Failed Intubation in Obese Patient with Achalasia

You are the duty anaesthetist at a busy tertiary hospital. Your provisional fellow calls you for urgent assistance with an airway emergency. They have performed a rapid sequence induction and attempted to intubate a 22-year-old man for a Per-Oral Endoscopic Myotomy (POEM) procedure for type 2 achalasia in the main theatres. Intubation was attempted with a videolaryngoscope and hyperangulated blade. The percentage of glottic opening visible was 10% and they were unable to pass the endotracheal tube or a gum elastic bougie. They were then unable to bag-mask ventilate the patient but successfully placed a second generation supraglottic airway. Ventilation has been restored, and green tinged fluid has been noted in the gastric port. Current observations are: HR 95 bpm BP 97/56 mmHg SpO2 90% on FiO2 1.0 ETCO2 41 mmHg (5.47 kPa) TV 400 mL with a small air leak Weight 169 kg Height 199 cm BMI 42 kg/m2 Past Medical History Type 2 achalasia Class III obesity Attention deficit hyperactivity disorder Mild developmental delay Severe anxiety Medication Lisdexamfetamine 70 mg once daily Melatonin 4 mg nocte Diazepam 10 mg was given orally preoperatively Allergies Nil known