4PM Case

[Aether2000]

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Called to ICU in a small hospital for an urgent intubation on a 74 year old patient in respiratory distress, SpO2 97 on 50% O2, aerophagia, copious viscous yellow secretions being coughed up, and he is obviously dyspneic. There is a high pitched rattle when he coughs or inspires deeply. He presented yesterday with some dyspnea that has worsened considerably throughout the day. No prior history of respiratory distress or respiratory disease. The CT is attached.

 

[Planktonmd]

Retropharyngeal hematoma obstructing the airway secondary to a leaking thoracic aneurysm?
Intubate then figure it out

 

[Aether2000]

One clue is the location of the cords at C4-6, most commonly at C5: Anatomic location of the vocal cords in relation to... : European Journal of Anaesthesiology (EJA)
The sternal angle and carina are located at the T4 level and sternal notch at T2.

 

[nimbus]

Subglottic intraluminal tracheal abscess? Seems like a bad problem.

 

[2Fast2Des]

Prop roc tube? And a surgeon

 

[vector2]

Page thoracic surgeon, strap on some heliox/hfnc/NRB/whatever you got, decadron 12 iv. Frank discussion with pt and family about prognosis if he can't be temporized and transported to a tertiary center with ecmo capability since intubation/trach placement might not be of use if the mass can't be bypassed by a cannula or tube, or if the mass is friable and he drowns in his own blood.

Transport to OR. Place back of table at 30 degrees. Prep neck. Glyco, topical, ketamine, surgeon at head of bed with rigid bronch (connected to blow by o2) and loaded with reinforced ETT.

 

[nimbus]

Page thoracic surgeon, strap on some heliox/hfnc/NRB/whatever you got, decadron 12 iv. Frank discussion with pt and family about prognosis if he can't be temporized and transported to a tertiary center with ecmo capability since intubation/trach placement might not be of use if the mass can't be bypassed by a cannula or tube, or if the mass is friable and he drowns in his own blood.

Transport to OR. Place back of table at 30 degrees. Prep neck. Glyco, topical, ketamine, surgeon at head of bed with rigid bronch (connected to blow by o2) and loaded with reinforced ETT.

Agree ecmo is best chance.

 

[Aether2000]

Radiologist believes it is a solid large subglottic tumor, possibly thyroid etiology. ENT did a quick flex laryngoscopy but could not get below the mass and was fearful of causing bleeding. Multiple medical centers with thoracic and cardiac surgeons refused to accept the patient via transfer because the patient was not intubated and because there was no biopsy. Our IR and surgeons refused biopsy due to the location and a tracheostomy would not help. Our center lacks jet ventilation capabilities, cardiac surgery or sternal splitting equipment and rigid bronchoscopy is not available. We believed endotracheal intubation without traversing the stenotic segment would most likely not be useful. Patient decompensated and began to have increasing dyspnea and the family asked he be intubated. A frank discussion regarding the risks was had with the family, consent signed by POA, and he was placed in the sitting position, placed on 100% O2, given 1mg midazolam, a bilateral glossopharyngeal block (intraoral injection) was performed, but no further topical or aerosolized local anesthesia was used for fear of losing the already tenuous airway. Videolaryngoscopy was used to place a flexible fiberoptic bronchoscope through the cords. Massive thick secretions encountered and suctioned but could not pass the scope below the tumor due to mucosal folds preventing ingress of the scope. Your next move?

 

[pgg]

Did the frank discussion with the family mention a morphine drip and a quiet room for all of them?

 

[Aether2000]

Yes.

 

[vector2]

Keep him spontaneous, leave the tube above the mass, and see if he lives. See if a tertiary center will accept him now that he's technically intubated.

Barring that. There is no "next move" other than the one pgg mentioned.

 

[Planktonmd]

Sometimes flexing the neck forward might help you clear a path for the scope beyond the mucosal folds.
You are already in the trachea and there must be a passage otherwise he wouldn't be breathing, so I would manipulate the neck while maintaining visualization with the scope and try to advance it beyond the compression then hopefully intubate.

 

[deleted171991]

You don't do cardiac surgeries in that hospital? No chance of a fem-fem bypass, at least to get the biopsy and finish intubating?

 

[T-burglar]

Needs surgical/medical consultation to see if anyone thinks they can resect the mass at all, then if they think they can do it on a heparinized patient, or shrink it with radx chemo. Referral center sends ECMO team and initiates ECMO for stable transfer. Operation or medical debunking on heparinized patient.

If the patient is not a candidate for any of these treatments then palliate

 

[Aether2000]

Not enough time to get ECMO team from another hospital- no surgeons in our hospital do this type of surgery. There may have been enough time earlier in the day, but the patient came in with DNR status. It is interesting how a slow suffocation changes the mind. Cannot ventilate enough...suspect severe hypercarbia is occurring as the patient is in and out of consciousness.

Your tools:
Immediately available- bronchoscope, Cmac, Cook intubating catheter 14Fr, Bougie (solid) 15Fr, 6.0 mm ETT, 5.5mm ETT, 5.0mm ETT, 14 ga angiocath
Available elsewhere in hospital: J-wire, cricothrotomy set

What would you do?

 

[Xerxes1729]

Just a thought on transferring from an emergency physician:

The patient has an emergency medical condition. It sounds like your hospital does not have the capability (rigid bronch, cardiac surg/ECMO, etc) to care for this patient. If the other hospital does, they generally cannot refuse to accept the patient, and certainly not because the patient hasn't had a biopsy. You have to stabilize the patient as best you can, which may mean an ineffective ETT. Sometimes you really can't do anything and they just have to go. But yeah, mention "EMTALA violation" to the prospective receiving hospital and you'll get an acceptance pretty quickly.

But obviously, the case is more interesting if the answer isn't "send him somewhere else". So I get that. 🙂

 

[Aether2000]

I agree...we tried sending the patient to several other hospitals while this was unfolding but they refused transfer. I suppose we could have loaded the patient in an ambulance and sent the patient anyway.

 

[deleted171991]

Not enough time to get ECMO team from another hospital- no surgeons in our hospital do this type of surgery. There may have been enough time earlier in the day, but the patient came in with DNR status. It is interesting how a slow suffocation changes the mind. Tracheal tube not relieving respiratory distress and cannot ventilate enough...suspect severe hypercarbia is occurring as the patient is in and out of consciousness.

Your tools:
Immediately available- bronchoscope, Cmac, Cook intubating catheter 14Fr, Bougie (solid) 15Fr, 6.0 mm ETT, 5.5mm ETT, 5.0mm ETT, 14 ga angiocath
Available elsewhere in hospital: J-wire, cricothrotomy set

What would you do?

I would try to pass the Cook or the bronch. Both allow ventilation while playing with them. The bougie may not be such a bad idea either; it might be maneuvered out the mucosal folds. Then try to pass the 5.0 ETT.

It ain't over till it's over. Keep cool and keep intubating.

P.S. Also, I assume you have already placed the patient in whatever position was easier to breathe in.

 

[AdmiralChz]

Next move - morphine/versed, get family, hold hand. Patient was a DNR earlier in the day, sounds like it’s his/her time. This isn’t the Apollo 13 mission when you need to fit a square peg into a round hole...

 

[Impromptu]

Ethics question. Did the POA sign the consent for intubation with the patient lucid? If so, not valid if the patient explicitly declined intervention. If they simply waited until the patient was not lucid, but prior to this he was lucid and declined intervention, then I also would not do anything. That is a bad POA.

 

[IMGASMD]

It is interesting how a slow suffocation changes the mind

I take that as the patient revoked the DNR?

 

[deleted171991]

Of course he did.

 

[dmk5n]

EMTALA violation?
$$$

 

[Ezekiel2517]

Wow, this is like deja vu. Had a similar case recently. On call, community hospital. Pt with a large subglottic mass/tumor. She has some SOB. Plan was for a DL, biopsy, and trach. Spoke with ENT surgeon preop (pretty fresh out of training), asked what his thoughts were. He said he believes I can slip a 5 cuffless ett in there, but that he would be prepared for a trach at any sign of trouble. I suggest just going with an awake trach but he prefers this route. I topicalized the airway well. Gave some sedation while keeping spontaneous ventilation intact. Only had a portable fiberoptic scope at this facility and obviously this cannot accommodate a 5 ett. Placed a glidescope gently into mouth, got a grade 1 view. Attempted passing a 6ett. No way of passing thru cords bc of complete obstruction by the mass. No airway visible at all. The ett was literally folding on itself. Tried passing the 5 cuffless. Same result. The mass was nearly bulging thru the cords. Obviously only chance was a surgical airway/trach at this point but bc of the extent of the mass, this proved difficult as well. Very difficult mask led to pt desatting quickly. The only thing that saved us was that the surgeon managed to excise a tiny part of the obstructing mass and create a small hole in it while he was dissecting which allowed us to at least oxygenate thru an LMA while he eventually placed the trach. We got very lucky.

 

[Aether2000]

All options available were considered and ultimately a bougie was passed beyond the obstruction with minimal difficulty. We calculated that a minimum 6.0 mm tube would be needed in order to have enough length to traverse the stenosis. The ETT traversed the mass with rotation of the tube over the bougie. The ETT was advanced to its full 30cm length. The final x-ray is shown below with the tip 3.3cm above the carina. Large amounts of thick yellow secretions were suctioned from the trachea below the mass. The patient stabilized and was transferred the next morning to a hospital with the ability to biopsy the lesion and surgically resect if indicated.

 

[shepardsun]

All options available were considered and ultimately a bougie was passed beyond the obstruction with minimal difficulty. We calculated that a minimum 6.0 mm tube would be needed in order to have enough length to traverse the stenosis. The ETT traversed the mass with rotation of the tube over the bougie. The ETT was advanced to its full 30cm length. The final x-ray is shown below with the tip 3.3cm above the carina. Large amounts of thick yellow secretions were suctioned from the trachea below the mass. The patient stabilized and was transferred the next morning to a hospital with the ability to biopsy the lesion and surgically resect if indicated.

Total baller. I don't think it's likely in this case but some of these thyroid cancers can be exquisitely sensitive to radiation and chemo. You acutely saved his life, you may have bought him an extra decade with his family.

You mentioned the bougie was solid- how long between placement of the tracheal tube and the bougie/definitive airway securing? Was the patient still spontaneous at this point? What were his sats? Do you have gas values?

 

[Aether2000]

He was spontaneously breathing....sats were in the low 80s high 70s prior to subglottic mass intubation but he was effectively unresponsive except for coughing. It was a last ditch effort and we were lucky. The time between bougie and ETT placement was <20 seconds since when the bougie was placed there was total obstruction. I posted the case here to make several points to residents- as pointed out by my erudite colleagues there are many ways to achieve a goal, in private practice sometimes we encounter less than optimal circumstances with inadequate resources, the need to use what tools are available in ways that may be unorthodox, and that we have the privilege of trying to do what is within our power to save others who want to live- even if it is for a short while. Sometimes we fail in our efforts but we have weigh the failure of not trying against the prolongation of suffering we might cause by being successful.