Happy Holidays - my gift from ENT

[Noyac]

And someone asked if I knew why he stopped breathing with 1mg of versed. I have no idea. Probably a combination of OSA, increased work of breathing and cirrhosis, among other things. I didn’t have romazacon drawn up (should have) but I’ve never given that either. I really felt like I was moving pretty carefully with him. Possibly the huge Lidocaine load, from nebs and other applications which will come into play as we move along here, didn’t help either.

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[periopdoc]

Question to those advocating AFOI. What size tube? What bronchoscope do you have that will fit through that tube? I’m going to guess that most institutions do not have a fiber optic scope small enough to go through a tube that is small enough to fit his airway.

 

[periopdoc]

And to Noyac, my mentioning romazicon is in the setting or him going apneic with 1mg versed. While I would go to the OR with romazicon and narcan drawn up, I wasn’t criticizing you giving him 1 mg without having romazicon on hand. I would have done the same.

 

[Noyac]

And to Noyac, my mentioning romazicon is in the setting or him going apneic with 1mg versed. While I would go to the OR with romazicon and narcan drawn up, I wasn’t criticizing you giving him 1 mg without having romazicon on hand. I would have done the same.

Yes I understood that.
And I will say that I am fully open for any criticisms people have as to how I handled this case once it’s all out there.

 

[deleted171991]

Yes I understood that.
And I will say that I am fully open for any criticisms people have as to how I handled this case once it’s all out there.

The first who throws a stone should tell us how s/he has ACTUALLY handled a similar case.

 

[Hork Bajir]

Surprised no one has mentioned jet ventilation… Of course the challenge is going to be getting a suitable jet catheter into the airway, and ensuring that your delivered tidal volume will have a mode of egress. Other ideas no one has mentioned yet: empiric chemo/xrt (obviously less desirable than targeted therapy, but perhaps more desirable than murdering the patient in the operating room); also having a thoracic surgeon around who is handy with a rigid bronch ( don’t get me wrong, this would not be my first plan for obvious reasons, but would be on the list of Hail Mary rescue maneuvers to try)

 

[Hork Bajir]

PS- thanks Noy for posting this, and others for the great case discussion. Threads like this are why I finally made an account to start posting on here

 

[Noyac]

Surprised no one has mentioned jet ventilation… Of course the challenge is going to be getting a suitable jet catheter into the airway, and ensuring that your delivered tidal volume will have a mode of egress. Other ideas no one has mentioned yet: empiric chemo/xrt (obviously less desirable than targeted therapy, but perhaps more desirable than murdering the patient in the operating room); also having a thoracic surgeon around who is handy with a rigid bronch ( don’t get me wrong, this would not be my first plan for obvious reasons, but would be on the list of Hail Mary rescue maneuvers to try)

Great questions. Let me ask you how confident you are with jet ventilation and how many you have done? Because this airway is not normal and sending compressed O2 into this area is not without risks.
And I will tell yuh that there is no possible way a thoracic surgeon even if they did Bronchs every day was going to get their scope in this trachea.

 

[Hork Bajir]

Great questions. Let me ask you how confident you are with jet ventilation and how many you have done? Because this airway is not normal and sending compressed O2 into this area is not without risks.
And I will tell yuh that there is no possible way a thoracic surgeon even if they did Broncos every day was going to get their scope in this trachea.

Agree 100%, which is why rigid bronch would be my Hail Mary rescue maneuver and not plan A, B, or C. The only chance would be if the proceduralist could core out the tumor (using balloon dilator, cryoablation, whatever)- it’d bleed like stink and probably fail, but when you’re already up a creek... as for jet ventilation, I’m very comfortable with it- I do it with some regularity in our thoracic rooms for suspension microlaryngoscopy cases and the like. You could even jet through rigid scope or a Hunsicker catheter above the cords (not necessarily needing to get into the trachea)... but again, this wouldn’t be my first choice!

 

[Noyac]

Agree 100%, which is why rigid bronch would be my Hail Mary rescue maneuver and not plan A, B, or C. The only chance would be if the proceduralist could core out the tumor (using balloon dilator, cryoablation, whatever)- it’d bleed like stink and probably fail, but when you’re already up a creek... as for jet ventilation, I’m very comfortable with it- I do it with some regularity in our thoracic rooms for suspension microlaryngoscopy cases and the like. You could even jet through rigid scope or a Hunsicker catheter above the cords (not necessarily needing to get into the trachea)... but again, this wouldn’t be my first choice!

Good thoughts but when I post what happened you will see how none of this would have worked. Except possibly the jet ventilator.

 

[anbuitachi]

Why do you need a thoracic surgeon? you have a ENT doc, who can do rigid scopes.
Also i dont know about other places, but at my institution no way in hell this guy gets bypass.

also it'd be cool if can see rest of CT neck, would like to see continuous images. Like I said, the CT is done with him lying down, so this is probably the worst it gets. if Do AFOI with him sitting straight up, the compression could be less, and airway could be larger to fit a smaller scope. And curious as to what it looks at a lower tracheal level. Possibly they can find somewhere to do an awake trach?

 

[VisionaryTics]

As an ENT resident, I've seen a fair number of patients who needed to be trached who could not undergo awake trach (patients like this case with massive neglected tumors).

The usual plan is sitting up awake FOI. And by awake, I mean no nothing, no versed or fentanyl or anything. Have patient sitting bolt upright with surgeon or anesthesia (whoever intubating) standing in front with a pediatric video broch, small tube, a strong suction, plenty of 4 percent lidocaine, and a trach tray ready to go if the worst happens. Take your time, trust the lido, and don't do anything that will turn this into an emergency .

With regards to the rigid bronch, I would have one set up ready to core through tumor if necessary. If it gets to that, patient likely toast from bleeding in airway anyway.

I last did one about two weeks on a guy with massive oropharyngeal tumor involving larynx, coming out through skin, etc. I counseled him and his family before procedure that his odds at surviving intubation were 50/50.

I really want to hear what was done in this case.

 

[nimbus]

Why do you need a thoracic surgeon? you have a ENT doc, who can do rigid scopes.
Also i dont know about other places, but at my institution no way in hell this guy gets bypass.

also it'd be cool if can see rest of CT neck, would like to see continuous images. Like I said, the CT is done with him lying down, so this is probably the worst it gets. if Do AFOI with him sitting straight up, the compression could be less, and airway could be larger to fit a smaller scope. And curious as to what it looks at a lower tracheal level. Possibly they can find somewhere to do an awake trach?

“CT NECK - 12/14/18: IMPRESSION:
1. Infiltrating mass centered in or adjacent to the right thyroid gland and in the prevertebral soft tissues posterior to the larynx. Tumor infiltration of the vocal cord on the right, the cricoid cartilage and arytenoid cartilage. Craniocaudal extent is from the C-3 vertebral body level to the upper mediastinum below the level the clavicular heads.”

The lumen of that trachea is a very small target. I was also wondering if it gets larger more distally and if the larger portions are accessible through the neck or if you need to go through the chest to reach it. This supra- and infra-glottic tumor is a bad combo.

 

[nimbus]

Let me just start with this. I gave this pt 1mg of versed to relieve his severe anxiety of what he was about to undergo. He went apnic. Never was able to start the Remi. It got a bit sketchy at this point.

Could you mask ventilate or assist at this point? If it was easy that would affect further management.

 

[pgg]

The Avalon catheter can be inserted in a subclavian vein. This would be a good case for it before any airway shenanigans get underway.

Or fem fem VV ECMO.

 

[Noyac]

Could you mask ventilate or assist at this point? If it was easy that would affect further management.

I could assist enough to keeps sats above 90%. I wouldn’t say I could mask ventilate though. I had to have someone help with the seal of the mask which may be the first time I’ve had to do that. I have big hands.

 

[IlDestriero]

Question to those advocating AFOI. What size tube? What bronchoscope do you have that will fit through that tube? I’m going to guess that most institutions do not have a fiber optic scope small enough to go through a tube that is small enough to fit his airway.

I think our smallest scope is 2.2mm and will definitely fit through a 3.0 ETT, I can’t remember if it will fit through a 2.5.
Unfortunately for the patient, I think the smallest MLT is 4.0 and a 2.5 or 3.0 ETT will be too short, so awake trach time. Or local, local, and more local. And and some handholding, music or a movie.
His airway is a pinhole.
Joking aside, he should get transferred to someplace that can crash onto ecmo.
All risk, zero reward for this terminal patient having surgery at a hospital with limited resources. Perhaps he can be salvaged with some chemo and radiation, but for how long? When it’s time to go it’s time to go.

 

[Echo33]

Wild case. God bless you for taking care of this disaster

I may have missed it, but how old is this patient?

This case should not be attempted anywhere but a tertiary center with full resources.

 

[Ronin786]

While I love the idea of having bypass on standby, realistically how many CT surgeons are going to show up and cannulate this guy for his biopsy? And what's the ECMO a bridge to? Tumor resection? A few days in the ICU post-biopsy? This is a bad situation to be in because even palliative is useless without a diagnosis.

The only thing that I'd do that hasn't been mentioned is ultrasound his neck. Mark out where his trachea really is, assuming you can actually visualize it on ultrasound. I'm not sure what size his trachea is lower down in the neck, but I'm marking that and maybe even sticking a catheter in there.

 

[Echo33]

While I love the idea of having bypass on standby, realistically how many CT surgeons are going to show up and cannulate this guy for his biopsy? And what's the ECMO a bridge to? Tumor resection? A few days in the ICU post-biopsy? This is a bad situation to be in because even palliative is useless without a diagnosis.

The only thing that I'd do that hasn't been mentioned is ultrasound his neck. Mark out where his trachea really is, assuming you can actually visualize it on ultrasound. I'm not sure what size his trachea is lower down in the neck, but I'm marking that and maybe even sticking a catheter in there.

Agree. I don’t know any cardiac surgeons who would cannulate for bypass for this. The comorbidities alone are prohibitive let alone the uncertainty of how the patient is going tk get off after the airway is established.

 

[anbuitachi]

I think our smallest scope is 2.2mm and will definitely fit through a 3.0 ETT, I can’t remember if it will fit through a 2.5.
Unfortunately for the patient, I think the smallest MLT is 4.0 and a 2.5 or 3.0 ETT will be too short, so awake trach time. Or local, local, and more local. And and some handholding, music or a movie.
His airway is a pinhole.
Joking aside, he should get transferred to someplace that can crash onto ecmo.
All risk, zero reward for this terminal patient having surgery at a hospital with limited resources. Perhaps he can be salvaged with some chemo and radiation, but for how long? When it’s time to go it’s time to go.

Are a lot of places willing to crash a patient like this onto ecmo? I think here if you have cancer with mets, you are out of ECMO. CT surgery will deny it. I dont know if there exceptions since i dont exactly ask for ECMO often

 

[Hork Bajir]

Yeah I mean, the crux of this is that no matter what we do we’re really just rearranging the deck chairs on the titanic.

Also since no one has said it yet: prop, sux, tube

 

[OB1🤙]

Retrograde wire.

Obviously.

 

[MirrorTodd]

Yeah I mean, the crux of this is that no matter what we do we’re really just rearranging the deck chairs on the titanic.

Also since no one has said it yet: prop, sux, tube

Love the username! Brings back memories.

 

[Mman]

Leaving him intubated is not the wrong thing to do.. but it begs the question. Why? and for how long? youre going to have to extubate him at some point? in two hour? four hours? overnight? When? I take these things out after the case. NO FENTANYL.. MINIMAL VERSED and if you get the volatile agent off at end of case they will be wide awake. THe remi will help you accomplish that. The question remains will you ask the surgeon to trach him .. If he is trached then everything else is simple.

The only wrong thing to do is extubate somebody like this that is going to be 100% guaranteed unable to be reintubated.

If I have to ask the surgeon to do a trach, I'm hoping to find a better surgeon.

But yeah, sure, no fentanyl, no versed, use remi, blah blah blah. The patient will still 100% be more obtunded at the end of the case than they were when you did your unsedated awake FOI. We act like they are awake, but it's not AS awake as before. And this dude is walking a tightrope over the Grand Canyon. While most people can tolerate that little bit of somnolence, this patient as described cannot.

 

[Mman]

2.5

2.5 is the internal diameter of the tube, the external diameter is significantly larger (I think roughly 3.5 mm for a 2.5 tube depending on the manufacturer.

 

[periopdoc]

No one interested in inhalational induction? I’m leaning that direction.

Lots of nebulized epi before starting to help reduce bleeding if you end up instrumenting him.

Leave him sitting up during induction and for the case should help.

Noy, can you palpate bony structures in his trachea. This sounds like a case for a retrograde wire if so.

 

[deleted162650]

2.5 is the internal diameter of the tube, the external diameter is significantly larger (I think roughly 3.5 mm for a 2.5 tube depending on the manufacturer.

It was a joke. I’m not aware of any tubes small enough that are long enough for an adult.

 

[Mman]

It was a joke. I’m not aware of any tubes small enough that are long enough for an adult.

I mean obviously a 2.5 neonatal tube isn't long enough, but I find people frequently forgetting what the number on the tube actually represents especially when looking at CTs and trying to figure out what size tube will fit where.

 

[IlDestriero]

Are a lot of places willing to crash a patient like this onto ecmo? I think here if you have cancer with mets, you are out of ECMO. CT surgery will deny it. I dont know if there exceptions since i dont exactly ask for ECMO often

I think my shop will crash almost anyone on to ECMO. We have an ECPR protocol as well. They come flying into the 1st available open OR like a swarm of locusts. Every one is surreal.

 

[deleted162650]

No one interested in inhalational induction?

Noy, can you palpate bony structures in his trachea. This sounds like a case for a retrograde wire if so.

A) No, not interested.


B) No way I’m poking a needle a needle into this guy’s neck.

 

[betamale]

Retrograde wire.

Obviously.

Like aiming a wire through a pinhole...blindly...then sheemy the tube through the golf ball

Racemic epi and Dex really helped a lot during post op

 

[anbuitachi]

Like aiming a wire through a pinhole...blindly...then sheemy the tube through the golf ball

Racemic epi and Dex really helped a lot during post op

ultrasound guided???

 

[deleted875186]

I must know how this case went down.

 

[Noyac]

Wild case. God bless you for taking care of this disaster

I may have missed it, but how old is this patient?

This case should not be attempted anywhere but a tertiary center with full resources.

He was or is around 70

 

[daneeka]

What do you guys think about this: Advanced upper airway obstruction in ENT surgery

Older article, but the gist is that the only two viable options for advanced laryngeal obstruction are awake tracheostomy, or inhalational induction with a nasal airway to prevent obstruction and an ENT surgeon holding a rigid bronchoscope. AFOI being unrealistic due to the 'cork-in-the-bottle' effect.

How about awake videolaryngoscopy with a hyperangulated blade? Caveat being that topicalisation can precipitate complete obstruction if you're unlucky.

 

[Noyac]

No one interested in inhalational induction? I’m leaning that direction.

Noy, can you palpate bony structures in his trachea. This sounds like a case for a retrograde wire if so.

I have to say, I never thought of an inhalation induction. My plan was to have this guy wide awake. Obviously, that plan changed after the versed but in my defense when’s the last time anyone has seen an anxious 260ish pound man go down with 1mg of versed?

Yes I could vaguely feel what I thought was trachea. Everything was pretty firm and not very mobile.

 

[Noyac]

What do you guys think about this: Advanced upper airway obstruction in ENT surgery

Older article, but the gist is that the only two viable options for advanced laryngeal obstruction are awake tracheostomy, or inhalational induction with a nasal airway to prevent obstruction and an ENT surgeon holding a rigid bronchoscope. AFOI being unrealistic due to the 'cork-in-the-bottle' effect.

How about awake videolaryngoscopy with a hyperangulated blade? Caveat being that topicalisation can precipitate complete obstruction if you're unlucky.

I took a look with the GS and that was a bad idea.

 

[deleted162650]

My plan was to have this guy wide awake. Obviously, that plan changed after the versed but in my defense when’s the last time anyone has seen an anxious 260ish pound man go down with 1mg of versed?

I took a look with the GS and that was a bad idea.

I hope there’s room for said 260ish pound man in that hole you keep digging yourself.

 

[daneeka]

I took a look with the GS and that was a bad idea.

Bad idea in that it looked horrendous? Or that it caused you to lose the airway?

Also, I reckon this guy would be a prime candidate for a staged extubation kit if you felt brave enough to take the tube out at the end (assuming he didn't end up with a trache).

Re: jet ventilation - surely that would end in tears? Especially transglottic or transtracheal with no way for gas to get out?

 

[Noyac]

I hope there’s room for said 260ish pound man in that hole you keep digging yourself.

Dick!!!

 

[deleted131481]

What level are these images we are looking at? C3ish? How far down do you have to go before the airway opens up? I know the CT says it's down to mediastinum but surely it's not 3mm diameter for that entire length?

I'd suggest to ENT awake trach below the level of stenotic airway. I don't understand all the comments about extubation. I feel very strongly I could not stick a tube in there because it's way too tight and would ask ENT if it would be possible to do a low lying trach if the airway is more patent there.

I've had a similar tracheal stenosis in that the narrow part was 3mm. The difference is the length of the stenosis was only a few mm and there wasn't a giant hulking tumor in the way. We had a 6.0 tube that looked like a giant pipe compared to the stenosis and no way was anything getting passed.

Sent from my Pixel 3 using Tapatalk

 

[propadope]

So you quickly draw up the flumazenil and give it.... so no harm no foul right?

 

[vector2]

Inhalational induction is a bad idea in an obese OSAer with a basketball in his neck. Induction with high dose vapor causes enough muscle relaxation that even normalish airways frequently need a bit of PPV or an oral airway to maintain ventilation.

 

[Planktonmd]

I probably missed it but did some one mention awake tracheostomy?
This patient has impending airway obstruction and he needs a tracheostomy before he dies.
He is going to die anyway from this tumor and from his other disasters but a tracheostomy might give him a few months.

 

[T-burglar]

The Avalon catheter can be inserted in a subclavian vein. This would be a good case for it before any airway shenanigans get underway.

Or fem fem VV ECMO.

Yes I was thinking the same thing, except if you ask me this should be femoral with fluoro and TTE. The avalon is a big nasty catheter that is really best placed in a large RIJ and TEE is almost mandatory (which you aren't going to be doing in this patient). But VV ECMO is the obvious choice here over CP bypass because ENT surgeons probably can't operate on heparinized patients.

If this patient NEEDS to be anesthetized, in 2019 a case like this should be done with TIVA and flowing on VV or not at all.

 

[bigdan]

Was there any discussion of neoadjuvent therapy? Or is that verboten if there is no 100% lock on the pathology diagnosis?

Single dose XRT?

Pulse another few days of steroids?

I know the point of the biopsy is to determine the treatment, but perhaps there’s a way to improve surgical, anesthetic and patient success without immediately going to the OR...

 

[Southpaw]

If ENT doesn’t think they can do an awake trach then the safest option, given that CT, is wedging some ETT in there w AFOI. Nothing is small enough/long enough to fit in that space per CT. You said he’s better post-steroids so maybe you get lucky. Completely awake. Generous local. Sit him straight upright.

Any form of extubation would be terminal. The tumor is invading the right vocal cord. The patient needed an awake trach a long time ago. If I get an ETT in there, it doesn’t come out until something takes its place.

 

[Southpaw]

Also, @Noyac is very experienced. Patient must’ve looked considerably better in person. Given the HPI and CT scan I don’t know of an ENT surgeon outside of tertiary care who just rolls in morning of procedure with ‘just need a little tissue here....’.

 

[Neuronix]

Was there any discussion of neoadjuvent therapy? Or is that verboten if there is no 100% lock on the pathology diagnosis?

Single dose XRT?

Pulse another few days of steroids?

I know the point of the biopsy is to determine the treatment, but perhaps there’s a way to improve surgical, anesthetic and patient success without immediately going to the OR...

I wouldn't consider radiation until airway is stable. Radiation can cause short term edema that would kill this patient even if there would otherwise be a good response. Even then I would strongly prefer to know the histology and probably start with chemo.

If steroids are working well, continue them and reimage. Untreated lymphomas respond to steroids alone.

Hard for me to tell based on the few images provided where this is most likely arising. In any case, without looking at the rest of the images, anaplastic thyroid, cervical esophageal or hypopharynx (usually squamous cell), or metastases would be most common. The chemo for those are very different, so need biopsy to know what might work. That tends to take a week or two.

Given that they already had an unsuccessful attempt at biopsy, did they have systemic imaging looking for other sites of tumor? Are there maybe regional lymph nodes involved? If anything else is present, a biopsy could be performed elsewhere as well.