or pulmonary aspiration and the availability of more advanced equipment. While there are many guidelines for management of the unanticipated difficult airway, there are few if any for routine airway management. It is likely that current practices are heavily influenced by national and institutional norms, personal experiences and preferences of the individual anaesthetist involved.

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