Success in Difficult Airway Managements with Video Laryngoscope After Two Failures in Intubation with Macintosh and McCoy Laryngoscope: A Case Report


Ali Abbasijahromi 1 , Mohammad Sadegh Sanie Jahromi 2 , Mehran Farzaneh 3 , * , Shohreh Javadpour 4 , Mohammad Ali Montaseri 5 , Navid Kalani 3

1 MSc in Critical Care Nursing, Anesthesiology and Intensive Care Department, School of Nursing and Paramedical Sciences, Jahrom University of Medical Sciences, Jahrom, Iran

2 Assistant Professor of Anesthesiology, Anesthesiology and Intensive Care Department, Jahrom University of Medical Sciences, Jahrom, Iran

3 Research Committee Student, Jahrom University of Medical Sciences, Jahrom, Iran

4 MSc in Critical Care Nursing, Intensive Care Department, School of Nursing and Paramedical Sciences, Jahrom University of Medical Sciences, Jahrom, Iran

5 MSc in Medical Surgical Nursing, Department of Medical- Surgical Nursing, School of Nursing and Paramedical Sciences, Jahrom University of Medical Sciences, Jahrom, Iran

How to Cite: Abbasijahromi A, Sanie Jahromi M S, Farzaneh M, Javadpour S, Montaseri M A, et al. Success in Difficult Airway Managements with Video Laryngoscope After Two Failures in Intubation with Macintosh and McCoy Laryngoscope: A Case Report, Iran Red Crescent Med J. 2017 ; 19(9):e60283. doi: 10.5812/ircmj.60283.


Iranian Red Crescent Medical Journal: 19 (9); e60283
Published Online: September 5, 2017
Article Type: Case Report
Received: January 18, 2017
Revised: March 9, 2017
Accepted: May 20, 2017




Introduction: Currently, creating a secure airway for general anesthesia is an integral part of the process of anesthesia. The difficulty of this process effects morbidity and mortality rates. In order to achieve further success in these patients, it is advised to use video laryngoscope.

Case Presentation: The patient was a 45-year-old female, who was a candidate for cholecystectomy along with laparoscopic surgery, and had referred to Peimaniyeh hospital of Jahrom, Iran, during September 2016. In the initial assessment, the patient seemed to be in a difficult airway class, while in her surgery documents from 5 and 10 years ago and in her previous records no history of this problem was mentioned. After the administration of drugs before surgery and anesthesia induction, tracheal intubation had failed by use of routine laryngoscope and McCoy laryngoscope in two stages. Finally, the use of video laryngoscope for tracheal intubation was successful. During the intubation attempts, the patient was ventilated with 100% oxygen mask and her arterial blood oxygen saturation had not decreased.

Conclusions: Therefore, it is recommended for the patient to be investigated carefully in terms of airway management. In addition, in case of difficult intubation, selecting video laryngoscope to facilitate intubation may be appropriate. The mere absence of a difficult airway management is not a reason that the problem will not occur in the future.


General Anesthesia Airway Management Intubation Video Laryngoscope Macintosh McCoy Laryngoscope

Copyright © 2017, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

Difficult intubation is referred to as a clinical condition in which the patient's endotracheal tube ventilation is not or hardly done (1). Difficult and inappropriate intubation may lead to several complications, including prolonged process of healing, inflammation of the throat and larynx spasms and in severe cases even the death of the patient (35%) (2).

Laryngoscopy is difficult in 6% to 10% of intubation cases. However, difficult intubation or failure in carrying out this procedure has been found in 1.8 - 5.8% and 0.13 - 0.30% of cases, respectively. Using direct laryngoscopy in patients undergoing general anesthesia endotracheal intubation was commonly used, unless certain conditions led to the selection of a different method (3). In comparison to direct laryngoscopy, video laryngoscopy in many circumstances has shown greater success in the first attempt (4). In this article, a patient with difficult intubation that was brought to the operating room for laparoscopic surgery is presented.

2. Case Presentation

The patient presented in this study was a 45-year-old female, who was moderately obese, weighing 85 kg, and had referred to Peimaniyeh hospital of Jahrom, Iran, during September 2016 with epigastric pain. Other symptoms included anorexia, constipation, nausea, and vomiting. Regarding history, the patient did not express specific underlying disease. After physical examination and additional tests, the patient was diagnosed with gallstones and was transferred to the operating room for cholecystectomy with laparoscopic surgery.

In initial examination by an anesthesiologist, in terms of airway management, the patient was diagnosed with Mallampati III-IV class and difficult intubation. Other findings in this patient confirmed a difficult intubation, including neck stiffness in head extension, short neck, thyromental distance of about 4 cm, limited mouth opening, anterior tracheal, and relatively prominent incisors. Therefore, the equipment required for difficult intubation was prepared previously. The equipment was calibrated.

The patient's vital signs on the day of surgery included: blood pressure of 125/85 mmHg, heart rate of 82 beats per minute, respiratory rate of 20 breaths per minute and temperature of 36.5°C. The SAADAT monitor (S1800) was employed for monitoring the patient during and after the surgery. Drugs used for anesthesia were as follows: 2 mg of Midazolam, intravenously, 10 mg of morphine, intravenously, 425 mg of sodium thiopental, intravenously, 34 mg of atracurium, intravenously, and 85 mg of 2% lidocaine, intravenously. The patient was ventilated for 3 minutes with a mask by 100% oxygen to become completely relaxed and ready for intubation with ETT tube of Supa Model, No. 7.5. The first attempt for intubation, under the direct vision of blade 4 common laryngoscope, failed after 30 seconds. In the next step, after re-ventilation with a mask and 100% oxygen, blade 4 McCoy laryngoscope with guide was used in the tracheal tube, and this effort was also not successful. In the third step, followed by re-ventilation by mask with 100% oxygen and using video laryngoscope with an intermediate size monitor, the difficult tracheal intubation was done successfully (Figures 1 and 2). In all these steps, ventilation of the patient with a mask and 100% oxygen was successful and patients’ arterial blood oxygen saturation was not decreased at any time. At the end of the surgery and after the patient’s recovery was complete, and the problem was recorded in her file, a full description was provided for the patient and her relatives, for them to explain this condition to the anesthesiologist if she needs a surgery in the future.

Epiglottis in Patient Airway in Laryngoscopy with Video Laryngoscope
Figure 1. Epiglottis in Patient Airway in Laryngoscopy with Video Laryngoscope
Insert the Endotracheal Tube in the Patient Airway
Figure 2. Insert the Endotracheal Tube in the Patient Airway

In the history taken from patient, there was a history of 2 previous surgeries under general anesthesia. The first was appendectomy, about 5 years ago, and the other was an ovarian cyst surgery about 10 years ago, without any side effects. No evidence of difficult tracheal intubation was observed by assessing the patient’s previous surgery documentation. Also, after a comprehensive investigation, there was no condition that led to stiffness of the upper airway such as rheumatoid arthritis, etc. during this period. Therefore, without any specific disease, the intubation had become difficult for the patient after a period of time.

Table 1. The Patient Informative Display
The PatientVariables
History45 year-old
Moderately obese
Weighing 85 kg
Nausea and vomiting
Epigastric pain
Physical examinationMallampati III-IV class
Neck stiffness in head extension
Short neck
Thyromental distance about 4 cm
Limited mouth opening
Anterior tracheal
Relatively prominent of incisor

3. Discussion

The American Society of Anesthesiologists in 1993 defined difficult intubation as 3 times of intubation or spending more than 10 minutes for intubation in order to keep the oxygen pressure of more than 90% using 100% oxygen (5, 6).

There are several ways to identify patients at risk of difficult intubation before anesthesia. Difficult airway assessment starts with a comprehensive medical history and physical and regional examination. There are several key factors for the physician to control, including: changes in normal anatomy, pathogenic conditions, limited mouth opening, prominent upper teeth, large tongue, and immobility of the head, neck, and jaws. Changes in normal anatomy and airway anatomy characteristics due to the pathogenic condition could lead to a number of problems. Several conditions have been reported, that predispose patients to difficult airway intubation. These conditions include infection, trauma, obesity, endocrine factors, foreign bodies, tumors, inflammatory conditions, congenital problems and etc. Generally, the factors that predispose patients to difficult airways are divided to 2 categories: congenital and acquired (7).

From the medical history of the patient and also from previous surgery files, no record of a difficult airway was observed. From the above-mentioned factors that are effective in creating a difficult airway, low mobility of head and neck, limited opening of the mouth, predominant incisor, obesity, and the anterior tracheal were observed in this patient. According to no difficult airway history in this patient, acquired factors could be effective in creating this problem. Acquired factors consist of infections (such as supraglottis and croup, etc.), arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.), tumors, obesity, etc. (7). After a comprehensive investigation was conducted on the patient, among the acquired factors, only obesity (BMI = 27.7) was present in this patient and other acquired factors were not involved in the creation of a difficult airway. Therefore, it could be suggested that anesthesiologists should not focus on the absence of difficult airway history and all patients should be examined carefully and even if there is a single factor in development of difficult airway, all the necessary preparations should be provided for laryngoscopy and difficult intubation.

Intubation with direct laryngoscopy and video laryngoscope are different from each other in terms of technique. In direct laryngoscopy, the operator should be pressed and move upper airway tissue to create a direct line of sight. This technique often leads to difficulty in observing the larynx properly. In the Video-laryngoscope, the blade with high angle and tiny camera allowed the operator to see the environment of structures that are impeding direct vision, so the necessity of displacement of upper airway tissues disappeared. The best view of the entrance of the larynx often comes with the video from the laryngoscope (8). Compared with direct laryngoscopy, video laryngoscope for difficult intubation has better visibility, higher success rate, faster intubation, and also low requirements for different maneuvers (9). In this patient after trying to use McCoy and normal laryngoscope for intubation that was unsuccessful, eventually intubation was performed using a video laryngoscope.

Mosier et al. (2013) reported that the use of a video laryngoscope has improved the success rate of emergency intubation and compared with a conventional direct laryngoscopy with Macintosh blade, the esophageal intubation rate was lower (4).


  • 1.

    Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002; 94(3) : 732 -6 [DOI][PubMed]

  • 2.

    Acar HV, Yarkan Uysal H, Kaya A, Ceyhan A, Dikmen B. Does the STOP-Bang, an obstructive sleep apnea screening tool, predict difficult intubation? Eur Rev Med Pharmacol Sci. 2014; 18(13) : 1869 -74 [PubMed]

  • 3.

    Griesdale DE, Liu D, McKinney J, Choi PT. Glidescope(R) video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth. 2012; 59(1) : 41 -52 [DOI][PubMed]

  • 4.

    Mosier JM, Whitmore SP, Bloom JW, Snyder LS, Graham LA, Carr GE, et al. Video laryngoscopy improves intubation success and reduces esophageal intubations compared to direct laryngoscopy in the medical intensive care unit. Crit Care. 2013; 17(5)[DOI][PubMed]

  • 5.

    Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD. A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesth Analg. 2006; 102(6) : 1867 -78 [DOI][PubMed]

  • 6.

    Rosenblatt WH, Sukhupragarn W. Clinical anesthesia. 2006; 5 : 595 -641

  • 7.

    Zarogoulidis P, Kontakiotis T, Tsakiridis K, Karanikas M, Simoglou C, Porpodis K, et al. Difficult airway and difficult intubation in postintubation tracheal stenosis: a case report and literature review. Ther Clin Risk Manag. 2012; 8 : 279 -86 [DOI][PubMed]

  • 8.

    Sakles JC, Mosier J, Patanwala AE, Dicken J. Learning curves for direct laryngoscopy and GlideScope(R) video laryngoscopy in an emergency medicine residency. West J Emerg Med. 2014; 15(7) : 930 -7 [DOI][PubMed]

  • 9.

    Jungbauer A, Schumann M, Brunkhorst V, Borgers A, Groeben H. Expected difficult tracheal intubation: a prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients. Br J Anaesth. 2009; 102(4) : 546 -50 [DOI][PubMed]