Worst Airway I’ve seen in a long time

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Noyac

Noyac

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Chin-on-chest syndrome, who has intubated one of these pts?

We plan to fuse this one from C2-T10. How would you handle this airway? We don’t have ECMO or CPB capabilities. Is that a problem?
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FFP said:
Why not (nasal) AFOI?

Cervical osteotomy for the correction of chin-on-chest deformity in ankylosing spondylitis
Click to expand...
Did exactly this for this same kind of airway and cervical case a while back, except I did it asleep. Grade 4 views with Glidescope/Mcgrath and every other type of blade imaginable. 3 different anesthesiologists attempted. Was even a difficult mask, requiring 2 people. Nasal fiberoptic was my last attempt before I would have woken him up and luckily it worked. I put a size 7ett into the nasal airway first to act sorta like a conduit and then scoped thru it into the cords. Would not put a patient like that to sleep again lol. You only get so many attempts with an airway like this bc of bleeding, edema, etc
 
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FFP said:
Why not (nasal) AFOI?

Cervical osteotomy for the correction of chin-on-chest deformity in ankylosing spondylitis
Click to expand...
Well of course. But this pt had a recent staph infection which was treated. And the plan was to go to ICU post-op intubated at least overnight. I wanted to attempt an oral airway in order to avoid a possible sinus infection if for some reason she remained intubated for a few days.
But what if you can’t intubate?
FFP said:
Why not (nasal) AFOI?

Cervical osteotomy for the correction of chin-on-chest deformity in ankylosing spondylitis
Click to expand...
So looking at the image in this article (fig 2) I would hardly blink at this airway after the one I just did. My pt could barely get her chin off her chest at all. I gave a bit of sedation and we started to crank on her. It didn’t help much at all.
I’ll stop here for now but suffice it to say, this was impressive.
 
I would topicalize very well and even do superior laryngeal and transtracheal blocks to minimize bucking/coughing since your first shot is your best shot. Sedation with precedex. If mask ventilation is easy, I would add versed with ketamine and have flumazenil available. I would use and airQ lma to provide a curved conduit to the larynx, then fiberoptic throught the lma. Badabing badaboom
 
Hang Vanco before instrumentation. Afrin, Lido neb, 5% lido jelly on trumpet to topicalize, glyco, little bit of background precedex. Put the patient in sitting position, introduce and advance 7.0 reinforced to act as a conduit past the pharyngeal obstruction. If you cover the mouth and other naris and hear breath sounds out the tube you know you're in the ballpark. Nasal scope in, and see what you can see when an assistant helps to extend the neck a bit.
 
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If you can’t do the blocks (probably can’t if chin is literally on chest), then I would topicalize larynx and tracheal by spraying local through my fiberoptic, no biggie
 
Is there a hole where he breathes out of? If he looks like he would be an easy mask ventilation then asleep glidescope with a fiber. If he is a difficult ventilation then afoi. Factors that make me concerned about difficult ventilation severe osa, large neck, large head circumference.
 
Dr.whom said:
If you can’t do the blocks (probably can’t if chin is literally on chest), then I would topicalize larynx and tracheal by spraying local through my fiberoptic, no biggie
Click to expand...

You've never done a transmental block?
 
Awake nasal FOI has the benefit of proving the patient has normal limb movement post intubation... and that your intubation didn't cause any neuro issue. I wonder how frequently such a dramatic fusion/distraction causes any neuro issues?
 
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Dr.whom said:
If you can’t do the blocks (probably can’t if chin is literally on chest), then I would topicalize larynx and tracheal by spraying local through my fiberoptic, no biggie
Click to expand...
put tube in nose, connect tube via t piece to nebuliser, put lido in nebuliser. be patient, nebulise as you go, get tube half way down, put scope through t piece, then railroad tube
 
Ezekiel2517 said:
Did exactly this for this same kind of airway and cervical case a while back, except I did it asleep. Grade 4 views with Glidescope/Mcgrath and every other type of blade imaginable. 3 different anesthesiologists attempted. Was even a difficult mask, requiring 2 people. Nasal fiberoptic was my last attempt before I would have woken him up and luckily it worked. I put a size 7ett into the nasal airway first to act sorta like a conduit and then scoped thru it into the cords. Would not put a patient like that to sleep again lol. You only get so many attempts with an airway like this bc of bleeding, edema, etc
Click to expand...
Geez. You are a cowboy/girl.
You put the patient to sleep with that airway? Do you like to live on the wild side or what? This seems like you are just asking for trouble. Did you ask for a second opinion from your partners?
 
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narcusprince said:
Is there a hole where he breathes out of? If he looks like he would be an easy mask ventilation then asleep glidescope with a fiber. If he is a difficult ventilation then afoi. Factors that make me concerned about difficult ventilation severe osa, large neck, large head circumference.
Click to expand...

Are you even going to be able to get the glide in the mouth with such severe flexion?

This is a true case for an awake FOI. With precedex or ketamine. So semi awake but breathing.

Nasal would be more of a straight shot and it would be a risk versus benefit scenario with the Staph. But if he's been treated and cleared what's the problem?

My AFOI skills aren't great so this would take me a bit of time and I would ask my buddies for help if available.

Glidescopes and McGraths have their limits too.
 
All good comments. A couple points to make here though. I tried the transtracheal injection but I could not get to her trachea. There was no way anyone was going to easily slip a glidescope in since here chest was in the way (but ultimately that’s what I did). I believe she was maskable but I wasn’t going to find out. My backup plan was an intubating LMA then FOI through it. But topicalization was an issue here. I did the neb’d lido after glyco but that never really works all that well. I should have added the viscous lido swish and swallow, big mistake on my part.
I’m surprised nobody said ENT in the room on stand by.
 
Arch Guillotti said:
If you lose the airway on this one the patient will probably die before an ENT can do a trach.
Click to expand...

Yeah.

@Noyac, so you did an awake Glidescope? With any drugs or just topicalization? What view did you get? Can't believe the jaw popped open enough for a Glide to go in. They are so bulky. Why not an oral AFOI?
 
You guys are making this more difficult than it needs to be.

Step 1: Find the biggest/burliest guy in your department
Step 2: Have patient sittiing on OR table with it lowered all the way down
Step 3: Burly partner keeps left leg firmly planted on ground and right knee in between patient’s shoulder blades with his hands interlocked around patient’s forehead
Step 4: Said burly partner pulls back with all his might in a rowing motion
(You’ll probably hear some crackling here - don’t worry, that’s expected - that’s what your looking for)
Step 5: Lay patient down and put in typical sniffing position
Step 6: Induce and DL as usual.
 
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Took care of one of these patients as a CA-1 for a hip. I wanted to do an awake nasal fiberoptic, but my attending wasn't having it so we did a continuous spinal.
 
SaltyDog said:
You guys are making this more difficult than it needs to be.

Step 1: Find the biggest/burliest guy in your department
Step 2: Have patient sittiing on OR table with it lowered all the way down
Step 3: Burly partner keeps left leg firmly planted on ground and right knee in between patient’s shoulder blades with his hands interlocked around patient’s forehead
Step 4: Said burly partner pulls back with all his might in a rowing motion
(You’ll probably hear some crackling here - don’t worry, that’s expected - that’s what your looking for)
Step 5: Lay patient down and put in typical sniffing position
Step 6: Induce and DL as usual.
Click to expand...
I totally laughed loudly on this one. Show us how it's done Salty!!
 
DrZzZz said:
Took care of one of these patients as a CA-1 for a hip. I wanted to do an awake nasal fiberoptic, but my attending wasn't having it so we did a continuous spinal.
Click to expand...
Wouldn't be sufficient for oral boards. You need a back up to the backup plan.
 
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DrZzZz said:
Took care of one of these patients as a CA-1 for a hip. I wanted to do an awake nasal fiberoptic, but my attending wasn't having it so we did a continuous spinal.
Click to expand...
If it worked then it was the right choice.
 
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DrZzZz said:
Took care of one of these patients as a CA-1 for a hip. I wanted to do an awake nasal fiberoptic, but my attending wasn't having it so we did a continuous spinal.
Click to expand...

I had a patient in pre-op clinic who was turned away from other hospitals due to fear of unable to intubate, so when he got to OR, our srna\crna combo got to do the case even though we made it known that this a complex airway a resident should have done. Was pissed we missed out on intubation of a 90 degree neck.
 
chocomorsel said:
Yeah.

@Noyac, so you did an awake Glidescope? With any drugs or just topicalization? What view did you get? Can't believe the jaw popped open enough for a Glide to go in. They are so bulky. Why not an oral AFOI?
Click to expand...
An oral AFOI is perfect. I think the nasal is probably even better but not ideal in this case as I mentioned.

But yes I used the glidescope because we were curious as to if it was possible and if so then I could just put her off to sleep since I couldn’t topicalization as well as I like to. I kept her at about a 45 deg angle and one of my male nurses did something akin to what @SaltyDog described. Minus the cracking and popping. I was standing at the pts side, well actually I was on one knee, and I sort of slipped the GS in her mouth while holding it like an ice axe. I really struggled to get the GS in her mouth because as you alluded to Choco, it was too bulky. But mostly it was the cord coming off the handle that was the problem. I couldn’t swing it around midline. But the pt was tolerating it ok so I just continued to advance from the cheek and base of the tongue until I could swing somewhat midline. Then all of a sudden it was there, the epiglottis. As soon as I saw the epiglottis my partner grabber the FOI that I was planning on going to next. I continued to work my way towards the cords which I could see but was really tough getting a good view of them. My partner began to slide over the GS with the FO scope and I got the cords into view. It took a couple minutes to pass the FO scope but he managed and we were off and running. The tube slid in but took a little finessing.
It was pretty cool. The surgeon was a nervous wreck though.
 
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Strong work. As I said, I would ask for help on this one as well.

I have actually never heard of this condition till you posted it. Had to read up on the link FFP put up.

Why was the surgeon so nervous about an awake airway? Or sedated but breathing patient?
 
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chocomorsel said:
Why was the surgeon so nervous about an awake airway? Or sedated but breathing patient?
Click to expand...
Not entirely sure. The pt was safe at all times but it wasn’t the prettiest intubation I’ve done. I think the fact that he was useless basically at this juncture and had no control of the situation made him very anxious. I didn’t even know he was in the room at this time. He told me afterward. Said something like, “holy crap that was the most nerve wracking part of the entire surgery for me.” I said, “ it was that bad, I knew that I either get this airway with her awake or we don’t do surgery today.”
 
Great thread. If nasal FOI was used first, I like closing the mouth and opposite nare to ventilate. After ETT is secure and gas is on we will usually go in with Glidescope to see what kind if view is present. Then document it for future anesthetics at our facility.
 
I still wanna know how all these weird ass cases end up at @Noyac ’s little hospital. It’s like a tertiary referral center for bizarre ****.
 
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Ezekiel2517 said:
Did exactly this for this same kind of airway and cervical case a while back, except I did it asleep. Grade 4 views with Glidescope/Mcgrath and every other type of blade imaginable. 3 different anesthesiologists attempted. Was even a difficult mask, requiring 2 people. Nasal fiberoptic was my last attempt before I would have woken him up and luckily it worked. I put a size 7ett into the nasal airway first to act sorta like a conduit and then scoped thru it into the cords. Would not put a patient like that to sleep again lol. You only get so many attempts with an airway like this bc of bleeding, edema, etc
Click to expand...
Were they fat?

I think if it’s skinny patient. I would have tried the same. But fat people scare me. And I wouldn’t attempt to put them to sleep with known airway issues.
 
Benzocaine spray. Awake intubating LMA coated with lidocaine for good measure. FO through LMA. My plan B would be to do what you did--seeing the difficulty of getting a Glidescope in this patient given the acute angles of both the blade and the patient's neck. The Glidescope/FO combo is a powerful one though.
 
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anbuitachi said:
Why would anyone put this patient to sleep.. awake foi
Click to expand...

They want to witness a clean kill or fail their oral boards.

Putting this patient to sleep is an incredible unknown.

There is essentially zero downside to an awake intubation however you choose to do it.

It's hard to believe that with all the talk of litigation around here sometimes that anyone would put a patient to sleep with such a crappy airway that even the ENT said no thanks.
 
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chocomorsel said:
Wouldn't be sufficient for oral boards. You need a back up to the backup plan.
Click to expand...

I don't see a problem necessarily if a continuous spinal is chosen although it wouldn't be my preference. You are right about the backup plan though. As long as your reasoning is sound and you have thought a few steps ahead I don't think the oral board examiners would give you too hard of a time.
 
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2Fast2Des said:
I had a patient in pre-op clinic who was turned away from other hospitals due to fear of unable to intubate, so when he got to OR, our srna\crna combo got to do the case even though we made it known that this a complex airway a resident should have done. Was pissed we missed out on intubation of a 90 degree neck.
Click to expand...

What is up with your program? And the other hospitals must suck if they got outplayed by an srna
 
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2Fast2Des said:
I had a patient in pre-op clinic who was turned away from other hospitals due to fear of unable to intubate, so when he got to OR, our srna\crna combo got to do the case even though we made it known that this a complex airway a resident should have done. Was pissed we missed out on intubation of a 90 degree neck.
Click to expand...

that is messed up. ridiculous. was this one of those states that allow CRNA to practice independently?
 
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chocomorsel said:
Geez. You are a cowboy/girl.
You put the patient to sleep with that airway? Do you like to live on the wild side or what? This seems like you are just asking for trouble. Did you ask for a second opinion from your partners?
Click to expand...

I’m not sure I, or my soft tissues, would be too happy with that plan. 3 dudes, so many attempts (all likely to fail). Awake fiber and done.


--
Il Destriero
 
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Arch Guillotti said:
If you lose the airway on this one the patient will probably die before an ENT can do a trach.
Click to expand...

If you can’t do a trans tracheal injection, ENT’s going to have a problem with a slash trach as well. If things were impossible, and you couldn’t do a fiber for some reason, awake trach seems like the only option.


--
Il Destriero
 
I did this case as a CA3. AS bamboo spine. My plan was AFOI attempt. My attending was not having it. She probably didn't remember how to do one. So plan B was asleep with spontaneous ventilation. I proved I could mask ventilate as planned and she pushed Roc...before we had suggamadex. I'm like ok WTF now I can't even wake them up. We managed to put a tube in on the first attempt with Fiber over the glide. I almost couldn't make the turn since the patient was so flexed. If they had a more anterior airway we would have been screwed.
 
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IlDestriero said:
If you can’t do a trans tracheal injection, ENT’s going to have a problem with a slash trach as well. If things were impossible, and you couldn’t do a fiber for some reason, awake trach seems like the only option.


--
Il Destriero
Click to expand...
How do you get to the neck? Seems impossible without risking at worst death at best a quadriplegia. Aren’t them bones fused?
 
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