Another "My Worst Airway Case"

[Aether2000]

56 year old presented to the OR this week for a PEG and IV infusion port and the surgeon asked for sedation. She had a squamous cell tumor from the mandible to the base of the neck on the left side protruding 4" off the side of the neck and was 4 inches wide and 5 1/2 inches long. CT scan showed tumor protruding into the oral pharynx, involving the tongue, lingual and palatine tonsils on the left side and extending more than half way across the pharynx at the level just superior to the cords. There was involvement of the epiglottis. The ENT refused to do a tracheostomy since her airflow was not yet impeded, and the palliative care pathway chosen was to place a PEG and send her home to die. The tumor was easily observed intraorally and was friable, easy to cause bleeding. So.....
-DL was out-friable tumor
-LMA was out-friable tumor
-Glidescope was out- friable tumor
-Have not done a retrograde wire in years and concern about tumor bleeding
-Concern was with sedation and airway obstruction
-Could not do exterior or interior hypoglossal nerve block due to the size of the intraoral tumor
-Have seen airway obstruction with nebulized local anesthetic in the past so this was on my mind

Options considered:
-Local anesthesia only without sedation- however the surgeon did not believe he could complete the surgery without sedation (slow surgeon)
-Nasal O2 with readily reversible midazolam plus fentanyl
-Awake nasal FOI

The latter was chosen- took me 25 min time to maneuver around the large tumor mass that lie directly above the cords, attempting to avoid touching the tumor with the scope. The anatomy was totally whacked out, and it was difficult to see any normal anatomy on the left 2/3 of the pharynx until the cords were visualized, and the left arytenoid fold appeared to be infiltrated with tumor.
Extubation was accomplished with bougie placed through the ETT and left in place for 2 min after the ETT was removed. following an uneventful course in the PACU, she was sent back to her hospital room, then the next day sent home to die with her PEG.

Question: what other options are there that I did not consider?

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[NightNight]

56 year old presented to the OR this week for a PEG and IV infusion port and the surgeon asked for sedation. She had a squamous cell tumor from the mandible to the base of the neck on the left side protruding 4" off the side of the neck and was 4 inches wide and 5 1/2 inches long. CT scan showed tumor protruding into the oral pharynx, involving the tongue, lingual and palatine tonsils on the left side and extending more than half way across the pharynx at the level just superior to the cords. There was involvement of the epiglottis. The ENT refused to do a tracheostomy since her airflow was not yet impeded, and the palliative care pathway chosen was to place a PEG and send her home to die. The tumor was easily observed intraorally and was friable, easy to cause bleeding. So.....
-DL was out-friable tumor
-LMA was out-friable tumor
-Glidescope was out- friable tumor
-Have not done a retrograde wire in years and concern about tumor bleeding
-Concern was with sedation and airway obstruction
-Could not do exterior or interior hypoglossal nerve block due to the size of the intraoral tumor
-Have seen airway obstruction with nebulized local anesthetic in the past so this was on my mind

Options considered:
-Local anesthesia only without sedation- however the surgeon did not believe he could complete the surgery without sedation (slow surgeon)
-Nasal O2 with readily reversible midazolam plus fentanyl
-Awake nasal FOI

The latter was chosen- took me 25 min time to maneuver around the large tumor mass that lie directly above the cords, attempting to avoid touching the tumor with the scope. The anatomy was totally whacked out, and it was difficult to see any normal anatomy on the left 2/3 of the pharynx until the cords were visualized, and the left arytenoid fold appeared to be infiltrated with tumor.
Extubation was accomplished with bougie placed through the ETT and left in place for 2 min after the ETT was removed. following an uneventful course in the PACU, she was sent back to her hospital room, then the next day sent home to die with her PEG.

Question: what other options are there that I did not consider?

I’m just curious what you did to topicalize/sedate this patient that allowed for a 25min AFOI?

 

[Aether2000]

Hurricane Spray plus 1mg midazolam IV. I have in the past used lidocaine 4% liquid in a nebulizer mask treatment, but was too timid this time.

 

[chessknt]

If patient was hospice would have recommended endo-guided (or blind) ng tube if po intake was deemed necessary for palliation. If tumor so unstable that bleeding could cause death/Airway compromise from endo procedure then probably just im morphine and send home with po intake as tolerated. Makes no sense to put a long term tube in if the next time he/she eats a sandwich she is going to die.

 

[chocomorsel]

Hurricane Spray plus 1mg midazolam IV. I have in the past used lidocaine 4% liquid in a nebulizer mask treatment, but was too timid this time.

How much hurricane spray? How many sprays? Must have used quite a bit.

 

[chocomorsel]

You shoulda taken a pic for us.

 

[narcusprince]

Excellent management. You definitely respected the airway. Thinking out of the box here but all the topicalization. And you passed the fiberoptic scope through the nose then you pass an ET tube then the surgeon passes the endoscope then you pull the ET tube. Why not topicalize lightly sedate 1 mg of versed then allow surgeon to place endoscope and do peg tube. Less passes. Less mess.

 

[cleansocks]

Regional and then ketamine is probably how I would've done it. Test pts response to ketamine during preop regional to see how they tend to react to the dissociative feeling and get a feeling for dosing intraop. Planning ahead with surgeon about need for handholding / moderately awake pt. Not a good case for personality disordered medical team that can't talk to eachother!

I think this post is meant to be more about how to do this if an airway is needed, though

 

[Ezekiel2517]

You did a great job getting the airway. But even the option you took was very high risk. What would you have done if the scope caused immediate massive bleeding of this oral tumor? Bc I have witnessed that exact situation take place.

I see issues that are very questionable far before even deciding how to intubate this patient. This is a palliative care patient. OK, so they want a PEG. That can completely be done with good localization and a good GI doc. And why the need for an "IV infusion port"? This patient will literally be dead in a matter of weeks. A PICC line can easily be placed at bedside. And an ENT saying that they wouldn't do a trach bc the airflow is not yet impeded is laughable. Bc that's the whole point, the airway will be compromised as soon as you sedate her and especially if you try and intubate her. And not just compromised but completely lost. You can easily find another ENT who could do this.

I had this exact same type of patient as a resident and have seen others. Worst airway you can encounter. With many of these tumors, simply touching it can result in bleeding which immediately puts you up a **** creek without a paddle. Knowing what I know now, I would not have done what you did without an ENT in the room and all difficult airway equipment available including a rigid bronch and a surgical airway ready to be done at a moment's notice.

 

[deleted162650]

Patient needs to go home and be allowed to die with a little dignity left.

 

[chocomorsel]

Patient needs to go home and be allowed to die with a little dignity left.

Exactly. But this here is Amerrrca. We don’t do that nonsense.

 

[Ezekiel2517]

I’m just curious what you did to topicalize/sedate this patient that allowed for a 25min AFOI?

Lidocaine toxicity can make for great sedation

 

[pgg]

Patient needs to go home and be allowed to die with a little dignity left.

Well yes, but being hungry sucks. Starving to death sucks. I totally get why this patient wanted a PEG and nothing else. Sounds like everyone got what they wanted.

 

[pgg]

You did a great job getting the airway. But even the option you took was very high risk. What would you have done if the scope caused immediate massive bleeding of this oral tumor? Bc I have witnessed that exact situation take place.

...

I had this exact same type of patient as a resident and have seen others. Worst airway you can encounter. With many of these tumors, simply touching it can result in bleeding which immediately puts you up a **** creek without a paddle. Knowing what I know now, I would not have done what you did without an ENT in the room and all difficult airway equipment available including a rigid bronch and a surgical airway ready to be done at a moment's notice.

I agree although a rigid bronch is going to be the worst kind of mess.

I once got talked into trying an AFOI in a patient with a base of tongue tumor, when she presented in the ER with dyspnea. She'd previously refused an elective trach but now wanted her airway secured. There was some other drama to that ER visit, but I abandoned my AFOI attempt after a couple minutes for fear of angering the mass. I think I was on the edge of killing her with the AFOI attempt.

Called ENT again and we did an awake trach.

 

[chocomorsel]

Well yes, but being hungry sucks. Starving to death sucks. I totally get why this patient wanted a PEG and nothing else. Sounds like everyone got what they wanted.

I get you and agree. But if you are drugged enough, are you gonna notice how hungry you are?

Also, why not an Open Gtube with an epidural/spinal/local? Why risk a PEG with that horrible ass airway?

 

[chocomorsel]

I agree although a rigid bronch is going to be the worst kind of mess.

I once got talked into trying an AFOI in a patient with a base of tongue tumor, when she presented in the ER with dyspnea. She'd previously refused an elective trach but now wanted her airway secured. There was some other drama to that ER visit, but I abandoned my AFOI attempt after a couple minutes for fear of angering the mass. I think I was on the edge of killing her with the AFOI attempt.

Called ENT again and we did an awake trach.

And the sad thing is, in this country, had you not been able to get the airway, you would likely have been sued and possibly lost. Even though in the past, she REFUSED a definitive airway. Gotta love medicine in Amerrrca.

 

[pgg]

I get you and agree. But if you are drugged enough, are you gonna notice how hungry you are?

Also, why not an Open Gtube with an epidural/spinal/local? Why risk a PEG with that horrible ass airway?

Maybe she wanted to be drugged less.

Regional is totally reasonable too.

 

[chessknt]

Well yes, but being hungry sucks. Starving to death sucks. I totally get why this patient wanted a PEG and nothing else. Sounds like everyone got what they wanted.

Seems a bit too risky for the outcome. If you can't tolerate po and want hospice why would you risk drowning in a bloody failed Airway in an or with no family just so you could feel full with no taste of food? Nutrition in terminal cancer does not prolong life or improve quality of life unless this person was expected to live the full 6 months.

To the op I appreciate the case, it serves as a good exercise in challenging Airway management and the power of topicalization.

 

[narcusprince]

What was this ladys code status?

 

[anbuitachi]

any contraindication to epidural/spinal?
the port placement can be done under local easily.

 

[Aether2000]

I very much appreciate the responses. I am not presenting this to be self-congratulatory since I was very lucky it worked, and am honestly looking for alternatives. The tumor was beefy red on the fiberoptic scope, and involved so many structures that I was struggling to see anything normal. I could have easily started a bloodbath. The reason a regional block was not considered was due to the potential of the gastroscope dislodging the tumor from the tonsillar pillar, lingual tonsils, and posterior tongue, but perhaps a regional would have been a better choice retrospectively. I used the local sparingly, spraying twice. As for the ENT decision to not perform a tracheostomy, I was very surprised, and had called the ENT in advance to discuss this, but he was resolute. There may have been other considerations he was weighing of which I was unaware. In any case, I hope I never see anything like this again. The patient was clearly in denial, saying the tumor had been there for only a few months. But in this case, perhaps death is the best option.

 

[deleted697535]

Why not spinal?
Just asking

 

[Arch Guillotti]

Why not spinal?
Just asking

What are you going to do when the surgeon/gi guy puts the scope in the throat?

 

[chocomorsel]

What are you going to do when the surgeon/gi guy puts the scope in the throat?

An open G tube procedure doesn't need a scope down the throat.

 

[Arch Guillotti]

An open G tube procedure doesn't need a scope down the throat.

Has anyone on this forum ever seen an open g-tube? I sure haven't.

 

[chocomorsel]

Has anyone on this forum ever seen an open g-tube? I sure haven't.

I have. Small abdominal incision, find stomach, put a hole in it for G Tube and staple the incision shut. I think that's it if I recall correctly. People still do it, although not frequently. Find a surgeon that does it.
In this case, with this high risk airway, may be the best bet.

 

[B-Bone]

I did an open G-tube with only rectus sheath blocks a few years ago. Pt was recovering from Guillan Barre and was extremely weak (still couldn't move against gravity). Last intubation had led to weeks on the ventilator. 1 mg midazolam plus bilateral blocks. Gave them 30 minutes to really set up, had surgeon stick to the midline. Easy peasy.

 

[Man o War]

You did a great job getting the airway. But even the option you took was very high risk. What would you have done if the scope caused immediate massive bleeding of this oral tumor? Bc I have witnessed that exact situation take place.

I see issues that are very questionable far before even deciding how to intubate this patient. This is a palliative care patient. OK, so they want a PEG. That can completely be done with good localization and a good GI doc. And why the need for an "IV infusion port"? This patient will literally be dead in a matter of weeks. A PICC line can easily be placed at bedside. And an ENT saying that they wouldn't do a trach bc the airflow is not yet impeded is laughable. Bc that's the whole point, the airway will be compromised as soon as you sedate her and especially if you try and intubate her. And not just compromised but completely lost. You can easily find another ENT who could do this.

I had this exact same type of patient as a resident and have seen others. Worst airway you can encounter. With many of these tumors, simply touching it can result in bleeding which immediately puts you up a **** creek without a paddle. Knowing what I know now, I would not have done what you did without an ENT in the room and all difficult airway equipment available including a rigid bronch and a surgical airway ready to be done at a moment's notice.

Agree with all of this. My old group covered a cancer hospital at one time so we saw a good bit of this.
I would’ve had an ENT standing there gloved and ready, trach kit open and ready to go.

 

[woopedazz]

As a junior I really appreciate these discussions.

 

[Noyac]

I'm really surprised at the ENT’s unwillingness to help. I have done this exact case twice now with the local ENT doc at my facility. It’s pretty simple actually.

 

[Man o War]

I'm really surprised at the ENT’s unwillingness to help. I have done this exact case twice now with the local ENT doc at my facility. It’s pretty simple actually.

I’ve never had a problem. Plus I’d think this patient would have an ENT already following them?

 

[Noyac]

And isn’t the reason to do the Trach so they don’t starve for air? I mean, WTF?

 

[chocomorsel]

Agree with all of this. My old group covered a cancer hospital at one time so we saw a good bit of this.
I would’ve had an ENT standing there gloved and ready, trach kit open and ready to go.

Ok, I am gonna ask again. How the hell is ENT gonna get all up in there without paralyzing or more likely killing the patient?

 

[deleted162650]

Ok, I am gonna ask again. How the hell is ENT gonna get all up in there without paralyzing or more likely killing the patient?

You’re thinking of the other airway case

 

[chocomorsel]

You’re thinking of the other airway case

Oh, thanks for orienting me.

 

[coffeebythelake]

I have. Small abdominal incision, find stomach, put a hole in it for G Tube and staple the incision shut. I think that's it if I recall correctly. People still do it, although not frequently. Find a surgeon that does it.
In this case, with this high risk airway, may be the best bet.

special circumstances demand not just a thoughtful anesthesiologist but a resourceful surgeon.

 

[deleted59964]

Question: what other options are there that I did not consider?

If ENT unhelpful, and planning an afoi but worried bleeding may turn it into a **** storm ... topicalise then put a cannula through the cricothyroid membrane and then put a wire through the cannula before starting your afoi.

You can always remove the wire and oxygenate through the cannula

or

remove the cannula and use the wire to get an airway using something like this ... Melker Cuffed Emergency Cricothyrotomy Catheter Set (Seldinger) | Cook Medical

 

[Noyac]

Worst case scenario, ECMO or CPB. An answer to Algosdoc’s earlier question.


Or did someone say that already?

 

[Noyac]

Or maybe this:
https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14217

 

[shepardsun]

Worst case scenario, ECMO or CPB.

I feel like this would be the desired oral boards answer, practicality and palliative ethics aside. AFOI with the patient cannulated for ECMO if stuff goes down.

Precedex as a component of the sedation plan is something else to consider.

 

[deleted59964]

Worst case scenario, ECMO or CPB. An answer to Algosdoc’s earlier question.


Or did someone say that already?

ecmo / cpb for a patient that’s palliative?

 

[Noyac]

ecmo / cpb for a patient that’s palliative?

Well I’m not endorsing this but I’d rather not live out my last few days or weeks starved for air.

 

[Twiggidy]

Patient needs to go home and be allowed to die with a little dignity left.

Best answer.

 

[deleted162650]

Well I’m not endorsing this but I’d rather not live out my last few days or weeks starved for air.

You can live for days to weeks without air???

Now I'm impressed.

 

[Psai]

Well I’m not endorsing this but I’d rather not live out my last few days or weeks starved for air.

Here's a script for morphine and there's the door

 

[pgg]

Well I’m not endorsing this but I’d rather not live out my last few days or weeks starved for air.

#2 on my "do not want" list on my advance directive when I get around to making one, is ECMO

#1 will be a VAD

 

[deleted171991]

#2 on my "do not want" list on my advance directive when I get around to making one, is ECMO

#1 will be a VAD

My number 1 is ICU.

 

[Ronin786]

#2 on my "do not want" list on my advance directive when I get around to making one, is ECMO

#1 will be a VAD

Had a patient the other day who presented for his umpteenth colonoscopy for GI bleeding from his VAD. We got to talking and he mentioned how if anybody had explained to him how terrible his lifestyle would be post-operatively, he'd never have agreed to the VAD.

Of course during the consent process, all people hear/are told is "risk of bleeding" and not "you're going to spend 3 out of every 4 weeks in the hospital undergoing transfusions and scopes". And that's just the GI bleeding.

 

[Twiggidy]

Had a patient the other day who presented for his umpteenth colonoscopy for GI bleeding from his VAD. We got to talking and he mentioned how if anybody had explained to him how terrible his lifestyle would be post-operatively, he'd never have agreed to the VAD.

Of course during the consent process, all people hear/are told is "risk of bleeding" and not "you're going to spend 3 out of every 4 weeks in the hospital undergoing transfusions and scopes". And that's just the GI bleeding.

Most thing we do in medicine borderlines on coercion vs actual informed consent