This case demonstrates a novel preoxygenation technique in a patient with difficult access to the airway after a severe traumatic facial injury.
Written consent was obtained from the patient for permission to use deidentified details of the case for the purpose of publication and also use of the photograph (Figure), which was also endorsed by the Human Research Ethics Committee of St Vincent’s Hospital Melbourne.
A 48-year-old man presented to the emergency department with machete wounds in the right arm, back, and face, in particular, the nose. There was copious, ongoing bleeding from his facial injuries despite pressure being applied to the dressings. He had a history of drug addiction for which he was receiving combination buprenorphine/naloxone treatment (Suboxone, Individior Pty Ltd, SW, Australia), although he still admitted to the recent use of intravenous drugs. He was a current smoker of tobacco and marijuana.
Intravenous morphine was administered for analgesia and agitation in the emergency department. Due to ongoing blood loss, it was decided to urgently transfer the patient to the operating room where it was planned to secure hemostatic control and repair the lacerations. Once in the operating room, after obtaining appropriate consent, large-bore intravenous access was secured and a 20-gauge radial artery catheter was inserted with a blood pressure of 130/90. Two liters of lactated Ringer’s solution was immediately administered for volume resuscitation, with resolution of sinus tachycardia from 110 to 90 beats per minute and maintenance of normotension. Preparations were made for general endotracheal anesthesia via rapid sequence induction, and included 2 high-flow suction-aspiration devices, a Macintosh 4 blade laryngoscope and a Glidescope Titanium video laryngoscope (Verathon Inc, Bothwell, WA). The patient remained agitated, and additional nursing staff was required to assist with calming the patient and delivering pressure to the remaining dressings.
Preoxygenation presented a significant challenge for several reasons. Access to the face was difficult with blood-stained bandages overlying and obstructing the nose (Figure). The patient complained of pain and became further agitated whenever pressure was applied over the nasal area. It was impossible to establish a seal with an anesthesia facemask and the placement and use of a simple Hudson mask would have been unsatisfactory for adequate preoxygenation. Optiflow nasal oxygenation (Fisher and Paykel Healthcare Limited, Auckland, New Zealand) was also not possible due to nasal trauma, profuse bleeding, and occlusion by dressings. Examination of the airway was limited by patient cooperation and revealed normal dentition with good mouth opening but, of concern, significant staining of the tongue and oropharynx, consistent with the ingestion of a significant amount of blood. In the context of a potentially difficult airway with a discolored view of airway anatomy and a planned rapid sequence induction, optimizing preoxygenation was deemed a priority in establishing safe anesthetic care.
To find a solution to this situation, a novel use of oxygenation equipment was trialed by altering and combining 2 pieces of equipment: a tracheostomy mask, normally used for oxygenation via a tracheostomy, was placed over the patient’s mouth, and this was then connected directly to the tubing of an Optiflow circuit from which the nasal cannula component had been removed (Figure). Optiflow has been demonstrated to prolong apnea time when used as a transnasal humidified rapid-insufflation ventilator exchange (THRIVE) device.1,2 Modifying this apparatus by combining it with a tracheostomy mask creates a novel fusion that, to the authors’ knowledge, has not been previously described. This combination delivered high-flow warm, humidified oxygen (60 L/min) orally in a manner that was comfortable, avoided further facial injury, and was well tolerated by an already agitated patient, thereby enabling cooperation with preoxygenation. After 3 minutes of tidal breathing, an arterial blood gas was performed with the following values: Pao2 539 mm Hg and Paco2 29 mm Hg. These values confirm successful preoxygenation.
A rapid sequence induction with cricoid pressure was then safely performed using a combination of intravenous midazolam, fentanyl, ketamine, propofol, and suxamethonium. The airway was successfully secured with an 8.0 oral endotracheal tube utilizing the Glidescope Titanium MAC 4 blade for laryngoscopy. The patient remained hemodynamically stable throughout the case, which involved repair of extensive facial and nasal lacerations. At the end of the procedure, a nasogastric tube was temporarily inserted to suction 300 mL blood from the stomach before extubation.
Individualizing patient care is integral to the delivery of quality anesthesia care. In this case, the use of, or persistence with, conventional airway devices such as a facemask would have not only provided insufficient oxygenation in the absence of an adequate seal, but would have also contributed to worsening the patient’s agitation and cooperation, thereby potentially exacerbating bleeding from the face or nose. This case therefore highlights the importance of flexibility and creative troubleshooting.
To the authors’ knowledge, this is the first published use of the fusion of a tracheostomy mask and the Optiflow device for preoxygenation. It was successfully demonstrated to be safe, to be well tolerated, and to provide effective preoxygenation in an agitated patient with compromised access to the face.
Despite the absence of a closed respiratory circuit such as with conventional facemask preoxygenation, the high flow rate of humidified oxygen delivered through this novel system would have exceeded the patient’s maximum inspiratory flow rate and therefore provided a high fractional inspired oxygen concentration (Fio2). This was supported by the arterial oxygenation result of 539 mm Hg. This Pao2 value is significantly higher than the previously published Pao2 of 345 ± 21 mm Hg achieved after standard preoxygenation with a facemask in American Society of Anesthesiologists physical status I and II patients with normal lungs3 and similarly replicated in other studies.4,5 This was despite the patient having a history of intravenous substance abuse, a compromised, bleeding upper airway, and potentially impaired lung function in the context of current inhaled tobacco and marijuana use.
Interestingly, the Paco2 of 29 mm Hg in this patient demonstrated a respiratory alkalosis with a pH of 7.58. This would be consistent with hyperventilation in an agitated patient; however, a contribution toward hypocapnea by the high-flow oxygenation delivery technique should be considered. A Paco2 reduction of 7.4% has been demonstrated when high-flow oxygen is delivered transnasally to hypercapnic patients, with a clearance of anatomical dead space and improvement in alveolar ventilation proposed as a mechanism for the reduction.6 A further physiological study identified that high-flow nasal oxygenation decreases the minute ventilation required to maintain normocapnia, with reduced CO2 production proposed as a contributory mechanism.7 These effects may extend to high-flow oxygen delivery provided orally, as with the novel fusion device used in this case report. As such, this technique could provide a protective role for the management of conditions where avoidance of hypercapnia is of paramount importance, such as raised intracranial pressure or pulmonary hypertension.
This case report supports the use of this novel Optiflow-tracheostomy mask fusion device as a safe, well-tolerated, and effective alternative to conventional airway devices for preoxygenation in appropriately selected cases. In addition to facial trauma, other possible uses of this novel fusion device could extend to patients with an obstructed nasal passage from any cause, and base of skull fractures where transnasal high-flow oxygenation is contraindicated due to the potential for pneumocephalus.
Name: Verna M. Aykanat, MBBS, FANZCA.
Contribution: This author helped care for the patient, create the novel fusion device, and write the manuscript.
Name: Desmond P. McGlade, FANZCA.
Contribution: This author helped write the manuscript.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
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