Another AW case

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To @vector2 ’s point from earlier: I would be nervous about trying to jet ventilate (or normally ventilate) through a rigid bronch with this airway- only a small scope would fit, and there would be not enough of a path for air to egress. Setup for barotrauma, PTX, auto peep
 
I honestly think if this lady isn't doing an awake (+ maybe a little anxiolysis) trach, then palliative care/hospice is the best alternative. Comfort care.
 
Hork Bajir said:
To @vector2 ’s point from earlier: I would be nervous about trying to jet ventilate (or normally ventilate) through a rigid bronch with this airway- only a small scope would fit, and there would be not enough of a path for air to egress. Setup for barotrauma, PTX, auto peep
Click to expand...
I mean, based on the image sevo just posted a couple posts up, it doesn’t look like there is a good option other than VV. That glottic opening is so small and the tissue looks so bad that even if you could ram a loaded rigid bronch through and try to railroad a reinforced tube rather than jet ventilate it’s prolly gonna start bleeding uncontrollably. And of course she’s fat and likely has COPD so good luck setting the fi to 30 if they have to bovie in the airway
 
I just want to repost these classic threads with some of the ogs: milmed, utsw, jet, noyac, sevo

forums.studentdoctor.net

Someone almost died

Got called STAT to the PACU. I run over and saw this lady sitting up right...looking uncomfortable and scared. There is a dressing on her neck....and an obvious hematoma...about grapefruit size. On top of this, she is pretty micrognathic. Vitals stable...SAO2 100%. What to...
forums.studentdoctor.net forums.studentdoctor.net
forums.studentdoctor.net

Difficult Airway Question

Fat guy, sleep apnea...airway exam reveals...short fat neck....I would rate the likelihood of a successful DL at < 10%. Case is a knee arthroscopy with a good surgeon....likely less than 15 minute case. Anesthetic plan was GA with LMA as the airway device. Patient is pre-oxygenated and...
forums.studentdoctor.net forums.studentdoctor.net
 
GassYous said:
I just want to repost these classic threads with some of the ogs: milmed, utsw, jet, noyac, sevo

forums.studentdoctor.net

Someone almost died

Got called STAT to the PACU. I run over and saw this lady sitting up right...looking uncomfortable and scared. There is a dressing on her neck....and an obvious hematoma...about grapefruit size. On top of this, she is pretty micrognathic. Vitals stable...SAO2 100%. What to...
forums.studentdoctor.net forums.studentdoctor.net
forums.studentdoctor.net

Difficult Airway Question

Fat guy, sleep apnea...airway exam reveals...short fat neck....I would rate the likelihood of a successful DL at < 10%. Case is a knee arthroscopy with a good surgeon....likely less than 15 minute case. Anesthetic plan was GA with LMA as the airway device. Patient is pre-oxygenated and...
forums.studentdoctor.net forums.studentdoctor.net
Click to expand...

Wow. Interweb remembers.
 
You likely only have 1 shot at an airway like this so it better be right. Considering the info provided in the thread, this patient would be a challenging awake FOI. I would not go that route.
 
Something I like to do to decrease coughing is nebulized lidocaine. Remi gtt. 1 midazolam. Nasal cannula on the patient with etco2. Also flexible suction cannula in patients mouth with an occlusion suction valve. Chief resident or surgeon places the trach. Move along.....
 
narcusprince said:
Something I like to do to decrease coughing is nebulized lidocaine. Remi gtt. 1 midazolam. Nasal cannula on the patient with etco2. Also flexible suction cannula in patients mouth with an occlusion suction valve. Chief resident or surgeon places the trach. Move along.....
Click to expand...
The ENT doesn’t want to do a trach.
 
Great case, thanks for sharing.

side note: Has anyone used the melker cric kits? Not the blue rhino perc trach kits. I shudder at the thought of doing anything percutaneously here. The odds of making a false passage or poking something that is not trachea (tumor, vessel) are high. Although I like the use of ultrasound to mark out the anatomy as was suggested earlier.
 
vector2 said:
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.
Click to expand...
I had a case like this in a big fatty with a remote trach history who came in for a goiter. Looked at her CT preop but she ended up having a web of tissue below the cords that wasn’t visible on imaging. Called Ent emergently when I couldn’t pass 6.0 tube but ended up cutting my losses and waking her up. I was losing the ability to mask ventilate her and I knew she’d be a difficult cric. Terrifying. Could have easily assassinated this lady.
 
Arch Guillotti said:
lol I meant an awake trach
Click to expand...

Seems like ENT wants this patient to die. And they want to blame anesthesia for it. We all learned thr maxim "it's hard to kill a breathing patinet" but it isn't impossible. Muck around thr airway a few times next thing u know that tiny little airway hole closes shut.
 
Ecmo shouldn't be offered. Agree that awake trach seems most reasonable or at the bare minimum a double setup with ent scrubbed and ready to go.

Make it clear to pt/family that an attempt can be made but chance of death is very high but not as high as her current chance of 100% death if she doesn't have anything done. I can't imagine a successful lawsuit ever coming to fruition from such a clear case of denial.
 
One thing we haven't addressed is the fact that once you successfully get your adult scope or flimsy peds bronchoscope through that tiny passageway (if you are even able), you are now likely occluding the entire airway. This lady, if awake, is not going to be calm and relaxed when she's suddenly experiencing 100% occlusion of her trachea. You won't have time to troubleshoot or mess around with trying to twist the tube this way and that to get it to slide over the bronchoscope. I just don't see how anything other than awake trach or palliative care is an option. Maybe I just lack imagination.

I look forward to hearing how this went down.
 
Honestly with one shot at this and having done a fair amount of these both in residency and now in PP...pseudo awake (spont breathing) glide with every type of tube out and ready is my now preferred method with with FO backup and ready as well as neck prepped and surgeon ready to go. Wouldn’t even think about touching this patient without a surgeon ready unless she’s dying in front of me.

In my experience these anxious, hyperventilating, obese patients do not tolerate awake FO at all. Coughing, secretions everywhere, fighting us. I hate it.

But as many above have stated, this almost always a surgical airway. We’re not trying to kill anyone here.
 
Anesthesia… nobody really knows what we do or deal with at all hours of the day and night. Type A dissections, crash C/S’s, major Trauma (recently had a hip disarticulation come through our trauma bay for major MVC with torn illiac arteries- what a case that was), ruptured AAA, exit procedures, VV/VA ECMO, I mean the list just keeps going. Funny how people (and even our fellow physicians) really don’t appreciate what we do day to day. This case is no exception… F’n love this specialty even though we are always the ninja’s hiding in the background.

So someone mentioned it earlier in the thread and I agree with them 100%… these cases suck- especially emergently at 2 am. Not only are they high risk, but careful planing and execution is key or things may spiral out of control quickly. One of my partners had a similar case last year with a 1 y/o pedi patient and the AW was lost. Traumatic for everyone involved.

The Case:

*Review the CT scan and any other images before taking these cases back. This patient demonstrated all the things that scare us regarding neck tumors including mass effect and 3mm hole (probably less) at the narrowest part of the AW. I then looked at the endoscopy pictures to get a feeling to the tumors friability… large ulcerated mass, huge inflamed arytenoids R>L, vocal cords obliterated by the tumor, etc and an extremely small hole the patient is breathing through. The mass over the glottic inlet did not look like a hard mass, but my spider sense was still going off at 1000%.

Note: The options are always the same. Awake trach vs awake/sv glide vs AFOI vs DL. Anyone giving neuromuscular blockers before an appropriate ETCO2 capnogram/wave form is not doing it right.

So ENT sat and reviewed the CT scan with me. My first question is exactly what many of you on this thread were going for and you guys are all correct. Awake trach please. Problem is this patient is a difficult trach due to her exaggerated kyphosis, poor landmarks as well a history of severe anxiety and inability to lie still (or flat for that matter) during her previous endoscopies. Crap. Deck is stacked against both of ENT and myself.

First thing to do with these cases is ALWAYS the same. You NEED to speak the patient and put the fear of god into their head because this is as serious as it gets and they need to be as cooperative as they can be. I told her that we were going to topicalize her, bring her back to the OR and I was going to place a video scope into her mouth for me to further asses her life threatening situation and make some decisions at that time.

The one bone that was thrown at me is that the patient was edentulous and she did not have fixed small mouth opening due to tumor invasion. The only positive of the case.

I tried being opened minded to ENT. She was definitely willing to attempt to do the trach awake, but it would be very difficult. Trach would basically be in the sitting position with difficult landmarks and an uncooperative patient. So I listened and definitely saw the challenge with an awake trach. She wasn’t being lazy or incompetent at all. Just as worried as I was with no great solutions.

So to the OR we go:

Ramped her up with a ton of blankets and had the head of the table flexed. Lowered the bed all the way to the ground and grabbed a step up so I could comfortably be positioned over her head. All rescue AW stuff in the room ready to go. I was fairly satisfied with the topicalization so I asked her to stick our her tongue while I placed the glidescope in her mouth. She did well for about 2 nano-seconds before the patient started freaking out, thrashing, etc. I did get a descent view of the tumor and a tiny little hole I assumed led be the glottic opening. Mass effect on the right was very evident… but I did get to take a look at inspiration and expiration and was able to see the arytenoids were not completely stuck in a fixed position. Well ****…. OK that is another positive.

Decision point time:

Some people on the thread here suggested midazolam, remi, ketamine, fentanyl, dexmedatomidine, etc… I think that in an AW like this, you need the most titratable on-off medication we have in our bag. For me this is propofol 100% of the time. I did the most gentle slow sedation known to man. 20 mg pushes while keeping the patient spontaneously breathing all the while assisting/feeling for compliance with my right hand on the bag. After a while I could tell she was getting where I needed her- I reached a depth of anesthesia I felt was good enough to take another look. I did so fully knowing this is likely the one shot I have to get this right. Gave her a final 30 mg of prop and waited 20 seconds before I inserted the low profile glide scope. Took it easy and started with the tongue and worked my way back- the last thing I wanted to do is to insert it too far and make the tumor start to bleed. The mass that was obstructing the glottic opening looked soft… so I gently pushed it out of the way with my 5.0 cuffed tube loaded on the glidescope stylet and then carefully twisted it past the tumor and into the little hole during inspiration to maximize the the caliber of the opening- railroaded off of the stylet. Based on the CT scan, I was pretty confident that there was no tumor that would obstruct ventilation past the vocal cord inlet as it opened up further down the trachea. Once I had ETCO2 I pushed 80mg of roc secured the ETT with a death grip benzoin/silk tape combo and the drama was suddenly over. Brought her iO2 down to 30 and proceeded to trach the patient right above the sternal notch with 2 ENT surgeons doing the work.


Here are a few learning points.

1). Insert the fear of god into patients during your interview to include them in the plan and let them know what to expect.
2). Look at imaging including CXR, CT scans and any endoscopy pictures that may alert you to the complexity of the case.
3). Respect a sitting patient that can hardly talk.
4). Always maintain SV with a drug that is quickly titratable. For me there is no better option than propofol- quick on quick off if performed by a knowledgeable anesthesiologist.
5). Topicalize heavily add some glyco. Regional AW blocks where applicable. Maybe insert a 18G angiocath through the cricoidthyroid membrane and squirt from below.
6). Have an exit plan. Prep the neck if you have to before you give it a go. Always have the option to back out.
7). Work together with ENT and try to understand their surgical issues- we are a team and rely on each other.
8). Don’t $hit your pants. Keep the room calm and collected and smelling good. You loose your $hit then the rest of the room will follow.
9). Call for help if you need to.

Glad things went well and the patient feels much much better after the trach. Comfort care is not quite what I would have wished for this poor patient. It was worth a try to get her the operation so that whatever life is left will be somewhat comfortable. Palliative care for an obstructing laryngeal tumor is an awful way to check out.

Below is the view I captured on the glidescope right before intubation. Nasty tumor, scary looking opening. As opposed to the inflamed hardy looking arytenoids, you get the feeling that the part of the tumor covering the glottic opening is somewhat mobile and pliable.

At the end of the day any strategy that doesn’t kill the patient is a viable strategy. Awake trach, SV intubation as well as palliative. VV ECMO would be the easiest but is institutional dependent. There is no right answer here.

Hope you guys enjoyed the case.
 
Last edited:
sevoflurane said:
Anesthesia… nobody really knows what we do or deal with at all hours of the day and night. Type A dissections, crash C/S’s, major Trauma (recently had a hip disarticulation come through our trauma bay for major MVC with torn illiac arteries- what a case that was), ruptured AAA, exit procedures, VV/VA ECMO, I mean the list just keeps going. Funny how people (and even our fellow physicians) really don’t appreciate what we do day to day. This case is no exception… F’n love this specialty even though we are always the ninja’s hiding in the background.

So someone mentioned it earlier in the thread and I agree with them 100%… these cases suck- especially emergently at 2 am. Not only are they high risk, but careful planing and execution is key or things may spiral out of control quickly. One of my partners had a similar case last year with a 1 y/o pedi patient and the AW was lost. Traumatic for everyone involved.

The Case:

*Review the CT scan and any other images before taking these cases back. This patient demonstrated all the things that scare us regarding neck tumors including mass effect and 3mm hole (probably less) at the narrowest part of the AW. I then looked at the endoscopy pictures to get a feeling to the tumors friability… large ulcerated mass, huge inflamed arytenoids R>L, vocal cords obliterated by the tumor, etc and an extremely small hole the patient is breathing through. The mass over the glottic inlet did not look like a hard mass, but my spider sense was still going off at 1000%.

Note: The options are always the same. Awake trach vs awake/sv glide vs AFOI vs DL. Anyone giving neuromuscular blockers before an appropriate ETCO2 capnogram/wave form is not doing it right.

So ENT sat and reviewed the CT scan with me. My first question is exactly what many of you on this thread were going for and you guys are all correct. Awake trach please. Problem is this patient is a difficult trach due to her exaggerated kyphosis, poor landmarks as well a history of severe anxiety and inability to lie still (or flat for that matter) during her previous endoscopies. Crap. Deck is stacked against both of ENT and myself.

First thing to do with these cases is ALWAYS the same. You NEED to speak the patient and put the fear of god into their head because this is as serious as it gets and they need to be as cooperative as they can be. I told her that we were going to topicalize her, bring her back to the OR and I was going to place a video scope into her mouth for me to further asses her life threatening situation and make some decisions at that time.

The one bone that was thrown at me is that the patient was edentulous and she did not have fixed small mouth opening due to tumor invasion. The only positive of the case.

I tried being opened minded to ENT. She was definitely willing to attempt to do the trach awake, but it would be very difficult. Trach would basically be in the sitting position with difficult landmarks and an uncooperative patient. So I listened and definitely saw the challenge with an awake trach. She wasn’t being lazy or incompetent at all. Just as worried as I was with no great solutions.

So to the OR we go:

Ramped her up with a ton of blankets and had the head of the table flexed. Lowered the bed all the way to the ground and grabbed a step up so I could comfortably be positioned over her head. All rescue AW stuff in the room ready to go. I was fairly satisfied with the topicalization so I asked her to stick our her tongue while I placed the glidescope in her mouth. She did well for about 2 nano-seconds before the patient started freaking out, thrashing, etc. I did get a descent view of the tumor and a tiny little hole I assumed led to be the glottic opening. Mass effect on the right was very evident… but I did get to get a look at inspiration and expiration and was able to see the arytenoids were not complete stuck in a fixed position. Well ****…. OK that is another positive.

Decision point time:

Some people on the thread here suggested midazolam, remi, ketamine, fentanyl, dexmedatomidine, etc… I think that in an AW like this, you need the most titratable on-off medication we have in our bag. For me this is propofol 100% of the time. I did the most gentle slow sedation known to man. 20 mg pushes while keeping the patient spontaneously breathing all the while assisting/feeling for compliance with my right hand on the bag. After a while I could tell she was getting where I needed her- I reached a depth of anesthesia I felt was good enough to take another look. I did so fully knowing this is likely the one shot I have to get this right. Gave her a final 30 mg of prop and waited 20 seconds before I inserted the low profile glide scope. Took it easy and started with at the tongue and worked my way back- the last thing I wanted to do is to insert it too far and make the tumor start to bleed. The mass that was obstructing the glottic opening looked soft… so I gently pushed it out of the way with my 5.0 cuffed tube loaded on the glidescope stylet and then carefully twisted it past the tumor and into the little hole during inspiration to maximize the the caliber of the opening- railroaded off of the stylet. Based on the CT scan, I was pretty confident that there was no tumor that would obstruct ventilation past the vocal cord inlet as it opened up further down the trachea. Once I had ETCO2 I pushed 80mg of roc secured the ETT with a death grip benzoin/silk tape combo and the drama was suddenly over. Brought her iO2 down to 30 and proceeded to trach the patient right above the sternal notch with 2 ENT surgeons doing the work.


Here are a few learning points.

1). Insert the fear of god into patients during your interview to include them in the plan and let them know what to expect.
2). Look at imaging including CXR, CT scans and any endoscopy pictures that may alert you to the complexity of the case.
3). Respect a sitting patient that can hardly talk.
4). Always maintain SV with a drug that is quickly titratable. For me there is no better option than propofol- quick on quick off if performed by a knowledgeable anesthesiologist.
5). Topicalize heavily add some glyco. Regional AW blocks where applicable. Maybe insert a 18G angiocath through the cricoidthyroid membrane and squirt from below.
6). Have an exit plan. Prep the neck if you have to before you give it a go. Always have the option to back out.
7). Work together with ENT and try to understand their surgical issues- we are a team and rely on each other.
8). Don’t $hit your pants. Keep the room calm and collected and smelling good. You loose your $hit then the rest of the room will follow.
9). Call for help if you need to.

Glad things went well and the patient feels much much better after the trach. Comfort care is not quite what I would have wished for this poor patient. It was worth a try to get her the operation so that whatever life is left will be somewhat comfortable. Palliative care for an obstructing laryngeal tumor is an awful way to check out.

Below is the view I captured on the glidescope right before intubation. Nasty tumor, scary looking opening. As opposed to the inflamed hardy looking arytenoids, you get the feeling that the the part of the tumor covering the glottic opening is somewhat mobile and pliable.

At the end of the day any strategy that doesn’t kill the patient is a viable strategy. Awake trach, SV intubation as well as palliative. VV ECMO would be the easiest but is institutional dependent. There is no right answer here.

Hope you guys enjoyed the case.
Click to expand...

Nice case. But I don't think propofol is the best sedative to use.
 
sevoflurane said:
IMO, it’s like any drug... it’s how you use it. What would you use?
Click to expand...

It doesn't have any analgesic or anxiolytic properties. What goal are you titrating to? Drowsiness? No specific antagonist exists. You are probably very slick at it,, but imo easily to miss target and oversedate. Tbh i would think cautiously about giving anything that reduces respiratory drive or reduces airway tone. And also possible to laryngospasm if too deep. Just my opinion against prop for a case like this
 
Nice work. I know the board answer is awake FO (for any residents out there) but I would do the same thing, kinda awake glide with SV is my personal best bet because it’s a device we use ALL the time and are freakin good at it.
 
Very nicely done. When I'm in GI and don't want to lose the airway, I titrate prop the same way and have the staff hold the head.
 
For completions sake: here is one from three or four years ago. The patient has since expired. Same situation though... urgent going on emergent AW. This one however was with a dentist @ 2am for multiple large tooth abscesses with a nasty squamous cell carcinoma that made intubation through the mouth nearly impossible.

18g through the cricothyroid membrane for topicalization/oxygenation/retrograde.
Managed to do a nasal FOI... and had a trauma surgeon for a trach if I needed it. Small mouth opening is a good reason for an awake trach.
 
Excellent, sevo.
I dont think many would use ppf but again you are 100% correct the choice of drug doesnt matter at all in comparison to how and when it is given.
How did you topicalise her, i dont think i see how you actually did this case?
 
coffeebythelake said:
It doesn't have any analgesic or anxiolytic properties. What goal are you titrating to? Drowsiness? No specific antagonist exists. You are probably very slick at it,, but imo easily to miss target and oversedate. Tbh i would think cautiously about giving anything that reduces respiratory drive or reduces airway tone. And also possible to laryngospasm if too deep. Just my opinion against prop for a case like this
Click to expand...
Same here. No true “reversal”. Whatever keeps them breathing though.
 
sevoflurane said:
For completions sake: here is one from three or four years ago. The patient has since expired. Same situation though... urgent going on emergent AW. This one however was with a dentist @ 2am for multiple large tooth abscesses with a nasty squamous cell carcinoma that made intubation through the mouth nearly impossible.

18g through the cricothyroid membrane for topicalization/oxygenation/retrograde.
Managed to do a nasal FOI... and had a trauma surgeon for a trach if I needed it. Small mouth opening is a good reason for an awake trach.
Click to expand...

did you try paralysis and using two hands to rip the mouth open?
 
Good job Sevo! I would’ve been extremely anxious seeing an airway like that. Reading this gives me the chills.

I had one case similar to this. I was on call and was ask by surgeon to eval an airway for a patient in ICU. It’s a patient with h/o head and neck CA s/p chemo radiation, she recently had a g-tube replacement, but 1 day after procedure, she was found obtunded, hypotensive. She was profoundly septic from the gastric perf and needed to be taken to the OR ASAP for ex lap. Her mouth opening was like the video, can’t even put my pinky through it. She was also obtunded. There was no ENT at our hospital but we did have a thoracic surgeon in ICU rounding who knows how to do traches and the ICU attending happened to be anesthesia trained. So with all these people nearby, I decided to check out her airway in the ICU using a bronch just to see how bad her airway is. We topicalized the S*** out of her nasal passage way and carefully put a small bronch in. Thank god the anatomy appeared normal. So since I got a great view, we shoved a 6.0 ETT nasally. I forgot what meds I gave...probably versed after we secured the tube. So, we basically did everything awake(well...she was obtunded...works in our favor)...and just jammed the tube in. We got extremely lucky as patient was not really reacting to us fidgeting around her airway.

Also of note...her BP was 50/32 on max levophed. With in and out Pulse Ox wave form. So yeah...i was extremely anxious about giving anything. I threw an a-line in after, there was no noticeable pulsatile flow...her pressure was that low. I stayed in the ICU ordered And flooded her with some fluid...(got her pressure up to like 80/40) before taking her to the OR. Case went well...but she expired a day later...she was hypotensive for way too long.
 
LifeofGas said:
Good job Sevo! I would’ve been extremely anxious seeing an airway like that. Reading this gives me the chills.

I had one case similar to this. I was on call and was ask by surgeon to eval an airway for a patient in ICU. It’s a patient with h/o head and neck CA s/p chemo radiation, she recently had a g-tube replacement, but 1 day after procedure, she was found obtunded, hypotensive. She was profoundly septic from the gastric perf and needed to be taken to the OR ASAP for ex lap. Her mouth opening was like the video, can’t even put my pinky through it. She was also obtunded. There was no ENT at our hospital but we did have a thoracic surgeon in ICU rounding who knows how to do traches and the ICU attending happened to be anesthesia trained. So with all these people nearby, I decided to check out her airway in the ICU using a bronch just to see how bad her airway is. We topicalized the S*** out of her nasal passage way and carefully put a small bronch in. Thank god the anatomy appeared normal. So since I got a great view, we shoved a 6.0 ETT nasally. I forgot what meds I gave...probably versed after we secured the tube. So, we basically did everything awake(well...she was obtunded...works in our favor)...and just jammed the tube in. We got extremely lucky as patient was not really reacting to us fidgeting around her airway.

Also of note...her BP was 50/32 on max levophed. With in and out Pulse Ox wave form. So yeah...i was extremely anxious about giving anything. I threw an a-line in after, there was no noticeable pulsatile flow...her pressure was that low. I stayed in the ICU ordered And flooded her with some fluid...(got her pressure up to like 80/40) before taking her to the OR. Case went well...but she expired a day later...she was hypotensive for way too long.
Click to expand...

At some point you need to make an executive decision and not take someone to the OR who won't benefit from it.
 
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