# 308 Ludwig's Angina & AFOI, Awake Trach, Retrograde Intubation
Ludwig's Angina is a rapidly progressing life-threatening usually odontogenic infection that spreads between tissues causing massive brawny edema of the floor of the mouth, submandibular and submental spaces which elevate and retropulse the tongue towards the roof of the mouth and towards the airway, the swelling also tracks into the spaces of the neck, swelling pharyngeal and pre-tracheal tissues. Extension can occur even into the mediastinum. Airway closure can occur within minutes during observation. Before the antibiotic era, the fatality rate was >50%.
The name "angina" harks back to the original meaning of the word as an intense strangling and smothering sensation.
Recognition of advancing Ludwig's Angina in a patient should put alarm in your soul and galvanize a full-on response from all resources available. Anesthesiology and Otorhinolaryngology should evaluate and plan airway measures. Flexible nasendoscopy may give you an early look at the glottis to estimate ability to intubate. If the airway is threatened, (things can worsen in minutes), the choice will be between Awake Tracheotomy or Awake Flexible Endoscopic Intubation; set-up for both simultaneously.
Read the references with commitment, imprinting in your mind the appearance, anatomy, course of illness, treatment goals and methods, so that you are armed with acumen and resolution should you encounter a case. Descriptions here are space-limited. Review references and local policies.
Your consultants may want to secure the airway in the Operating Room "where we have everything." However, do not transport without all the team and the equipment; don't be caught alone in an elevator. Do not scan the patient without a secured airway unless all agree that it is safe, but do not send the patient to the scanner unaccompanied by a qualified airway person.
What may be surprising is the implacable density and firmness of the swollen tissues which will not give way, constrained as it is, with increasing pressure, against fascia.
Attaining Airway Control
Keep the patient upright. Give an antisialogue early to avoid puddles of secretions. Preoxygenate and give supplemental oxygen throughout.
Maintain spontaneous breathing. Needing to ventilate an apneic patient with a precarious airway greatly complicates what must be done. Apnea, or paralysis, add flaccidity and collapsibility to the problem list. Now, there is no opposing tone to resist the swelling or to keep open the only space through which a breath manually given, or a feeble recovering breath must travel.
Emergency Front of Neck Access
If Cricothyrotomy or Tracheotomy is most likely inevitable, have the best qualified person do so first, rather than wait. Do not allow the infection to crawl over where you must cut while dithering. It is better to not cut through septic tissues.
Sedation?
Procedures can be done with verbal anesthesia and local or topical anesthesia. Awake patients can cooperate, but if need be, 'awake' does not necessarily mean aware: Consider Anxiolytic, dissociative, or amnestic medications. Avoid inducing unconsciousness or loss of muscular tone. Adrenergically driven muscle tone may be all that is keeping the airway open.
Plan
Have as many expert airway helpers as possible. Have a Shared Plan (Model) that everyone understands. Be multimodal. "Burn no bridges behind you." Always be simultaneously prepared for "the next step" as you start the present step.
AFOI
The Standard Preferred method is "Awake" Flexible Endoscopic (fiberoptic or 'chip on a stick' camera type scope) to see where you're going, 'drive' (guide) direction, suction, spray meds, or give oxygen, through a 'working channel', then slide an introducing catheter or the ETT itself through the glottis; and be able to confirm intratracheal placement by seeing tracheal rings and carina, and sensing waveform capnography.
DL/VL?
While the inverted use of a DL laryngoscope or VL videolaryngoscope may work, it is awkward and adds its own complexities. It is more stimulating to threatened tissue. It is harder to use the nasal route which naturally aligns the approach with the glottic opening. The ability to continuously inspect, suction, spot-spray the vocal cords or spasming tissue with lidocaine, oxygenate, or even slide a guidewire through the 'working channel' makes the flexible method the champion.
Have respect for the tissues; it is easy to cause trauma. Do not 'force' your way through.
Hollow Catheter Jet Rescue
Consider a "hollow" catheter (e.g., Frova or Airway Exchange Catheter) as your bougie or introducer; that is easier to manipulate, less likely to block vision, and may be used to "jet" oxygen with a manual jet ventilator; apart from its value to 'railroad' an endotracheal tube.
Have smaller sizes of ETTs than those expected to be used. Consider an 'armored' or 'flexometallic' endotracheal tube.
Observed Tracheostomy of Intubated Patient
Once the flexible scope has traversed the airway, or a partially inserted endotracheal tube over the scope holds the cords apart, if it is decided to use the safety thus given to facilitate a percutaneous tracheotomy under more controlled conditions, the scope can continuously observe the tracheotomy attempt from within the trachea to check for position, angle, or injury.
Lower-Tech
The method of Retrograde Wire-Guided Intubation has worked, especially when the costly flexible technology is not available, it is less certain, takes longer and ought not be tried in one who is apneic, has risk, and it lacks the safety and luxury of seeing conditions as one goes. It is considered sub-standard in modern areas.
Briefly, one must puncture the cricothyroid membrane with an IV cannula or Tuohy needle into the trachea (confirmed by aspirating free air through 4 ml of 4% Lidocaine within the syringe; having done so, the lidocaine can be squirted into the trachea). The cannula, directed cephalad, is to pass a guidewire or epidural catheter until it exits the mouth or nose; or is seen in the pharynx and grasped by forceps.
Current recommendation is to pass the wire into the distal endotracheal tube and out the Murphy Eye; the wire is held taut (or clamped at the neck entry) to allow the tube to be slid down the wire past the cords into the trachea. Hang-up can occur at the arytenoid cartilages, so the bevel should be rotated 90° or 180° leftwards to pass over the bumps. Alternatively, a long catheter passed over the wire can enter the trachea and ease the passage of the tube a bit further into the proximal trachea. Once the tube is confirmed in correct position and is secure, the wire can be drawn outwards. In the past, the wire would be tied to the Murphy Eye and used to 'pull-down' the tube. This offers less control, and the wire cannot be released.
Reference & Readings
Dr Chris Nickson. Ludwig angina. LITFL-Life In The Fast Lane. Last update April 23rd, 2019.
Dr Ella Burden. The True Angina. LITFL-Life In The Fast Lane. Last update March 16th, 2019.
Richard Slama, MD. Ludwig's Angina: Pearls, Pitfalls, and Highlights. emDocs.net. February 3rd, 2015.
DeAngelis, A. F., Barrowman, R. A., Harrod, R., & Nastri, A. L. (2014). Maxillofacial emergencies: oral pain and odontogenic infections. Emergency Medicine Australasia, 26(4), 336-342. [Free Access} [epdf] [PDF]
Daniel Cabrera, M.D. & Dustin Leigh, MD. A pain in the neck. Ludwig's Angina. EMBlog Mayo Clinic. November 9th, 2014.
Kassam, K., Messiha, A., & Heliotis, M. (2013). Ludwig's angina: the original angina. Case reports in surgery, 2013. Volume 2013, Article ID 974269, 4 pages. [PDF]
DOI: 10.1155/2013/974269
Brotherton, H., Montague, M. L., Rowney, D., & Templeton, K. (2012). Ludwigs Angina: lessons learned. Archives of disease in childhood, 97(Suppl 1), A13-A13. {Abstract & Paywall} (13 month-old girl)
Candamourty, R., Venkatachalam, S., Babu, M. R., & Kumar, G. S. (2012). Ludwig's Angina–An emergency: A case report with literature review. Journal of natural science, biology, and medicine, 3(2), 206. PMID: 23225990. PMCID: PMC3510922
DOI: 10.4103/0976-9668.101932
Hasan, W., Leonard, D., & Russell, J. (2011). Ludwig's Angina—A Controversial Surgical Emergency: How We Do It. International journal of otolaryngology, 2011. Volume 2011, Article ID 231816, 4 pages. [PDF]
http://dx.doi.org/10.1155/2011/231816
Dr. Laura Duggan on Twitter: "Ludwig's Angina. Cannot open mouth ... https://twitter.com/drlauraduggan/status/923026027298693120?lang=en
Oct 24, 2017 - Ludwig's Angina. Twitter discussion of Airway Management in Ludwig's Angina; emphasizing AFOI, minimal to no sedation, verbal sedation, topicalization, etc.
Chin Kim Hong., et al. "'Cannot Intubate, Cannot Ventilate' Scenario and Failed Tracheostomy in a Patient with Massive Neck Swelling: A Case Report". EC Anaesthesia 2.1 (2015): 38-43. Published: July 28th, 2015.
https://www.ecronicon.com/ecan/anaesthesia-ECAN-02-00007.php
Heidegger, T., & Schnider, T. W. (2017). "Awake" or "Sedated": Safe Flexible Bronchoscopic Intubation of the Difficult Airway. Anesthesia & Analgesia, March 2017. 124(3), 996-997. [Free Access] [PDF] DOI: 10.1213/ANE.0000000000001748
AL HARBI, Mohammed, THOMAS, J., Khalil, H. N., Said, H. N., Wannous, S., Abouras, C., ... & Dimitrou, V. (2016). Anesthetic management of advanced stage Ludwig's angina: a case report and review with emphasis on compromised airway management. Middle East journal of anaesthesiology, 23(6), 665. [Open Access] [PDF]
Vieira, D., Lages, N., Dias, J., Maria, L., & Correia, C. Retrograde intubation: an old–new technique. OA Anaesthetics 2013 Nov 01;1(2):18. C [PDF] ***Excellent analytic review of different techniques. ***Excellent review of process. Don't miss.
Dhara, S. S. (2009). Retrograde tracheal intubation. Anaesthesia, 64(10), 1094-1104. [PDF] [Free Access] ***Excellent analytic review of different techniques. Don't miss.
All Tips: 2019 NEW (05/13/2019)
2018 Complete & Re-Edited
2017 2016 2015 2014 2013
