Another AW case

[sevoflurane]

It’s Friday, you are not on call and just finished an EF of 15% AVR/cabg x3. You have one foot out the door when all of a sudden you get called for a trach (fauk).

65 y/o morbidly obese patient with a pharyngeal mass. Smoked her whole life, can’t lie flat, can hardly talk. Below is her CT scan.

Plan?

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[abolt18]

Awake trach under local, sitting up at 45 degrees. That's all I've got.

 

[vector2]

It’s Friday, you are not on call and just finished an of EF 15% AVR/cabg x3. You have one foot out the door when all of a sudden you get called for a trach (fauk).

65 y/o morbidly obese patient with a pharyngeal mass. Smoked her whole life, can’t lie flat, can hardly talk. Below is her CT scan.

Plan?

Put my 2nd foot out the door.

 

[GassYous]

Call the backup ENT. Sit her up. Tell her to take some nice shallow breaths. Give some fentanyl to decrease ventilation. Slide in a nasal airway. Have jet ventilator hooked up ready to go. Hi flo nasal cannula maxed out. Igel4 lubed up and ready to go. Surgeon to put some lido at the site and have the nurse hold her hand.

 

[dabears505]

I'm having one of the call guys do that case. I'm taking over one of the lap choles running.

 

[sevoflurane]

Put my 2nd foot out the door.

g’dangit. 😂😂

 

[sevoflurane]

Awake trach under local, sitting up at 45 degrees. That's all I've got.

Can’t lie flat. No neck. ENT really doesn’t want to do an awake trach.

 

[abolt18]

Can’t lie flat. No neck. ENT really doesn’t want to do an awake trach.

Just like you don't "want" to do that case, but it doesn't mean it's not a great option. (I can't imagine there are any "great" options here.)

 

[Arch Guillotti]

Can’t lie flat. No neck. ENT really doesn’t want to do an awake trach.

The ENT is a punk. What does the nasopharyngeal scope look like?

 

[deleted697535]

Can’t lie flat. No neck. ENT really doesn’t want to do an awake trach.

Well thats great then...
Have a reasonable attempt at marking her neck and freeze it up. So called double setup with ent there ready to cut
Then topicalise her up, low dose remi and some midaz... Try afoi it with one of those lovely nasal tubes that are really long but also like down to size 6...

It it doesn't do, it doesnt go...

1 shot at that then ent better man up and do their job

You could try one shot at a transtracheal injection to numb her up. If you could get it and leave a 20g catheter in there than might at least mark the neck for ent to follow. Ive seen that done twice but never did it myself, and both times ent were not present and eventually not needed anyway... The anesthesia doing it was more comfortable with a perc trache than a surgical one, thay was the logic

 

[MirrorTodd]

Standing vv ecmo.

 

[GassYous]

Standing vv ecmo.

Placing those cannulas is no joke in a fatty. And you have to heparinize which I would prefer not to do.

 

[WheezyBaby]

Then topicalise her up, low dose remi and some midaz... Try afoi it with one of those lovely nasal tubes that are really long but also like down to size 6...

It it doesn't do, it doesnt go...

1 shot at that then ent better man up and do their job

That's more or less what I had in mind, except maybe ketamine instead of versed. Any benefit to a reinforced ETT in trying to push past the compression?

 

[MirrorTodd]

Placing those cannulas is no joke in a fatty. And you have to heparinize which I would prefer not to do.

I was definitely not serious. lol shoulda used a smiley.

 

[nimbus]

I see a hole.

 

[Arch Guillotti]

Call the backup ENT. Sit her up. Tell her to take some nice shallow breaths. Give some fentanyl to decrease ventilation. Slide in a nasal airway. Have jet ventilator hooked up ready to go. Hi flo nasal cannula maxed out. Igel4 lubed up and ready to go. Surgeon to put some lido at the site and have the nurse hold her hand.

Wait, what? The ENT is presumably the one who has called for an OR for the trach.

Would be very wary of giving anything to decrease ventilation. If it gets so bad that the patient needs to be jetted then a surgical airway is the surgeons responsibility. And what's the LMA for?

 

[deleted875186]

hate these cases.

ENT ready to go with neck prepped. Hi flow 100% oxygen.

topicalize, fentanyl and ketamine or fentanyl and low dose versed, try with a 6.0 tube, if it doesn’t go than awake trach.

I second the nasal scope by ENT preop, can tell you how it looks, if these friable tissue, etc, would help inform your plan

 

[GassYous]

Wait, what? The ENT is presumably the one who has called for an OR for the trach.

Would be very wary of giving anything to decrease ventilation. If it gets so bad that the patient needs to be jetted then a surgical airway is the surgeons responsibility. And what's the LMA for?

Two ents are better than one. Dynamic variable extrathoracic airway obstruction calls for decreasing ventilation. She is probably nervous and breathing harder than she should from being fat and obstructed and low dose opioids should help with both.

You can jet through the nasal trumpet. LMA for if you can't get any air in cause masking her is pita from too much soft tissue. Just shove it in and try to oxygenate a little before they reach trachea. I think tubing this patient is a mistake.

Another thing is you can use ultrasound to look for landmarks for the surgeons before you start and mark the site.

 

[vector2]

The ENT is a punk. What does the nasopharyngeal scope look like?

Based on the CT (and presentation) I bet her scope also looks horrible. Her epiglottis is super edematous, then the airway begins deviating significantly to her left, and of course right at the glottis and subglottis is where it narrows to like 2-3 mm. Even if the ENT got a decent look at the cords, the pretest probability of being able to pass the cords with even a pedi scope and small ETT is questionable. And of course pharyngeal/laryngeal masses in lifelong smokers are not infrequently friable and bleed like stink, so even doing FOI fully awake, between spasm, bleeding, or worsened swelling you might lose the airway anyway unless you nail it first attempt.

So, with the premise that ENT is absolutely refusing to do an awake trach (which is somewhat understandable considering we’re dealing with a huge pt, no neck, big mass, and deviated airway) .... Based on what @sevoflurane is saying, this lady is urgent bordering on emergent. Sometimes you have difficult airway masses in perfectly stable people, and then you have difficult airway masses in fatties where the buzz phrase “can hardly talk” has been mentioned. Taking your time for a 20-30 min slow and thorough topicalization is nice, but it’s not necessarily possible in this situation. Morbidly obese people breathing through a straw tend not to be the most coherent or most cooperative pts for topicalization, nor the best candidates for receiving even mild sedation like precedex.

That being said, I would prefer to do it awake with topical, and perhaps with actual eyes on her I could make the assessment that we have more time and she’s cooperative and it’s more feasible than what it sounds like right now on paper. But I would be leaning toward glyco, high flow nasal cannula on (the actual vapotherm at 60L/min and 100% FiO2), reverse trendelenburg, pre-ox, neck prepped. In room: 2nd set of hands, glidescope, pedi fiber loaded up with a 6.0 reinforced, bougie, LMAs, and most importantly, ENT with a rigid bronch ready to connect to an O2 source. I have a pretty high confidence based on the CT (and if the ENT saw glottis on their preop scope) that we’ll be able to get glottic exposure with videolaryngoscopy. So 2 of versed, 100 of ketamine, roc, sugammadex at the ready, prop drip at the ready, then glidescope in, 2nd person drives pedi bronch through cords and sees if 6.0 will pass.

If no dice, ENT jams this down her trachea and we TIVA until the trach is secured.

 

[Arch Guillotti]

Based on the CT (and presentation) I bet her scope also looks horrible. Her epiglottis is super edematous, then the airway begins deviating significantly to her left, and of course right at the glottis and subglottis is where it narrows to like 2-3 mm. Even if the ENT got a decent look at the cords, the pretest probability of being able to pass the cords with even a pedi scope and small ETT is questionable. And of course pharyngeal/laryngeal masses in lifelong smokers are not infrequently friable and bleed like stink, so even doing FOI fully awake, between spasm, bleeding, or worsened swelling you might lose the airway anyway unless you nail it first attempt.

So, with the premise that ENT is absolutely refusing to do an awake trach (which is somewhat understandable considering we’re dealing with a huge pt, no neck, big mass, and deviated airway) .... Based on what @sevoflurane is saying, this lady is urgent bordering on emergent. Sometimes you have difficult airway masses in perfectly stable people, and then you have difficult airway masses in fatties where the buzz phrase “can hardly talk” has been mentioned. Taking your time for a 20-30 min slow and thorough topicalization is nice, but it’s not necessarily possible in this situation. Morbidly obese people breathing through a straw tend not to be the most coherent or most cooperative pts for topicalization, nor the best candidates for receiving even mild sedation like precedex.

That being said, I would prefer to do it awake with topical, and perhaps with actual eyes on her I could make the assessment that we have more time and she’s cooperative and it’s more feasible than what it sounds like right now on paper. But I would be leaning toward glyco, high flow nasal cannula on (the actual vapotherm at 60L/min and 100% FiO2), reverse trendelenburg, pre-ox, neck prepped. In room: 2nd set of hands, glidescope, pedi fiber loaded up with a 6.0 reinforced, bougie, LMAs, and most importantly, ENT with a rigid bronch ready to connect to an O2 source. I have a pretty high confidence based on the CT (and if the ENT saw glottis on their preop scope) that we’ll be able to get glottic exposure with videolaryngoscopy. So 2 of versed, 100 of ketamine, roc, sugammadex at the ready, prop drip at the ready, then glidescope in, 2nd person drives pedi bronch through cords and sees if 6.0 will pass.

If no dice, ENT jams this down her trachea and we TIVA until the trach is secured.

View attachment 329284

Pretty good although I might just skip the part with driving the fiberoptic scope. Driving is easy until it isn't. Load a 6.0 reinforced tube on the glide scope stylette and jam it home.

 

[vector2]

Pretty good although I might just skip the part with driving the fiberoptic scope. Driving is easy until it isn't. Load a 6.0 reinforced tube on the glide scope stylette and jam it home.

That was my initial thought, but again it looks like subglottic stenosis. Maybe give it a quick shot first to see if you can pass the tube normally, but I’ve had a case exactly like this where I got called into a room to help after my colleague had already induced cause a 5.5 tube, even with an attempt at full rotation right left and right to keep the bevel from hanging, absolutely would not go more than a millimeter past the cords. I then told my colleague to hold the glidescope exposure and I was able to ram the loaded pedi bronch past the tracheal stenosis and railroad the tube over it.

 

[Arch Guillotti]

Reminds me of the greatest prose ever written on SDN by the old zipster:

Last day of residency was ,without a doubt, one of the best days of my life... I was on call, 3AM get a call from burn unit to emergently intubate a big guy that had been 50% burned upper torso with smoke inhalation. Half a stick of STP and 100 o' sux-- all edema. I told myself I wasn't goin' out like this. Just rammed a 7.5 where I thought it should be and it slid in. BS bilateral and PCXR was solid. O2 sats golden and RT lady all happy. No procedure note, no charge sheet. Beeper left at OR board when no one was lookin'. Slid out hospital at 0645 with no goodby's, thank you's or gonna miss you's. Got to the apt. and loaded up U-Haul with 100% VA disability, 100% SS disability uncle( Vietnam, agent orange, PTSD--you know the bogus gig). Letter and keys in an envelope dropped in the apt. night box. No change or forwarding of address with post office, no cares about apt. or electric deposits. ZIPPY DONE EVAPORATED! Roll on out at 1700 with floorboard boom box playin' "Comfortably Numb", and a bottle of chilled Wild Turkey in the ice chest. Uncle drivin' and on outskirts of town we light up a big fat doober. I told him not to shut off the old biitch until we were home. Ole Hunter Thompson didn't have a thing on us that night... Regards, ---Zip

 

[Hork Bajir]

Anyone down for a retrograde wire? As suggested above, visualizing the cords from above wouldn’t be the issue here... but having a wire over which to seldinger a small Parker tip tube would allow you to corkscrew the tube as needed to pass the point of obstruction, not to mention serve as a placeholder for a cric if needed

I’ve never actually done a retrograde wire, but been waiting for my chance and this seems like a good case : )

 

[GassYous]

Anyone down for a retrograde wire? As suggested above, visualizing the cords from above wouldn’t be the issue here... but having a wire over which to seldinger a small Parker tip tube would allow you to corkscrew the tube as needed to pass the point of obstruction, not to mention serve as a placeholder for a cric if needed

I’ve never actually done a retrograde wire, but been waiting for my chance and this seems like a good case : )

Haven't done it personally but have seen several in residency. It is not easy to pass the tube even over the wire. I wouldn't want to mess with that mass.

 

[Consigliere]

Can’t lie flat. No neck. ENT really doesn’t want to do an awake trach.

Tough sh_it. Awake trach or find someone else to do the case.

 

[coffeebythelake]

Anyone down for a retrograde wire? As suggested above, visualizing the cords from above wouldn’t be the issue here... but having a wire over which to seldinger a small Parker tip tube would allow you to corkscrew the tube as needed to pass the point of obstruction, not to mention serve as a placeholder for a cric if needed

I’ve never actually done a retrograde wire, but been waiting for my chance and this seems like a good case : )

Putting an ultrasound probe on the neck and finding trachea might be useful though. If u can do a retrograde wire u can easily do a trach by seldinger technique

 

[Arch Guillotti]

Putting an ultrasound probe on the neck and finding trachea might be useful though. If u can do a retrograde wire u can easily do a trach by seldinger technique

Trach or cric?

 

[coffeebythelake]

Trach or cric?

Either
Dealers choice

 

[abolt18]

Anyone down for a retrograde wire? As suggested above, visualizing the cords from above wouldn’t be the issue here... but having a wire over which to seldinger a small Parker tip tube would allow you to corkscrew the tube as needed to pass the point of obstruction, not to mention serve as a placeholder for a cric if needed

I’ve never actually done a retrograde wire, but been waiting for my chance and this seems like a good case : )

Done it on pig cadavers. To say the least, the success rate between groups attempting it was abysmal. I had significant doubts in my ability to do it successfully in an emergent situation. I'd rather just do a cric at that point. I feel I'd have a greater chance of success.

 

[coffeebythelake]

Done it on pig cadavers. To say the least, the success rate between groups attempting it was abysmal. I had significant doubts in my ability to do it successfully in an emergent situation. I'd rather just do a cric at that point. I feel I'd have a greater chance of success.

agree, retrograde wire is something cool to talk to your friends about, but actually pulling it off especially in a disaster sounding airway like this will be extremely unlikely

 

[Hork Bajir]

Interesting- I always thought it looked pretty easy. What was the point where people were getting hung up? Passing tube thru cords? If so, did you try doing it under direct visualization, or loading your tube on a fiber scope and guiding the fiber scope in by feeding the wire thru the working channel?

 

[abolt18]

Interesting- I always thought it looked pretty easy. What was the point where people were getting hung up? Passing tube thru cords? If so, did you try doing it under direct visualization, or loading your tube on a fiber scope and guiding the fiber scope in by feeding the wire thru the working channel?

Difficulty threading the wire correctly, it seemed to get caught a lot. Difficulty pulling getting it out through the mouth. Wire kinking when trying to thread a tube over it (though I think your bronchoscope suggestion would help with this part). Overthreading the tube past the wire insertion site leading to a new kink and inability to remove the wire.

There are so many parts where it can go wrong.

 

[Arch Guillotti]

Difficulty threading the wire correctly, it seemed to get caught a lot. Difficulty pulling getting it out through the mouth. Wire kinking when trying to thread a tube over it (though I think your bronchoscope suggestion would help with this part). Overthreading the tube past the wire insertion site leading to a new kink and inability to remove the wire.

There are so many parts where it can go wrong.

Getting the right wire would seem to be a major stumbling point.

 

[abolt18]

Getting the right wire would seem to be a major stumbling point.

We had an actual "retrograde wire" kit.

 

[GassYous]

Use the epidural wire and snake it through the murphy's eye

 

[sevoflurane]

We had an actual "retrograde wire" kit.

Ya the wires are super long and stiff and I always railroaded the bronchoacope over the wire with a preloaded ETT.
3 for 3 retrogrades for me. Last one i did was like 10 years ago though.
Kind of a lost art with few indications.

I think in this particular patient placing the guidewire from below would be tough with all the mass effect. Putting a wire through the narrowest part of her 3mm AW might actually cause some problems. Furthermore, i find the indication for retrograde intubation to be associated mostly with extremely poor mouth opening- not necessarily a base of the tongue/pharyngeal/laryngeal mass.

 

[sevoflurane]

The ENT is a punk. What does the nasopharyngeal scope look like?

Nah. She was super nice. I called her up to go an hour early since it was Friday so she had already garnished some points from me.

We met in pre-op to discuss the case and review images. She had some serious concerns. This patient was extremely kyphotic, morbidly obese and had a history of freaking out during her nasal endoscopy. She basically had one level just above the sternum where she had a shot of a trach- regardless, the trachea was deep and the tumor was in close proximity. We did discuss doing a sternotomy/retrosternal tracheostomy.

Just a crapy case all around.

 

[sevoflurane]

The ENT is a punk. What does the nasopharyngeal scope look like?

Great question and a great learning point:

A lot these patients have had a nasal scope and have some pix to look at prior to heading back to the OR

A little more history:

This patient was scheduled for a trach months ago.... but she refused until she showed up in the ED w/ a compromised AW and worsening SOB.

I will try to uplod the nasal endoscopy pic. The problem is... the pix were a few months old and the tumor had likely grown.

 

[sevoflurane]

Based on the CT (and presentation) I bet her scope also looks horrible. Her epiglottis is super edematous, then the airway begins deviating significantly to her left, and of course right at the glottis and subglottis is where it narrows to like 2-3 mm. Even if the ENT got a decent look at the cords, the pretest probability of being able to pass the cords with even a pedi scope and small ETT is questionable. And of course pharyngeal/laryngeal masses in lifelong smokers are not infrequently friable and bleed like stink, so even doing FOI fully awake, between spasm, bleeding, or worsened swelling you might lose the airway anyway unless you nail it first attempt.

So, with the premise that ENT is absolutely refusing to do an awake trach (which is somewhat understandable considering we’re dealing with a huge pt, no neck, big mass, and deviated airway) .... Based on what @sevoflurane is saying, this lady is urgent bordering on emergent. Sometimes you have difficult airway masses in perfectly stable people, and then you have difficult airway masses in fatties where the buzz phrase “can hardly talk” has been mentioned. Taking your time for a 20-30 min slow and thorough topicalization is nice, but it’s not necessarily possible in this situation. Morbidly obese people breathing through a straw tend not to be the most coherent or most cooperative pts for topicalization, nor the best candidates for receiving even mild sedation like precedex.

That being said, I would prefer to do it awake with topical, and perhaps with actual eyes on her I could make the assessment that we have more time and she’s cooperative and it’s more feasible than what it sounds like right now on paper. But I would be leaning toward glyco, high flow nasal cannula on (the actual vapotherm at 60L/min and 100% FiO2), reverse trendelenburg, pre-ox, neck prepped. In room: 2nd set of hands, glidescope, pedi fiber loaded up with a 6.0 reinforced, bougie, LMAs, and most importantly, ENT with a rigid bronch ready to connect to an O2 source. I have a pretty high confidence based on the CT (and if the ENT saw glottis on their preop scope) that we’ll be able to get glottic exposure with videolaryngoscopy. So 2 of versed, 100 of ketamine, roc, sugammadex at the ready, prop drip at the ready, then glidescope in, 2nd person drives pedi bronch through cords and sees if 6.0 will pass.

If no dice, ENT jams this down her trachea and we TIVA until the trach is secured.

View attachment 329284

Nice post. And good job picking up on the buzzword. When they can’t talk things have progressed beyond comfort levels. Spider sense was going off after I examined her.

 

[sevoflurane]

 

[deleted162650]

Pretty sure that’s just the scrap bucket at your local butcher shop.

 

[sevoflurane]

Hamburguesa?

 

[sevoflurane]

So we didn’t have a nasal endoscopy, but did have speech therapist note with some pics which were obviously concerning. Diving further into their notes... i did find this one which was mildly sphincter relaxing.

 

[sevoflurane]

But again... these were old pics.

 

[IMGASMD]

That’s from a few months ago?! And since it’s getting bigger?

I am not sure why we are even deciding how to intubate? Trach, trach trach!! Are you sure you can even pass any reasonable sized tube through that slim opening?

 

[WheezyBaby]

**** that, that's so much worse than I expected. Bless yall

 

[sevoflurane]

😂😂

Pictures definitely give you a sense that if you pass a guidewire for a retrograde you may end up with a bigger problem than what you started with. Can you guys identify the glottic opening in the first pic?

 

[Hork Bajir]

If awake trach isn’t an option, homeboy needs VV ECMO. No way I’m sticking a scope (or anything else) into his mouth- first do no harm. Just because he’s dying doesn’t mean we need to kill him.

 

[sevoflurane]

Our CT surgeons/anesthesiologists place patients on ECMO, but that is with Stanford heli on the roof which takes some coordination. Valid point though.

 

[MirrorTodd]

😂😂

Pictures definitely give you a sense that if you pass a guidewire for a retrograde you may end up with a bigger problem than what you started with. Can you guys identify the glottic opening in the first pic?

I want to say that tiny little black spot that is almost center in the first pic.