yet another airway...

[hoyden]

---

Members do not see this ad.

Precedex is a nice drug that is looking for an indication!
It's similar to lumbar plexus blocks: nice technique that is looking for an indication.

It also has to be available - it was not available in my program, started to be, when I was done, it is not available in my hospital. Maybe yet 🙂

 

[Jeff05]

awake FOI. period. nasal is ok, likely easier.

 

[Fastrach]

awake FOI. period. nasal is ok, likely easier.

This just makes no sense if the guy's getting a trach anyways, but again, where I am, our ENT's prefer awake trachs.

One last time, the best approach for this patient is as follows:
1) Do an awake trach in the first 5-10 min of the case.
2) Kick back the remaining 4 hours.

😉

 

[Noyac]

This just makes no sense if the guy's getting a trach anyways, but again, where I am, our ENT's prefer awake trachs.

One last time, the best approach for this patient is as follows:
1) Do an awake trach in the first 5-10 min of the case.
2) Kick back the remaining 4 hours.

😉

I agree completely.

 

[IN2B8R]

Just posting a few questions here, Plank: can an awake FOI be physically non traumatic (presumably from excellent topicalization/nerve blocks), yet be traumatic from a memory/remembrance standpoint? In the patient's mind, does the fear of the procedure play into the experience being more "traumatic?" Will a soothing voice (or a good pre-op lecture) be better than a drug at dispelling the anxiety--errasing the memory--throughout the procedure? I think that some sedation is a far better approach than limited/no sedation. Every sedative/analgesic comes with a risk, that we both know.... I think that I am aware of your answers even before you reply, I just wanted to point out my personal reasons for moderate sedation: blanketing the patient's memory of the procedure after the aw has been properly anesthetized.


best regards.👍

Awake fiberoptic intubation in experienced hands is not a traumatic experience!
The key here is good airway anesthesia, if you know how to do that and you know how to drive a fiberoptic scope, the patient will not have a traumatic experience.

 

[Planktonmd]

Every patient is different and there are patients that simply are not good candidates for any awake procedures!
last week I had a 30 Y/O woman that was so nervous and crazy that I decided to do a mask induction on her then start the IV!
In general though I try to limit my sedation in awake fiber optic intubations but I explain to the patient exactly what we are going to do and I also keep communicating with them while we are working.
If the airway anesthesia is good they might be uncomfortable a little but they usually tolerate it very well.

Just posting a few questions here, Plank: can an awake FOI be physically non traumatic (presumably from excellent topicalization/nerve blocks), yet be traumatic from a memory/remembrance standpoint? In the patient's mind, does the fear of the procedure play into the experience being more "traumatic?" Will a soothing voice (or a good pre-op lecture) be better than a drug at dispelling the anxiety--errasing the memory--throughout the procedure? I think that some sedation is a far better approach than limited/no sedation. Every sedative/analgesic comes with a risk, that we both know.... I think that I am aware of your answers even before you reply, I just wanted to point out my personal reasons for moderate sedation: blanketing the patient's memory of the procedure after the aw has been properly anesthetized.


best regards.👍

 

[Fastrach]

Okay. Suppose they go with an awake trach. Are you only going to give midazolam? If so, I hope the surgeon localizes well.

Here's exactly how they go at our house:

1) A whiff of midaz +/- fentanyl, a little reassurance/hand holding, and generous local by the surgeon.
2) Surgeon works his way down just to the point where it's time to put in a tube, then tells you "we're ready."
3) Propofol, sux, good night now.
4) Hand a wire-reinforced tube to surgeon who puts it exactly where he wants it.
5) +ETCO2
6) Chillin like a villain.

 

[nap$ter]

Okay. Suppose they go with an awake trach. Are you only going to give midazolam? If so, I hope the surgeon localizes well.

yes. you do an awake trach or awake fiberoptic if you fear you won't be able to mask or intubate. so respiratory depression should be minimized as much as possible, as it can be deadly in this particular patient. and yes, the surgeon does accomplish adequate local analgesia. midazolam only, stingy doses only (in my hands). but, as noyac says, everyone has their own methods. the goals should be the same, though.

none of these are rigid rules - there are always going to be exceptions. but if you are going down the road of awake intubation of the trachea, you should keep the reasons for doing so in the forefront of your mind.

i would like to try precedex for awake trachs or FOI's - haven't had the opportunity yet...

 

[Licoricestick]

👍

Radiation to the neck always has me on high alert.

No radiation to his neck yet - limited MO secondary to trismus secondary to medial pterygoid involvement by tumour.

 

[Licoricestick]

Can't believe how many people are suggesting awake tracheostomy - we entertained it for all of 5 sec in discussion with ENT.

Well, had a chat to the surgeons this morning, and they said they wanted to proceed in the following order: neck dissection, mandibulotomy, excise tumour, tracheosotomy, plastics in to do flap. So they definitely wanted a nasal tube (which ruled out the previous approach of DL + bougie) and preferred not to do an awake trache if we had other viable options (I also think the patient would have freaked over this suggestion).

Consultant's opinion was that there are plenty of oppotunities to practice FOIs and not enough to practice managing a difficult airway without FOI, so his preference was for the FOI to be a backup plan. He also wanted IV induction with sux (on the basis that the patient was previously able to be facemask ventilated and nothing had changed in that regard since his previous GA).

So all my high tech plans went out the window 🙂mad: I really wanted to do another FOI)

New plan A - IV glyco 0.2mg in holding bay in case FOI required. IV induction (propofol, remi, sux) and ventilate then asleep, apnoeic blind nasal by me
plan B - ventilated again and hand over to consultant for second attempt at asleep, apnoeic blind nasal
plan C - break out the scope for asleep FOI

Everything went smoothly and the blind nasal (7.0 nasal RAE) was successful on the first attempt.😀
Case is still going - likely to take 12-15hrs. When I left at the end of my shift they were stitching the flap in, but hadn't started on the vascular anastomoses 😴.

Obviously if this was an older person with significant respiratory disease who wouldn't have been able to tolerate periods of apnoea to allow an asleep FOI, the plan would have been different.

 

[Licoricestick]

Here's exactly how they go at our house:

1) A whiff of midaz +/- fentanyl, a little reassurance/hand holding, and generous local by the surgeon.
2) Surgeon works his way down just to the point where it's time to put in a tube, then tells you "we're ready."
3) Propofol, sux, good night now.
4) Hand a wire-reinforced tube to surgeon who puts it exactly where he wants it.
5) +ETCO2
6) Chillin like a villain.

Problem with that was they wanted it in the nose.

 

[Licoricestick]

Can run a remi drip too.

Yep - that was my original sedation plan. even if you overdo it (which obviously you shouldn't with carfeul titration...but just say you do) they'll breathe if you tell them to, fast offset, and if you need it to wear off even faster we all have this handy little drug called naloxone.

Hmm - not that I've actually used naloxone in anaesthetics... only in previous ward jobs (and with one exception, for opioids others administered).

 

[2win]

Can't believe how many people are suggesting awake tracheostomy - we entertained it for all of 5 sec in discussion with ENT.

Well, had a chat to the surgeons this morning, and they said they wanted to proceed in the following order: neck dissection, mandibulotomy, excise tumour, tracheosotomy, plastics in to do flap. So they definitely wanted a nasal tube (which ruled out the previous approach of DL + bougie) and preferred not to do an awake trache if we had other viable options (I also think the patient would have freaked over this suggestion).

Consultant's opinion was that there are plenty of oppotunities to practice FOIs and not enough to practice managing a difficult airway without FOI, so his preference was for the FOI to be a backup plan. He also wanted IV induction with sux (on the basis that the patient was previously able to be facemask ventilated and nothing had changed in that regard since his previous GA).

So all my high tech plans went out the window 🙂mad: I really wanted to do another FOI)

New plan A - IV glyco 0.2mg in holding bay in case FOI required. IV induction (propofol, remi, sux) and ventilate then asleep, apnoeic blind nasal by me
plan B - ventilated again and hand over to consultant for second attempt at asleep, apnoeic blind nasal
plan C - break out the scope for asleep FOI

Everything went smoothly and the blind nasal (7.0 nasal RAE) was successful on the first attempt.😀
Case is still going - likely to take 12-15hrs. When I left at the end of my shift they were stitching the flap in, but hadn't started on the vascular anastomoses 😴.

Obviously if this was an older person with significant respiratory disease who wouldn't have been able to tolerate periods of apnoea to allow an asleep FOI, the plan would have been different.

"IV glyco 0.2mg in holding bay in case FOI required"
Hey mate in The USA they get dry with much more than that...
What about Aussies - only 0.2 mg of glyco?
That means that the beer is doing the rest of it 😍
Regarding the blind intubation - I wouldn't go with it - by the textbook....Tumor maybe is friable and you can dislodge it and so on. Doesn't mean that a fiberoptic is better - you control only the direction of the tube.
What about a nasal assisted by a glydescope?
"Case is still going" - glad that I am not there....

 

[Licoricestick]

"IV glyco 0.2mg in holding bay in case FOI required"
Hey mate in The USA they get dry with much more than that...
What about Aussies - only 0.2 mg of glyco?
That means that the beer is doing the rest of it 😍

Don't underestimate the power of beer! Of course it has to be titrated to effect😀

As to the glyco - what doses would you be giving?

The blind nasal - yes, I was concerned about causing bleeding (hence the plan to hand off to the consultant after one try!) but the boss wanted him asleep and no FOI and ENT didn't want to temporise with an oral tube and do an early trache - kind of limits your options, esp with no videolaryngoscope.

 

[2win]

Don't underestimate the power of beer! Of course it has to be titrated to effect😀

As to the glyco - what doses would you be giving?

Hey dude - I have a great respect for Australia and NZ anesthesia!
Regarding the beer - I would go in details but we drink here the sh itty Foster "Australian" beer (made in Canada) so I cannot elaborate .
Without to look in the books or to try a Google - I remember that is 0.8 mg of Glyco. If I am wrong - blame on me - this is the dosage that I give it....

 

[Licoricestick]

Hey dude - I have a great respect for Australia and NZ anesthesia!

Glad to hear! Was wondering about the avatar btw - wouldn't happen to be the australian rugby team? I've tried blowing it up but it just pixelates.

Regarding the beer - I would go in details but we drink here the sh itty Foster "Australian" beer (made in Canada) so I cannot elaborate .

The 'real' fosters stuff isn't beer - it's PISS, I shudder to think what happens when it's made under licence.

 

[Planktonmd]

Wow!
Blind nasal asleep with muscle paralysis for a known difficult intubation!
So, let's say you put the patient to sleep, gave sux, inserted the ETT in the nose and caused a significant nose bleed but could not pass the tube into the trachea!
What were you going to do next?

 

[militarymd]

Can't believe how many people are suggesting awake tracheostomy - we entertained it for all of 5 sec in discussion with ENT.

Well, had a chat to the surgeons this morning, and they said they wanted to proceed in the following order: neck dissection, mandibulotomy, excise tumour, tracheosotomy, plastics in to do flap. So they definitely wanted a nasal tube (which ruled out the previous approach of DL + bougie) and preferred not to do an awake trache if we had other viable options (I also think the patient would have freaked over this suggestion).

Consultant's opinion was that there are plenty of oppotunities to practice FOIs and not enough to practice managing a difficult airway without FOI, so his preference was for the FOI to be a backup plan. He also wanted IV induction with sux (on the basis that the patient was previously able to be facemask ventilated and nothing had changed in that regard since his previous GA).

So all my high tech plans went out the window 🙂mad: I really wanted to do another FOI)

New plan A - IV glyco 0.2mg in holding bay in case FOI required. IV induction (propofol, remi, sux) and ventilate then asleep, apnoeic blind nasal by me
plan B - ventilated again and hand over to consultant for second attempt at asleep, apnoeic blind nasal
plan C - break out the scope for asleep FOI

Everything went smoothly and the blind nasal (7.0 nasal RAE) was successful on the first attempt.😀
Case is still going - likely to take 12-15hrs. When I left at the end of my shift they were stitching the flap in, but hadn't started on the vascular anastomoses 😴.

Obviously if this was an older person with significant respiratory disease who wouldn't have been able to tolerate periods of apnoea to allow an asleep FOI, the plan would have been different.

that's what I would have done if a nasal tube was planned...

There is just no need to do an awake when you know that you can mask ventilate someone.

 

[Planktonmd]

that's what I would have done if a nasal tube was planned...

.

You would have induced GA, gave Sux and did a blind nasal intubation?

 

[IN2B8R]

I personally do not see the utility of choosing to go blind. Why would anyone do that?

You would have induced GA, gave Sux and did a blind nasal intubation?

 

[militarymd]

I personally do not see the utility of choosing to go blind. Why would anyone do that?

I believe lic said this was a training exercise.

I had a CA-3 who had never done a blind intubation....

although this guy is not the best candidate for a blind intubation.

 

[Planktonmd]

that's what I would have done if a nasal tube was planned...

this guy is not the best candidate for a blind intubation.

 

[IN2B8R]

Ahh, right on, thanks Mil. Been a while since I had my head in academia. I suppose there maybe some utility in doing it once or twice.... The day may arrise in PP, where these new grads may see a wired jaw and not have a fiberoptic.... I just hope that neither I, nor a family member is on the receiving end!

I believe lic said this was a training exercise.

I had a CA-3 who had never done a blind intubation....

although this guy is not the best candidate for a blind intubation.

 

[Licoricestick]

Wow!
Blind nasal asleep with muscle paralysis for a known difficult intubation!
So, let's say you put the patient to sleep, gave sux, inserted the ETT in the nose and caused a significant nose bleed but could not pass the tube into the trachea!
What were you going to do next?

Yes, well, the boss didn't seem too concerned about that (didn't stop me from worrying or planning).

However, had that been the case....I would have left the tube in the nose to avoid making things worse (yeah, might need to take it out later to ventilate, but I wouldn't do that until I needed to), a bit of trendelenburg, sucker in his mouth, laryngoscope in his mouth. Depending on how much blood, what I saw, apnoea time, SpO2 (and of course whether the boss took over 🙁) probably make one further attempt to place the tube using techniques appropriate to what was causing me difficulty in the first place (btw I think 'blind nasal' as a label is slightly misleading...the absence of direct vision doesn't mean you don't know where the tube is going). If that still fails, options include
1) place an LMA (they got a fastrack in before, just couldn't intubate through it), remove the tube, ventilate, suction, then use other methods to intubate (probably orally and make the surgeons do the trache first up rather than neck dissection and tumour)
2) place L lateral, remove tube, ventilate by facemask, wake patient up, attempt awake airway (sucks to be the patient, but I think this would be the safest option)

Other considerations would also include getting the ENT surgeons to help stop the epistaxis.

 

[Licoricestick]

There is just no need to do an awake when you know that you can mask ventilate someone.

That was the point made by some of the older consultants. And the fact that I knew we could ventilate was what made awake trache such a surprising suggestion for me.

 

[Licoricestick]

This just makes no sense if the guy's getting a trach anyways, but again, where I am, our ENT's prefer awake trachs.

One last time, the best approach for this patient is as follows:
1) Do an awake trach in the first 5-10 min of the case.
2) Kick back the remaining 4 hours.

😉

Fastrach - where are you doing your free flap cases that the surgeons are so fast? Any chance they can come and teach our plastics guys to speed up? 4 hrs is about what it takes to suture the flap in and plug in the vascular connections, additional time required to raise flap (couldn't be done simultaneous with the resection in this case as the ENT surgeons needed the arm in for surgical access), and perform the ENT part of the operation (ENT bit took about 4 hrs).

 

[militarymd]

Yes, well, the boss didn't seem too concerned about that (didn't stop me from worrying or planning).

However, had that been the case....I would have left the tube in the nose to avoid making things worse (yeah, might need to take it out later to ventilate, but I wouldn't do that until I needed to), a bit of trendelenburg, sucker in his mouth, laryngoscope in his mouth. Depending on how much blood, what I saw, apnoea time, SpO2 (and of course whether the boss took over 🙁) probably make one further attempt to place the tube using techniques appropriate to what was causing me difficulty in the first place (btw I think 'blind nasal' as a label is slightly misleading...the absence of direct vision doesn't mean you don't know where the tube is going). If that still fails, options include
1) place an LMA (they got a fastrack in before, just couldn't intubate through it), remove the tube, ventilate, suction, then use other methods to intubate (probably orally and make the surgeons do the trache first up rather than neck dissection and tumour)
2) place L lateral, remove tube, ventilate by facemask, wake patient up, attempt awake airway (sucks to be the patient, but I think this would be the safest option)

Other considerations would also include getting the ENT surgeons to help stop the epistaxis.

blood in the lung is fairly benign....you do know that, right?

 

[Planktonmd]

blood in the lung is fairly benign....you do know that, right?

"Blood in the lungs" is NOT benign!
It is less destructive to the lung tissue than HCL from the stomach but it does obstruct the airway depending on the amount aspirated and it is an excellent medium for bacterial growth.

 

[Planktonmd]

Excellent answer!
Not that many people (especially here in the U.S.) would have attempted to do a blind nasal intubation under GA on this patient but you did it and it worked.
One little thing to add: In my experience, doing a blind nasal intubation on an apneic patient is like tossing a coin, you are hoping it will enter the right hole and you optimize the head position and apply pressure to the trachea for it but you can't really tell where your tube is going can you?

Yes, well, the boss didn't seem too concerned about that (didn't stop me from worrying or planning).

However, had that been the case....I would have left the tube in the nose to avoid making things worse (yeah, might need to take it out later to ventilate, but I wouldn't do that until I needed to), a bit of trendelenburg, sucker in his mouth, laryngoscope in his mouth. Depending on how much blood, what I saw, apnoea time, SpO2 (and of course whether the boss took over 🙁) probably make one further attempt to place the tube using techniques appropriate to what was causing me difficulty in the first place (btw I think 'blind nasal' as a label is slightly misleading...the absence of direct vision doesn't mean you don't know where the tube is going). If that still fails, options include
1) place an LMA (they got a fastrack in before, just couldn't intubate through it), remove the tube, ventilate, suction, then use other methods to intubate (probably orally and make the surgeons do the trache first up rather than neck dissection and tumour)
2) place L lateral, remove tube, ventilate by facemask, wake patient up, attempt awake airway (sucks to be the patient, but I think this would be the safest option)

Other considerations would also include getting the ENT surgeons to help stop the epistaxis.

 

[hoyden]

C
New plan A - IV glyco 0.2mg in holding bay in case FOI required. IV induction (propofol, remi, sux) and ventilate then asleep, apnoeic blind nasal by me
plan B - ventilated again and hand over to consultant for second attempt at asleep, apnoeic blind nasal
plan C - break out the scope for asleep FOI

WOW. Your consultant, although a gentleman, is just a cowboy. IMHO.

 

[Fastrach]

Fastrach - where are you doing your free flap cases that the surgeons are so fast? Any chance they can come and teach out plastics guys to speed up? 4 hrs is about what it takes to suture the flap in and plug in the vascular connections, additional time required to raise flap (couldn't be done simultaneous with the resection in this case as the ENT surgeons needed the arm in for surgical access), and perform the ENT part of the operation (ENT bit took about 4 hrs).

Ok, maybe 5-6 hrs on average. But we have one guy who is just so unbelievably good and fast, I'd let him trach me just to say "he's my surgeon." (Provided he gave me a speaking valve.)

 

[coprolalia]

Pretty cush.

Are you still mad that nobody here wanted to hire you?

You've obviously gotten me confused with someone else. I've never set foot in the state of Colorado in my life. No intention to either. I just figured out who you were based on the bombastic posts of another previous forum member, slim. Wasn't hard. Be careful how much info you let out there...

Oh, and I'm just glad that you're not really ignoring me, like you once said you were. Hope you continue to enjoy my posts! 🙂

-copro

 

[Fah-Q]

38yo male with locally advanced SCC L tonsil (T4aN0M0) for L mandibulotomy, completion of L tonsillectomy, excision of L base of tongue and lateral oropharyngeal wall, L neck dissection, tracheostomy and a radial free forearm flap for reconstruction of oropharynx.

Airway findings at biopsy/partial L tonsillectomy/panendoscopy (a month ago - anaesthetic by a experienced consultant anaesthetist):

Your surgeons screwed you. They should have trached him when they performed the biopsy. Trismus in the setting of tongue cancer = ptyergoid invasion and by definition a T4 lesion. They knew they were going to be back to perform the resection and recon soon. There really is no excuse for not doing the safe thing for the patient and traching him. What if he had a major tonsil bleed after the biospy...add massive hemorrhage to your list of things that make it a difficult airway. The patient would have died for sure.

Given the situation you've presented above I would absolutely do an awake trach. Why didn't they do the trach after you put the tube in and got him off to sleep? Were they resecting this oropharyngeal tumor while working around a tube??? Have they ever heard of airway fires down there??? Ridiculous.

Trach is never the wrong answer.

 

[Licoricestick]

Your surgeons screwed you. They should have trached him when they performed the biopsy. Trismus in the setting of tongue cancer = ptyergoid invasion and by definition a T4 lesion. They knew they were going to be back to perform the resection and recon soon. There really is no excuse for not doing the safe thing for the patient and traching him. What if he had a major tonsil bleed after the biospy...add massive hemorrhage to your list of things that make it a difficult airway. The patient would have died for sure.

Given the situation you've presented above I would absolutely do an awake trach. Why didn't they do the trach after you put the tube in and got him off to sleep? Were they resecting this oropharyngeal tumor while working around a tube??? Have they ever heard of airway fires down there??? Ridiculous.

Trach is never the wrong answer.

Actually the surgeons thought it looked a lymphoma at the original biopsy, therefore they didn't know they'd be coming back to do the excision. And when he was first seen the notes imply that everyone thought it was pain not trismus that was preventing MO, so no one consented him for a trach.

As for airway and post op bleeding - are you suggesting that any difficult airway having a head and neck procedure with a risk of post op haemorrhage should have a trach? If he had bled and they couldn't manage his airway then surgical airway in an emergency is a cricothyroidotomy (scalpel, artery forceps, size 5-6 ETT). Faster than trach, doesn't need ENT availablility and this guy was skinny with easily palpable neck anatomy.

As for airway fire... you gotta be kidding me????? Do you do your tonsillectomies with a trach to avoid the risk of airway fire? Or do you think they were resecting with laser?

With the mandibulotomy there was excellent surgical exposure of the region - the only point at which they were at risk of not being able to see the tube was during the tracheostomy (and they weren't about to use diathermy to enter the trachea). After the selective neck dissection they performed the mandibulotomy and then worked their way up dissecting tumour out along the outside of the carotids (external first then internal). Tongue stitch used to retract tongue for access and excision of base of tongue lesion. Most of the dissection was with scissors not diathermy and haemostasis with clips and some diathermy. I'm not sure at what point they did anything that increased the risk of airway fire over the normal, very low, risk of diathermy within the airway UNDER DIRECT VISION.

Some people on this forum seem to think trachs are benign and a perfectly valid alternative to an ETT. They are not. Tracheostomy is a procedure with significant complications and the ability to seriously compromise the airway in and of itself. That isn't to say that I don't recognise their importance in airway management, but understanding the potential risks and benefits of anything you use (or ask others to use on your behalf) is essential.

 

[hoyden]

Some people on this forum seem to think trachs are benign and a perfectly valid alternative to an ETT. They are not. Tracheostomy is a procedure with significant complications and the ability to seriously compromise the airway in and of itself. That isn't to say that I don't recognise their importance in airway management, but understanding the potential risks and benefits of anything you use (or ask others to use on your behalf) is essential.

We are talking about this specifically delineated situation, aren't we?
In this particular pt trach is unavoidable anyway - so why tiptoe around?

 

[Licoricestick]

We are talking about this specifically delineated situation, aren't we?
In this particular pt trach is unavoidable anyway - so why tiptoe around?

I was talking about the suggestion to trach him at his previous operation, prior to the biopsy results being available and prior to a treatment plan being formulated.

 

[hoyden]

I was talking about the suggestion to trach him at his previous operation, prior to the biopsy results being available and prior to a treatment plan being formulated.

Agree on this one.

 

[Fah-Q]

Actually the surgeons thought it looked a lymphoma at the original biopsy, therefore they didn't know they'd be coming back to do the excision.

I can certainly understand being surprised by an unexpected diagnosis. My argument is that given the clinical history you've provided the otolaryngologist shouldn't have been surprised.

And when he was first seen the notes imply that everyone thought it was pain not trismus that was preventing MO, so no one consented him for a trach.

Yikes. This is an absolute embarrassment for the otolaryngologist. If he cannot separate pain from trismus when assessing a patient with an oropharyngeal mass then he really shouldn't be caring for those patients.

As for airway and post op bleeding - are you suggesting that any difficult airway having a head and neck procedure with a risk of post op haemorrhage should have a trach?

Yes.

As for airway fire... you gotta be kidding me?????

Clearly, you've never resected an oropharyngeal malignancy before. Airway fire is a low probability but with a trach there is essentially a zero probability.

Some people on this forum seem to think trachs are benign and a perfectly valid alternative to an ETT.

They are a perfectly valid alternative to death by airway obstruction. The trach was clearly indicated in this case and the delay in performing the indicated procedure exposed this patient to unnecessary risks.

 

[Licoricestick]

Fah-Q: I've reread my earlier post, apologies for it sounding a bit vicious, but I rather felt attacked for things I had no control over.

I can certainly understand being surprised by an unexpected diagnosis. My argument is that given the clinical history you've provided the otolaryngologist shouldn't have been surprised.

I certainly agree with that, although this is a young guy (38), with a relatively small smoking history (~10 pack yrs), so he wasn't quite your standard H&N SCC. Not sure on their thought processes, but his age certainly surprised most people involved in the case.

Clearly, you've never resected an oropharyngeal malignancy before. Airway fire is a low probability but with a trach there is essentially a zero probability.

I would agree that a trach REDUCES the risk, but I certainly wouldn't say it eliminates it. We had a case about 3 weeks ago where the connection between pilot balloon and cuff tube broke whilst plastics were manipulating the head for the free flap - that gets enriched O2 into surgical field pretty quickly.
Of course, there is the airway fire risk for actually getting the trach in - and had there been an airway issue whilst they were placing the trach then the surgeons had very easy access to the epiglottis so they could have easily grasped the epiglottis and intubated from the top if required. Obviously this would not have been possible prior to the mandibulotomy.

That said, I might ask the surgeons exactly why they wanted to do the procedures in the order they did (although my experience is that they do tend to do resections first, hence not being surprised that they had planned the order they did).

They are a perfectly valid alternative to death by airway obstruction. The trach was clearly indicated in this case and the delay in performing the indicated procedure exposed this patient to unnecessary risks.

I think we'll have to agree to disagree on a trach at his original procedure.

Ultimately, as I wasn't involved in the Bx/tonsillectomy, all I could do was work with what the patient actually presented to theatre with. I'm also a registrar and therefore have little (all right, absolutely no) control over the ENT fellows and consultants 🙁. Especially when my consultant is happy with their plan.

 

[pd4emergence]

Let's recap, pt comes to us with a nonobstructing tonsillar mass, poor mouth opening, but was able to be easily ventilated at his last procedure, surgeons want to resect and do a flap. As far as the trach goes...we can ask, "Hey Mr. Neckcutter will you put the trach in first?" No, well ok... Should they do the trach first? Do they have a good reason for not doing it at the beginning? We don't know because we weren't there. The poster did what we all did as residents and followed the plan that was made by the attending anesthesiologist for the case. We can nitpick this case all day, but the fact is we weren't there.

I have read through the posts and I think our knee jerk reaction for a difficult airway is to say "awake trach", an option here as it is an option for any difficult airway case. But, read through it again, how many times do you actually go to the awake trach option. Does this guy sound like one of those patients that you would insist on a trach as your initial airway management plan. He does not to me. I think the poster has responded well to questions, had well thought out plans and backups. We can get into the pro's and con's of doing this or that but I don't think we should criticize the op for things that were not in her control.

 

[Fah-Q]

Fah-Q: I've reread my earlier post, apologies for it sounding a bit vicious, but I rather felt attacked for things I had no control over.

I'm sorry you felt attacked. My intention was to criticize the otolaryngologist's management of this case, not yours.