BACKGROUND
Prediction of difficult intubation and ventilation is essential and challenging. Airway devices have been favorable for managing these situations but, sometimes, a secure airway is not possible. Endotracheal intubation through laryngeal mask with fibrobronchoscope is an effective and secure way to ensure airway permeability and ventilation. 
CASE REPORT
 51-year-old woman was required emergency laparoscopic cholecystectomy. Past medical history: bipolar syndrome, fibromyalgia and necrosis of temporomandibular joint which required surgery in 2014, with prosthesis implantation. Airway examination: regular neck length with excellent cervical extension, thyromental distance higher than 6 cm, mouth opening of less than 4 cm, Mallampati III. 
We used rapid sequence intubation with fentanyl, Propofol and rocuronium and first attempt was done with laryngoscope, and no structures couldn’t be visualized. We chose Airtraq number 3 with endotracheal tube 7 for second attempt and, due to limited mouth opening, manipulation of airtraq wasn’t possible and intubation was unsuccessful. We performed manual ventilation and we decided to place a laryngeal mask Ambu Auregain #3. After starting mechanical ventilation, we tried to introduce a stomach tube through laryngeal mask gastric channel, being this attempt unsuccessful and gastric content with air couldn’t be aspirated. Due to this finding, possible misplacement of supraglottic device was considered and we decided to perform fibrobronchoscope intubation through laryngeal mask. Intubation with ET was successful, and aspiration was performed. No other incidences were found during extubation. We explained the situation to our patient and we wrote an alert of difficult airway management for future intubations. 
DISCUSSION
Features for difficult airway intubation were found in this patient. Using supraglottic devices and others are essential in our daily practice for these cases, but sometimes, a total correct placement is not possible. Endotracheal intubation with fibrobronchoscope through laryngeal mask is a safe and effective option for intubation and ensuring airway permeability when objective findings about misplacement are seen during ventilation. 


02 / Difficult airway management in emergency surgery: fibrobronchoscope intubation through laryngeal mask