The management of severe airway obstruction poses major challenges for anesthetic and surgical management. Maintaining oxygenation and pulmonary ventilation in these life-threatening circumstances is essential. Although different approaches are possible, careful preoperative assessment along with interdisciplinary discussion is important. The perioperative strategy should be unambiguously determined beforehand and will depend not only on the availability of specific equipment or patient consent, but also on the experience and preferences of the attending surgeon and anesthetist. In recent years, advances in the field of airway management have provided new possibilities for these challenging patients.
In this case report, we present the management of severe airway obstruction after failed awake oral bronchoscopic intubation. Ventilation via an Arndt exchange catheter (Cook Medical, Bloomington, IN) was provided by the Ventrain device (Ventinova Medical BV, Eindhoven, the Netherlands) during 40 minutes until surgical tracheostomy was completed under general anesthesia. Written informed consent to publish this material was obtained from the patient.
A 71-year-old man (weight 71 kg, height 176 cm) presented to the emergency department of a tertiary academic hospital with dyspnea, hoarseness, dysphagia, and retrosternal discomfort. Three years previously, he had been treated with chemoradiotherapy for a squamous cell carcinoma of the right vocal cord (T2N0M0). Further immunochemotherapy was administered for recurrent disease 2 years later. An attempt to place a percutaneous endoscopic gastrostomy feeding tube was unsuccessful 3 weeks before presentation because a gastroscope would not enter the proximal esophagus. No evidence of impending airway obstruction was noted at the time. Further medical problems included atrial flutter and cardiomyopathy. Two weeks beforehand, there was a recurrence of atrial flutter with hemodynamic instability, but electrical cardioversion was considered contraindicated, because transesophageal echocardiography to exclude intracardiac thrombus was impossible. Anticoagulation with therapeutic doses of subcutaneous enoxaparin was started.
On examination, the patient was tachypneic with inspiratory stridor and showed signs of partial airway obstruction. Airway assessment revealed postradiotherapy induration of the cervical soft tissues along with laryngeal fixation and reduced cervical extension. Interdental mouth opening was >3 cm with a Mallampati score of 4. Importantly, an experienced colleague had previously found difficulty with bag/mask ventilation. On admission to the intensive care unit, an arterial cannula was placed for pressure monitoring and blood gas analysis. Initial values whilst breathing room air were: pH 7.36, Pao2 70 mm Hg, Paco2 51 mm Hg, oxygen saturation 94%. Fiberoptic laryngotracheoscopy by the otorhinolaryngologist revealed fibrosed, almost immobile vocal cords leading to a narrow glottic opening. Electrocardiographic monitoring showed atrial fibrillation with a rapid ventricular response rate (118/min). The enoxaparin was stopped and methylprednisolone was administered (125 mg IV). Repeated corticosteroid therapy provided temporary improvement and so an urgent tracheostomy was planned 24 h later. Preoperative ultrasound examination of the neck proved difficult due to extensive tumor growth, and the position of the cricoid cartilage could not be confidently determined. Therefore, after interdisciplinary discussion and careful explanation of the risks, the patient consented to awake intubation.
In the operating room, he received an aerosol of lidocaine (2%, 5 mL) in the sitting position. Oxygenation was continued via nasal cannulae at a flow rate of 50–60 L/min, fraction of inspired oxygen 1.0 (Optiflow, Fisher & Paykel, Auckland, New Zealand). Standard monitoring (electrocardiography and saturation) plus invasive arterial pressure was applied and glycopyrrolate was administered (0.2 mg IV). The tongue and pharynx were sprayed with lidocaine (10%, total dose 80 mg). No sedation was used. A cuffed endotracheal tube (internal diameter 5.5 mm) was loaded onto a lubricated regular size Ambu aScope 3 (outer dia meter 5.0 mm, Ambu-Hospithera, Brussels, Belgium). After positioning of the bronchoscope in the hypopharynx, local anesthetic was injected onto the vocal cords (lidocaine 2%, total dose 120 mg). Because repeated attempts to advance the scope failed after 20 minutes, a soft-tipped, straight guidewire (0.038 inch, 140 cm) was passed easily into the trachea via the working channel. An Arndt exchange catheter (14 French, 70 cm) was then threaded without difficulty over the wire into the trachea to a depth of 23 cm (teeth). This “rail-roading” procedure was observed after repositioning the bronchoscope in the hypopharynx. A Ventrain device was attached and a capnography trace was observed via the side arm (Figure 1). IV anesthesia was induced using propofol and remifentanil and muscle relaxation was provided with rocuronium. Manual ventilation proceeded while observing chest wall excursions (flow rate 15 L/min, inspiration/expiration 1:1, fraction of inspired oxygen 1.0). Inspiration/expiration lasted approximately 2 seconds each and equilibration of the lungs and chest wall was allowed every 5–10 breaths (Figure 2). Ventilation continued for 40 minutes until placement of the tracheal cannula (7.0 mm). Arterial blood gas analysis was performed at 10 and 30 minutes after the onset of Ventrain ventilation (Table). Atrial flutter (heart rate 130–140/min) continued throughout the procedure and multiple bolus doses of phenylephrine (0.1 mg) were necessary to maintain the arterial pressure. Peripheral saturation remained at 98%–100%. At the end of the procedure, the patient awoke comfortably.
Awake bronchoscopic intubation is not always successful, even in experienced hands and a failure rate of 2% in the general surgical population has been described.1 In head and neck pathology, awake intubation failed in 4 of 23 fiberoptic intubations reported in the NAP4 database, but the prevalence in this group could not be determined.2 Bronchoscopic intubation in airway obstruction remains controversial not only because it might fail, but also due to the risks of complications such as laryngospasm. Failure arises for different reasons, but, in our case, in spite of obtaining a clear view, we could not advance the bronchoscope through the narrowed glottis.
We performed this procedure in the absence of sedation but with lidocaine administered topically and by aerosol. Our inability to identify the cricothyroid membrane by ultrasound precluded both the intratracheal injection of local anesthetic and preoperative placement of a transcricoid cannula. The total dose of 300 mg (4.2 mg/kg) is low in comparison to the maximum recommended dose of 9 mg/kg for topical airway anesthesia,3 but we aimed to minimalize topicalization due to the patient’s cardiac and hemodynamic status. Our patient was highly motivated and collaborated well during the procedure.
The Ventrain device is an ejector ventilator initially developed for emergency ventilation via short, narrow-bore cricothyrotomy cannulae, eg, the Cricath (internal diameter 2 mm, 7 cm, Ventinova Medical BV). In contrast to jet ventilation, which requires a patent upper airway for the passive egress of gas, the Ventrain provides suction during the expiratory phase-expiratory ventilation assistance. Although Ventrain ventilation may be a safer technique in airway obstruction, due to lower airway pressures, a postoperative chest radiograph should be taken to search for evidence of barotrauma. It is noteworthy that airway pressure was not measured in this case, but barotrauma did not occur. Efficacy of Ventrain ventilation has already been demonstrated in vitro4,5 and in animal studies,6,7 and there are increasing numbers of clinical case reports describing its use via transtracheal cannulae.8–10 Furthermore, the Ventrain has been used with exchange catheters in a porcine model11 and in pediatric practice.12 However, its use with a bronchus blocker during repair of an iatrogenic bronchial laceration was associated with profound hypercarbia and respiratory acidosis.13 Ventilatory efficacy has therefore been questioned, even if oxygenation can be assured.14 In our adult patient (body mass index 23.0), blood gas values demonstrated effective ventilation via a 14-French Arndt exchange catheter at a flow of 15 L/min, in the supine position with muscle paralysis.
Our patient presented a number of management issues, namely severe airway obstruction secondary to tumor progression, atrial flutter, and therapeutic anticoagulation. We were reluctant to proceed directly to a palliative tracheostomy because the anticoagulated state would have complicated an anticipated difficult procedure. After repeated attempts, we were unable to advance beyond the vocal cords and abandoned the procedure to avoid provoking bleeding and edema. The guidewire passed easily via the 2.2 mm working channel of the bronchoscope. The Arndt exchange catheter (internal diameter 2.77 mm) measures 70 cm long and has a tapered tip with an open end (1.07 mm) and 6 lateral side holes along the distal 4 cm. It was positioned easily and allowed excellent manual ventilation of the lungs for 40 minutes.
Securing the airway under deep inhalational anesthesia with sevoflurane and spontaneous ventilation may not have been a suitable technique in this case due to the precarious cardiovascular state. Indeed, the patient became hypotensive after induction and required support with phenylephrine throughout the procedure.
Progression of the tumoral process in the neck rendered the surgical procedure long and difficult. The tracheal tissue was extremely fibrotic and excision of hard pretracheal tumor was necessary before placing the cannula. Awake tracheostomy under local anesthesia would therefore have been uncomfortable for the patient who could not have been positioned optimally, making surgical operating conditions even more challenging.
In summary, this case report illustrates a novel use of the Arndt exchange catheter combined with Ventrain ventilation in rescuing a failed awake intubation. This technique should be considered as a back-up, especially if front of neck access might be difficult or if a transtracheal cannula cannot be positioned beforehand. Simulation plays an important role in physician training and improving patient outcomes.15 We therefore advocate the teaching and practicing of this technique on airway models/simulators.
Name: Stuart Morrison, MBChB, FFARCSI.
Contribution: This author helped prepare, edit, and revise the manuscript.
Name: Sophie Aerts, MD.
Contribution: This author helped obtain consent, and prepare, edit and revise the manuscript.
Name: Diane Van Rompaey, MD.
Contribution: This author helped review the manuscript.
Name: Olivier Vanderveken, MD, PhD.
Contribution: This author helped review the manuscript.
This manuscript was handled by: Markus Luedi, MD, MBA.
1. Law JA, Morris IR, Brousseau PA, de la Ronde S, Milne AD. The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study. Can J Anaesth. 2015;62:736–744.
2. Cook TM, Woodall N, Frerk C. Major Complications of Airway Management in the United Kingdom: Report and Findings 4th National Audit of the Royal College of Anaesthetists and the Difficult Airway Society. 2011.London, UK: National Patient Safety Agency.
3. Williams KA, Barker GL, Harwood RJ, Woodall NM. Combined nebulization and spray-as-you-go topical local anaesthesia of the airway. Br J Anaesth. 2005;95:549–553.
4. Hamaekers AEW, Götz T, Borg PAJ, Enk D. Achieving an adequate minute volume through a 2 mm transtracheal catheter in simulated upper airway obstruction using a modified industrial ejector. Br J Anaesth. 2010;104:382–386.
5. Hamaekers AE, Borg PA, Götz T, Enk D. Ventilation through a small-bore catheter: optimizing expiratory ventilation assistance. Br J Anaesth. 2011;106:403–409.
6. Paxian M, Preussler NP, Reinz T, Schlueter A, Gottschall R. Transtracheal ventilation with a novel ejector-based device (Ventrain) in open, partly obstructed, or totally closed upper airways in pigs. Br J Anaesth. 2015;115:308–316.
7. Hamaekers AE, van der Beek T, Theunissen M, Enk D. Rescue ventilation through a small-bore transtracheal cannula in severe hypoxic pigs using expiratory ventilation assistance. Anesth Analg. 2015;120:890–894.
8. Fearnley RA, Badiger S, Oakley RJ, Ahmad I. Elective use of the Ventrain for upper airway obstruction during high-frequency jet ventilation. J Clin Anesth. 2016;33:233–235.
9. Escribá Alepuz FJ, Alonso García J, Cuchillo Sastriques JV, Alcalá E, Argente Navarro P. Emergency ventilation of infant subglottic stenosis through small-gauge lumen using the Ventrain: a case report. A A Pract. 2018;10:136–138.
10. Onwochei DN, El-Boghdadly K, Ahmad I. Two-stage technique used to manage severe upper airway obstruction and avoid surgical tracheostomy: a case report. A A Pract. 2018;10:118–120.
11. de Wolf MW, Gottschall R, Preussler NP, Paxian M, Enk D. Emergency ventilation with the Ventrain® through an airway exchange catheter in a porcine model of complete upper airway obstruction. Can J Anaesth. 2017;64:37–44.
12. Willemsen MG, Noppens R, Mulder AL, Enk D. Ventilation with the Ventrain through a small lumen catheter in the failed paediatric airway: two case reports. Br J Anaesth. 2014;112:946–947.
13. Evers VM, Immink RV, van Boven WJP, van Berge Henegouwen MI, Hollmann MW, Veelo DP. Intraoperative use of the Ventrain for single lung ventilation after iatrogenic trauma to the left main bronchus during thoracoscopy: a case report. A A Case Rep. 2017;9:116–118.
14. Grocott HP. Using the Ventrain with a small-bore catheter: ventilation or just oxygenation? Anesth Analg. 2018;126:1426–1427.
15. Kovatch KJ, Powel AR, Green K, et al. Development and multidisciplinary preliminary validation of a 3-dimensional-printed pediatric airway model for emergency airway front-of-neck access procedures. Anesth Analg. 2018; [epub ahead of print].