An awake tracheostomy is indicated for acute upper airway obstruction, when other methods of securing the airway, such as intubation and cricothyrotomy, have failed or are inappropriate.1 This option is rarely considered in pediatrics because of the concerns of patient cooperation and safety. Although there are reviews of awake tracheostomies performed on adult patients, reports of awake tracheostomy in children are rare, save for stories from the 1820s of Pierre Bretonneau and his pupil Armand Trousseau performing tracheostomies on patients (including children) suffering from croup and diphtheria.2 This case report describes the anesthetic management of an awake tracheostomy performed on a 7-year-old girl, with a large supraglottic mass and impending complete upper airway obstruction.
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The patient’s family provided written permission for publication of this report.
A previously healthy 7-year-old girl presented to the emergency department with worsening voice changes, dysphagia, and difficulty laying flat at night over several weeks. An awake flexible nasopharyngoscopy performed by the otolaryngology surgeon showed a mass at the base of the tongue occupying the entire hypopharynx. The size of the mass was substantial enough that it prevented the nasopharyngoscope (2.8 mm) from sliding past it, and thus, the laryngeal introitus and vocal cords could not be visualized. A computed tomography scan confirmed a large heterogeneous mass expanding the epiglottis with obliteration of the vallecula and obstruction of the laryngeal introitus (Figure 1). The risk of complete airway obstruction prompted the consideration of securing the airway before further airway evaluation. After discussing the case with several anesthesiology airway specialists involved with the Pediatric Difficult Intubation Registry, we determined that inducing general anesthesia through an inhalation or intravenous (IV) technique was not appropriate, because the dynamic nature of the mass could cause complete airway obstruction after the induction of anesthesia, particularly if positive pressure ventilation was required. Endotracheal intubation through the oropharynx or nasopharynx would also be difficult, because the large mass obstructed direct and indirect visualization of the vocal cords and possible passage of a fiber optic scope and tracheal tube. There was also the potential of causing bleeding of the mass or swelling of the pharynx with either approach. After further discussion with the otolaryngology surgeon on the safest approach to secure the airway, an awake tracheostomy was planned. The family explained the plan to the patient in an age-appropriate context with assistance from a child-life specialist—a pediatric health care professional who works with children and families to help them cope with the challenges of hospitalization, illness, and disability. The patient and her family remained calm despite the gravity of the situation.
Before transferring the patient to the operating room, the anesthesiology, otolaryngology, and nursing teams discussed airway management plans, confirmed equipment availability, and assigned roles to all team members in case of an emergency. We discussed a minimal sedation plan because of the risk of exacerbating airway obstruction and/or rendering the patient uncooperative or disinhibited. We stressed the importance of preoxygenation and reviewed needle cricoidectomy to be performed by the otolaryngology surgeon as the backup airway plan should the patient obstruct her airway during the procedure.
The child-life specialist assisted during insertion of an IV line and applying 4% topical lidocaine cream to the patient’s neck. In the operating room, the patient remained calm, watching a movie on a tablet. She cooperated with the positioning, skin preparation, and application of surgical drapes without receiving any sedation. She was positioned supine with a shoulder roll and arms tucked at the sides. The head of the bed was elevated at 45°, and the tablet was taped to the operating room monitor facing her so that she could continue watching the movie throughout the procedure (Figure 2). In addition, 2 anesthesiologists and the child-life specialist stood next to the patient’s head and distracted her through conversation and play. The patient remained calm and cooperative during the injection of 1% lidocaine with 1:100,000 epinephrine just inferior to the cricoid in the midline and tolerated a mask with 100% oxygen. Glycopyrrolate (IV) 0.1 mg was given to decrease her oral secretions. IV midazolam (0.05 mg/kg) and ketamine (0.5 mg/kg) were slowly titrated over 10 minutes. The patient remained responsive to verbal stimuli and was breathing spontaneously through a facemask without any distress with a pulse oximetry reading of 100%. We discussed the risk of airway fire and informed the surgeon that we would administer 100% oxygen by mask for the initial part of the surgery and would decrease the oxygen concentration once the trachea was exposed. After confirming adequate local anesthetic on the neck, the surgeons used a #15 blade to incise through the skin and into the subcutaneous tissue. Bovie cautery and forceps were used to defat the area and expose the fascia investing the strap muscles. The strap muscles were split in the midline with Bovie cautery dissection and Jake dissectors. The strap muscles were retracted laterally, and the trachea was exposed. The cricoid cartilage was identified. One milliliter of 2% lidocaine was injected into the trachea, and the patient coughed a bit yet remained stable. The inspired oxygen concentration was reduced to 25% before the tracheal incision. Immediately before accessing the airway, a dexemedetomidine infusion was started at 0.6 μg/kg/h without a bolus dose. Next a #15 scalpel blade was used to make a vertical incision into the midline of the trachea between the second and third tracheal rings. This was opened with a Jake dissector and a 4.5mm cuffed tracheal tube was advanced into the airway. The patient was instructed that she would feel an increase in pressure, and she responded by coughing, while the tracheal tube was inserted. The anesthesia circuit was connected to the tracheal tube and once the end-tidal CO2 was confirmed, general anesthesia was induced through a propofol bolus (2 mg/kg) and sevoflurane 3%. At this point, the patient’s pulse oximetry transiently dropped <90% while she coughed. Rescue hand ventilation was delivered through the new tracheostomy, and the patient’s pulse oximetry returned to 100% within seconds.
The time from incision to inducing general anesthesia was 16 minutes. Two paramedian interrupted 3-0 silk sutures were placed in the trachea as retention sutures, and the tracheal tube was swapped out for a 4.5mm cuffed tracheostomy tube. This was connected to the anesthesia circuit, and end-tidal CO2 was confirmed again. The surgeons then performed a tracheobronchoscopy by passing a flexible endoscope through the tracheal tube to visualize the tip of the tracheal tube at approximately 2 cm above the carina. Throughout the procedure, she remained calm and responsive, without tachypnea, hypoxemia, or respiratory distress.
The surgeons then performed a microlaryngoscopy that showed a large mass originating from the right aryepiglottic fold filling the hypopharynx (Figure 3). The remainder of the case was uneventful as the surgeons performed biopsies and a partial resection of the mass, which pathology later showed to be a pleomorphic rhabdomyosarcoma. The patient was safely transported to the Pediatric Intensive Care Unit with a stable tracheostomy and began a treatment protocol for the rhabdomyosarcoma. On follow-up visit with the patient and family, the patient did not have any recollection of the tracheostomy in the operating room.
Awake tracheostomy in children has not been described in the modern era. Pediatric anesthesia and otolaryngology textbooks do not mention the procedure nor is it included in difficult airway algorithms. When asked about their experience with pediatric awake tracheostomies, several senior otolaryngology surgeons across the United States replied that they have never done one, nor had they heard of one being performed. None of the anesthesiology airway specialists we consulted on the Pediatric Difficult Intubation Registry had performed an awake tracheostomy on a child either. We performed an awake tracheostomy on this patient, because it was the most reliable option. An awake or sedated fiber optic nasal or oral intubation would have been difficult given that even the otolaryngology surgeon’s 2.8-mm nasopharyngoscope could not pass by the large mass. There was also the risk of causing bleeding and swelling if we had tried to squeeze the scope by the mass. We considered suggestions from specialists on the Pediatric Difficult Intubation Registry, such as topicalization of the airway with lidocaine followed by a mask induction and intubation in a lateral position. However, the size and location of the mass, coupled with the risk of complete airway obstruction from the dynamic nature of the mass after inducing general anesthesia, made this option less feasible.
An awake tracheostomy also has several safety concerns. The primary concern was the patient obstructing her airway before the surgeon was securing the tracheostomy. We were aware that she did not tolerate laying flat and therefore placed her in a 45° head-up position to help with her spontaneous ventilation. We also discussed with the otolaryngology surgeons beforehand that, if she were to have complete airway obstruction that was unrelieved by jaw thrust and other maneuvers, the surgeons would perform a needle cricoidectomy to provide oxygenation until they could secure the tracheostomy. Another concern was the risk of the patient becoming agitated or disinhibited during the procedure, which could result in harm to herself or others. We were careful in titrating midazolam and ketamine slowly, while constantly assessing her consciousness through conversation and play. Patient selection was also a factor in proceeding with the awake tracheostomy. She appeared calm with a mild temperament and had no issues following commands throughout the preoperative evaluation period.
As with any difficult airway, preparation is absolutely paramount. We emphasize the importance of teamwork between all the services involved in caring for patients with challenging airways. We ensured that all team members were aware of the plan to proceed with minimal sedation and express any concerns before starting the procedure. The operating room was set up with appropriate difficult airway equipment, including age-appropriate fiber optic bronchoscope, laryngeal mask airway, video laryngoscope, rigid bronchoscope, and needle cricoidectomy and tracheostomy kit. In the future, pediatric awake tracheostomy should be considered for selected patients, based on the availability of skilled personnel and specialized pediatric airway equipment.