Safe airway management in a patient with previous difficult intubations and distrust of the medical system: A case report

We present the case of a 72-year-old Sri Lankan woman with a complex and traumatic airway history, including multiple failed and prolonged intubation attempts both in the United States and Sri Lanka, resulting in oropharyngeal injury and post-traumatic stress. Despite concerning anatomy—severe dental crowding, limited mandibular translation, and a short thyromental distance—no formal records of past airway management were available, leaving significant uncertainty about the true nature of her airway difficulty. While the ASA Pre-Airway Management Decision-Making Tool supported induction of anesthesia prior to intubation, the lack of documentation and the patient's psychological trauma led to a shared decision to proceed with awake flexible scope intubation. The intubation was performed smoothly with topical anesthesia and sedation, and a Cormack-Lehane grade 1 view was observed upon confirmation. This case illustrates how geographic, institutional, and resource-based contexts can shape the definition of a difficult airway and impact clinical decision-making. It also underscores the value of emerging technologies like AI, ultrasound, and endoscopy in airway assessment, while emphasizing that patient experience and shared decision-making remain central to safe, individualized care.