Airway pre-op case

[CanGas]

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45 yo male. Booked for laser surgery by ENT. Asked to see in pre-op center re possibility of using a hunsaker tube during the case.

278 lbs. 6'.
HTN
DMII - retinopathy, peripheral neuropathy
OSA - home CPAP
GERD

Extended intubation with failed extubation requiring tracheostomy 4 months ago following neuro problem that is now fully resolved. Presented 1 month ago to ER with SOB and inspiratory and expiratory stridor.

Seen by ENT who on FOB saw a “2-3mm airway 2nd to posterior vocal cord web”.

Pt reports limited exercise tolerance 2nd to SOB (3-4 stairs). Unable to lay flat 2nd to SOB without CPAP machine, otherwise must be at 30-40 degrees.

On exam a big guy. Full teeth. MP 4. 3 finger mouth opening and thyro-mental distance. Normal cervical ROM. Obvious inspiratory and expiratory noisy breathing.

How would you manage this airway and case?

 

[urge]

Carefully.


What's a hunsaker tube?

 

[CanGas]

It's a fancy jet ventilator tube.

Monograph at: http://www.medtronicent-techcomms.com/inserts-web/68E1504_A.pdf

Want to elaborate on what you mean by "carefully"?

 

[huktonfonix]

not sure what a hunsaker is either. I would probably just share the airway with ENT if he looks maskable since the vocal cord opening looks too small to get a tube past. Keep him asleep with IV medications of your choice (propfol, remi would be my choice). Paralyze since you dont want the cords moving(sux drip if short procedure) . Might want to see if this guy has any significant pulmonary hypertension since theres likely gonna be some permissive hypercapnia going on. Since ENT is there they can re trach him if necessary. If not I suppose jet ventilation with a 14/16 is also a possibility although Im not sure if this would get in the way of the laser

 

[Planktonmd]

It's a fancy jet ventilator tube.

Monograph at: http://www.medtronicent-techcomms.com/inserts-web/68E1504_A.pdf

Want to elaborate on what you mean by "carefully"?

If the airway is only 3 mm it appears to me that your best option would be transtracheal jet ventilation to avoid having to intubate the patient.
I believe there is a laser resistant catheter out there for this purpose.

 

[urge]

can you put that thing via an awake fiberotic?

otherwise i might consider to breath him down with sevo, bolus some lidocane, maybe ketamine, and let the ent guy have a crack at laryngoscopy.

 

[militarymd]

Hunsaker tubes are a bitch....he doesn't sound like a good candidate for it.

vessel dilator through cricothyroid membrane and jet through that.....tiva for the anesthetic.

 

[Noyac]

Never placed a Hunsaker tube but I would attempt it only if he is awake with a backup plan just as the master MIL described.

Why would anyone remove his trach?

 

[jetproppilot]

Why would anyone remove his trach?

I think its already gone.

 

[jetproppilot]

I think its already gone.

OHHHHHHHHHHHHHHH

Silly me.

You were asking why they'd remove it in the first place.

Kind slow tonight.

 

[cchoukal]

This came up in a thread a few months back, but if jet ventilation was your strategy, this could be achieved via the ENT's laryngoscope, rather than via the trans-tracheal route.

 

[militarymd]

not quite the samee

This came up in a thread a few months back, but if jet ventilation was your strategy, this could be achieved via the ENT's laryngoscope, rather than via the trans-tracheal route.

 

[Planktonmd]

This came up in a thread a few months back, but if jet ventilation was your strategy, this could be achieved via the ENT's laryngoscope, rather than via the trans-tracheal route.

If they are going to laser the vocal cords (which appears to be the case here) I am not sure you can ventilate through the laryngoscope.

 

[zippy2u]

Dude, "2-3 mm airway" is like breathing through a couple swizzle straws. Retrach him awake at the dungeon, depressing hospital and then bring him to the compassionate, beautiful, airy ASC where we'll handle the laryngeal web laser money show. Who needs a Hunsaker when ya have a nice and shiny trach. Regards, ----Zippy

 

[CanGas]

So this case has not been done yet, but when it gets done I will try and post back what was actually done.

Of course the consult was sent with no CT result so I am trusting the fiberoptic exam of no subglotic stenosis but have asked for the report to make sure no sub-glottic component.

We recommended that since there was no subglottic stenosis just do an awake trach, laser away, and decannulate later. However, my impression was that the ENT dude really did not want to have to trach the guy and just see if he could do a quick laser with us ventilating in some manner.

In my mind a 2-3mm opening is not large enough to allow for passage of a jet ventilator cathater and leave enough room for gas release to avoid the lungs going "pop". Thought about the transtracheal jet but: 1) there are plenty of reports of the jet ventilator dissecting the trachea because you don't know if your ventilator canula is abutting the wall of the trachea and that would really suck in this case. 2) He is a big guy and I did not think that ventilating with the jet would be that easy and then not sure that trying to do this with 30% O2 would be feasible (remember, jet ventilating with 100% O2 is not a great idea for laser surgery).

After talking to some colleagues some mentioned that since this was just a posterior vocal cord web you could just do direct laryngoscopy (but remember this guy does not look easy) and worse case scenario is just ram a tube through and break the web. I personally don't think I would have the balls for this unless the ENT doc tells me this web is thin and this would be a feasible option.

I'll try and let you know what happens for the case.

CanGas

 

[Jeff05]

i would NOT put this guy to sleep without an airway in place. it does not seem like a tube could be placed via VC. jet ventilation would not be the best method in this heavy patient.

he must have a surgical airway since there is an actual anatomic hindrance to ETT insertion and transtracheal jet ventilation may be an ineffective method of ventilation.

recently all the clinical scenarios call for TRACH.

 

[Fah-Q]

This is a situation when the ENT needs to have a solid plan that you feel like you can carry out.

Here is what I would ask of my anesthesiologist:
Breathe him down with gas and whatever else he needs for a quick DL, breathing spontaneously. I'll look with my favorite scope and topicalize his cords/scar. If I can't get a decent look then we'll wake him up and do an awake trach. Get him deeper but still spontaneously breathing. Turn table 90 degrees. I'll position him and put in the biggest operating scope I can. Take him as deep as you want. Give me the Hunsaker and we'll jet for pre-oxygenation. The nurse is ready with a rigid bronch I can slam in if he can't be adequately ventilated, which will also dilate his stenosis. Position the laser, pull the Hunsaker, I'll suck the oxygen out of his airway, fire the laser to work on the scar till he starts to desat. Replace the Hunsaker and repeat.

Feel OK with that? I realize that his body habitus might make a few of the above steps difficult or impossible. Awake trach is the default in my mind.