What would you do (airway management case)?

[sevensandeights]

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I read this forum every once in awhile and the posts I seem to enjoy most are case reports. I finally have one of my own to post:

71 year old 62" 52kg female presents for modified radical neck dissection, total laryngectomy and right hemithyroidectomy.

The pt was dx with squamous cell CA of the right pyriform sinus (without esophageal or vocal cord extension per CT scan report) 3 weeks ago after DL and bx under GETA at our hospital. The pt has no other PMHx and is on no medications. She does have a 50 pack yr smoking hx but quit 1.5 years ago.

The anesthesia record from the DL and bx 3 weeks ago indicates that intubation was successful after one attempt with a 6.0 ETT using a MAC 3 blade and grade 2 view. There are no other comments about the intubation other than the material above that is listed in the "fill in the blanks" airway section of the anesthesia record. Intubation was facilitated with Propofol and SUX.

My attending and I spoke with the attending ENT regarding airway management prior to the case and he said the mass was small and non-obstructing 3 weeks ago with very minor medialization of the right vocal cord. The pt had no hx of stridor or hoarseness on interview and exam the morning of sx.

How would you manage this airway? Please, no oral boards/text book answers (unless that's what you would do 😀 ) - we all know that the "proper" answer isn't always the right answer (or at least what we think is right 😀 )!

After there are a few replies, I'll let you know what we did and what the outcome was.

 

[DreamMachine]

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[fval28]

Agree with using surgical airway once it is established- and nothing from your presentation suggests that there was a problem with the airway 3 weeks ago- correct? Although I assume the question in your post was regarding what to do to initially secure the airway?

I would consult with the anes. provider who intubated her the last time (if possible) and see what his/ her input is- they would probably be able to tell you more that the record reflects and if they see the patient now, may be able to tell you if they notice any changes in airway assessment, barring any major changes- I would probably proceed as previous provider did.

Having the ENT doc's input is IMHO invaluable- and as a plus, it's always good to have another person in the room who is as attentive to the airway as we are!

 

[militarymd]

Big syringe

small syringe of long acting stuff

Full speed ahead.

 

[sevensandeights]

Bummer - I was hoping for a better response.

Anyways, here's how it went down. We consented the pt for a possible awake fiberoptic and also discussed a possible awake (under local) tracheostomy. The awake trach would be less than ideal for the surgeon since he is going to do a radical neck dissection and this would make it more difficult.

We felt fairly comfortable with standard IV induction considering the discussion with ENT and easy intubation 3 weeks prior - we did have the surgeon in the room though. 100mg of Propofol followed by 100mg of SUX. I used a MAC 3 blade and it slid into the valleculae easily. However, the "small right sided mass" had nearly quadrupled in size! The mass covered 75-80% of the subglottic opening. The mass was immediately under the epiglottis and I considered using a Miller blade and displacing it and the epiglottis together but was concerned about massive bleeding if the tumor ruptured.

We abandoned the DL and were able to mask the pt easily. We had the fiberoptic in the room but were worried about being able to pass it around the mass and then ramming the ETT over the scope and next to the mass to get to the cords. So, we got the Glidescope (super cool piece of equipment by the way) out and were able to barely visualize the cords but again we didn't have enough room to advance the ETT around the mass without roughing things up. As opposed to a fiberoptic scope, we could visualize the mass and could actually see it becoming beefy red with agitation

By this point there were several anesthesia attendings in the room and I therefore went into resident "fetch boy" mode. While I was out of the room tracking down supplies, the ENT ended up intubating with some sort of special largyngoscope blade (I think it is called a Dedo blade). He also struggled but finally managed to pass a 6.0 ETT.

The pt's sats never dipped below 98% because she was easy to mask so we had time to trouble shoot and intubate as atraumatically as possible.

Needless to say, everyone was shocked at how quickly this tumor grew in only three weeks time! In this case, an awake fiberoptic may have been the textbook answer and a "safer" option but I don't think we could have intubated the pt anyway for the reasons mentioned above. Granted, the pt would not have been asleep and paralyzed but she still wouldn't have been intubated either.

FYI - a radical neck dissection is one of the coolest surgeries I have ever seen. I have been doing this long enough now that I rarely find myself gawking over the drape but seeing every anatomic structure carefully dissected out of the neck is simply amazing. Then, they hacked out the entire larynx, including the hyoid bone and you are left just staring at the anterior esophagus!

 

[militarymd]

Bummer - I was hoping for a better response.

What do you mean...."better response"?

In real life.....meaning in private practice where we don't mentally masturbate...and where the players are all experienced and actually do this stuff everyday.....as opposed to academic attendings (I was one at an earlier point in my life).....This is the answer.

IF, the patient can be ventilated without an ETT tube....and there are many ways of doing this......the answer is....big syringe, small syringe of the long acting stuff...and intubate in one of a variety of MANY different ways....

1) DL
2) lightwand
3) optics
4) retrograde wire
5) etc.
6) etc.
7) etc.

 

[sevensandeights]

Last time I checked, this was a Anesthesia Residency forum. What better place to mentally masturbate! I was wondering how many would try a DL vs. awake fiberoptic vs. awake trach as their first option given the info presented.

I agree with you and your plan. However, I also think it's interesting that none of the options on your list of a "variety of ways" to intubate would work well in this case. You need the view of a DL but the confirmation of the scope so you can see BOTH the mass and the cords. Sure, you cou;d just jam a tube down there and hope for the best but is this really the best option, especially since the pt was stable while being mask ventilated?

Ultimately, I think the ENT performed my intial plan by displacing the mass with the blade and passing an ETT around it.

 

[militarymd]

I agree with you and your plan. However, I also think it's interesting that none of the options on your list of a "variety of ways" to intubate would work well in this case.

.

Ahhhh....the resident who knows what experienced attendings don't know...

What don't you post an image of the CT scan.......something that would guide you in your plan.

I assume you reviewed the CT prior to inducing GA ...right?

 

[sevensandeights]

CT scan was the same one that was taken before the bx 3 weeks ago - I referenced this in the inital post.

I didn't say that any of your options would NOT work, but rather they might not be the BEST option.

If you think I am the "know-it-all" resident then you must be the attending who thinks his way is the only way and that all other options are wrong and ridiculous and should not even be discussed.

 

[Noyac]

One thing that one must not forget when dealing with these airways that involve tumors. The tumor can be very friable. If you go in there with any instrument and bang/brush against the tumor it will bleed. Some of them will really bleed alot. I usually go with DL since I can easily see the tip of the blade and carefully advance without causing very much bleed at all. With FOB you can easily cause bleeding while passing the scope and then you screwed. If I feel that I can mask the pt then the pt goes to sleep and I proceed with gentle DL.

 

[militarymd]

CT scan was the same one that was taken before the bx 3 weeks ago - I referenced this in the inital post.

Well, then post the image.

I didn't say that any of your options would NOT work, but rather they might not be the BEST option.

What option are you talking about....I did NOT mention ANY particular technique of intubation......The exact technique used would be based on PE of the patient and correlation with imaging studies which you have not posted.

If you think I am the "know-it-all" resident then you must be the attending who thinks his way is the only way and that all other options are wrong and ridiculous and should not even be discussed.

If you're saying this based on what I posted, then that is a big "YEP", you're one of those uppity "know-it-all" residents that I have always had extreme pleasure in dealing with.

 

[militarymd]

Did you even take the time to review the ACTUAL images on CT scan?


From what you have posted.....I'm willing to bet that you only bothered to look up the radiology report, but never actually spent the time to LOOK at the actual images.

Well....so did you actually look?

 

[sevensandeights]

One thing that one must not forget when dealing with these airways that involve tumors. The tumor can be very friable. If you go in there with any instrument and bang/brush against the tumor it will bleed. Some of them will really bleed alot. I usually go with DL since I can easily see the tip of the blade and carefully advance without causing very much bleed at all. With FOB you can easily cause bleeding while passing the scope and then you screwed. If I feel that I can mask the pt then the pt goes to sleep and I proceed with gentle DL.

I agree - ultimately I felt more comfortable having the ENT take a look and manipulate the tumor. In this case, you couldn't even see cords around the tumor because it was that large and obstructing and was immediately subglottic.

Military - I don't have access to the image and cannot post it. I'm on call at another hospital and don't even have access to the chart/report. I'm not sure how exactly I offended you but I am certainly done arguing with you (you know what they say about arguing on the internet ). This is a message posting board that facilitates discussion of anesthesia issues. I was simply asking what you would have done. You said you would induce GA with IV agent and a paralytic and then intubate - that's fine but HOW would you intubate and would you change your plan after actually visualizing the obstructing lesion described above?

I don't even pretend to know anything let alone everything. All I do know is that our plan did not work this time but I'm not sure what I would do differently the next time (that is the purpose of this thread). If the pt could not be ventilated then the answer is easy - throw in an LMA or have the ENT trach the pt. This case was kind of unique in that we had all the time in the world to do the best thing for the pt and provide the best surgical field for the ENT.

Addendum (after seeing your last post): No, I didn't look at the actual CT scan. I was comfortable with the previous intubation note and my conversation with the ENT. I suppose I should have looked at the images although in this case, the mass definitely changed in the 3 weeks since the scan and bx (as per the ENT) and those images may not have been all that relevant.

 

[militarymd]

I agree - ultimately I felt more comfortable having the ENT take a look and manipulate the tumor. In this case, you couldn't even see cords around the tumor because it was that large and obstructing and was immediately subglottic.

Military - I don't have access to the image and cannot post it. I'm on call at another hospital and don't even have access to the chart/report. I'm not sure how exactly I offended you but I am certainly done arguing with you (you know what they say about arguing on the internet ). This is a message posting board that facilitates discussion of anesthesia issues. I was simply asking what you would have done. You said you would induce GA with IV agent and a paralytic and then intubate - that's fine but HOW would you intubate and would you change your plan after actually visualizing the obstructing lesion described above?

I don't even pretend to know anything let alone everything. All I do know is that our plan did not work this time but I'm not sure what I would do differently the next time (that is the purpose of this thread). If the pt could not be ventilated then the answer is easy - throw in an LMA or have the ENT trach the pt. This case was kind of unique in that we had all the time in the world to do the best thing for the pt and provide the best surgical field for the ENT.

You didn't offend me....I'm playing the senior oral board examiner.

What I'm saying is it doesn't matter how you intubate.

Review of the actual CT image is important.

Once, the scope is in the trachea, it is very easy to guide the ET tube in with your hand.....you can reach, with your hand into someone's airway...almost to the vocal cord....you can guide the tube around the mass...or use your fingers to move the mass out of the way.....

Using your fingers to reach into someone's airway is something that is not taught in residency...why? I don't know..but it is something that can help you a LOT in get a tube in.

 

[jwk]

I know you want to ignore the voices of experience in favor of a "better response", but here's my two cents...

1) Since the patient ends up with a trach anyway, I think the awake trach at the start of the procedure is an excellent choice, and have seen it done this way many times over the years.

2) If I "barely visualize the cords" with the glidescope, then I've probably got room to get the tube in (yes, I know, I wasn't there). Since you're able to ventilate the patient, you can play with the curve on your stylet as needed to avoid the tumor as much as possible. I don't RAM a tube anywhere. Lately, I've been using the glidescope (impresses everyone else in the room 😉 ) and a bougie, and then gently pass a reinforced tube over the bougie. If they're not already out, the next generation glidescope is supposed to have a thinner blade - if I ever have a problem with the glidescope, it's usually due to the blade being too thick to get into a small mouth.

 

[sevensandeights]

I know you want to ignore the voices of experience in favor of a "better response", but here's my two cents...

I don't understand this comment at all - I posted this thread to inspire discussion not to ignore other's opinions.

The glidescope view was less than impressive. The ENT was there and he pointed out what he thought was the cords but they didn't look like cords to me (or my attending). Remember, this mass covered at least 75% of the glottic opening. Even with a 6.0 ETT we were still bumping into the mass and when you add the thickness of ETT to the thickness of the mass, there was a 100% obstruction so the cords couldn't be visualized while the ETT was being passed.

Military's suggestion of fiberoptic with some sort of displacement tool (fingers . . . really 😱 ) would have been ideal. Keep the eye on the prize through the scope and minimize tumor irritation.