To the Editor:--A 47-yr-old woman and her 70-yr-old mother experienced difficult intubations within 2 months of each other while undergoing general endotracheal anesthesia.
Preoperatively, the daughter's airway revealed a three-finger-breadth mouth opening with partial visualization of her uvula, three-finger-breadth thyroid-mental distance, adequate neck mobility, and full dentition. She stood 158 cm tall, weighed 80 kg, with the majority of her weight distributed to the lower portion of her body. No other significant medical history existed. After intravenous sodium thiopental and succinylcholine, one unsuccessful tracheal intubation attempt by the student nurse anesthetist, two attempts by the certified registered nurse anesthetist, and two attempts by the staff anesthesiologist included varying head position, cricoid cartilage pressure, and use of both Macintosh and Miller laryngoscope blades. Laryngoscopy in all attempts permitted visualization of the epiglottis but not the vocal cords. Adequate ventilation was possible via face mask between intubation attempts. A call for help and a request for the difficult airway cart occurred simultaneously with return of the patient's spontaneous respirations. A blind nasal tracheal intubation by a second staff anesthesiologist succeeded on the third attempt. The gynecologic surgical procedure progressed uneventfully. A second airway assessment postoperatively was similar to her preoperative airway evaluation. Postoperatively, the patient experienced hoarseness and soreness of her pharynx and larynx for 10 days. The patient registered with the Difficult Airway Medic Alert Registry and purchased a Medic Alert bracelet* **.
Subsequently, her edentulous mother, at another hospital, after intravenous induction of general anesthesia and use of a combination of rocuronium and mivacurium for muscle relaxation, was found to require three attempts before successful tracheal intubation. Her height was approximately 153 cm, and she weighed approximately 68 kg, with most of her body weight in her abdomen, hips, and thighs. Again, visualization of the epiglottis but not the vocal cords occurred. The patient had previous laminectomy surgery many years ago, but these medical records were not available. Her orthopedic surgery progressed uneventfully, and postoperatively, she experienced a minimal sore throat. Postoperatively, no other existing medical conditions revealed a potential for a difficult intubation, and her previous medical records for her laminectomy could not be located. She also wears a Medic Alert bracelet.
When assessing the surgical patient preoperatively, one includes a question about family problems with anesthesia. We suggest a heightened awareness when taking the preanesthetic history regarding possible difficult intubation in family members. As the registry of difficult intubations acquires data, the presence of genetically related patients might be addressed.
Janet N. Siler, M.D., Daniel B. Walter, M.D., Mary Finnerty, C.R.N.A., Michelle Byrnes, S.R.N.A., Nazareth Hospital, 2601 Holme Avenue, Philadelphia, Pennsylvania 19152.
Idona Umali, M.D., Hazelton-St. Joseph's Medical Center, 667 North Church Street, Hazelton, Pennsylvania 18201.
(Accepted for publication April 10, 1995.)
* Mark L: Medic Alert National Registry for Difficult Airway/Intubation, The Johns Hopkins University, Alert or Patient Enrollment, 1-410-955-0631 or fax 1-410-955-0994.
** Medic Alert 1-800-432-5378, Medic Alert Foundation, Turlock, California 95381-1009.