Awake video laryngoscopy and tracheal intubation in a super morbidly obese critically ill patient with a physiologically difficult airway

Standard airway management in deteriorating super morbidly obese patients can lead to cardiovascular collapse because of their poor physiological reserves. In this report, we describe a case of awake tracheal intubation in a super morbidly obese patient who was rapidly deteriorating in the intensive care unit. The patient was approached as having a physiologically difficult airway, and therefore, we accounted for the four Hs: hypoxia, hypotension (systemic), hydrogen ions (metabolic acidosis) and hypertension (pulmonary). To optimise these patient factors, we administered pre- and apnoeic oxygen through a high-flow nasal cannula to prevent hypoxia. Awake video laryngoscopy was performed to avoid cardiovascular compromise that could arise from using sedation/induction agents. Intravenous metaraminol was run in parallel to fluid support to reduce cardiovascular compromise risks and worsening acidosis. Approaching the patient as an anatomically and physiologically difficult case provided a safe technique for securing an extremely challenging airway.