A novel nasal mask-face tent provided continuous nasal ventilation/oxygenation and lowered aerosol/droplet spread during GA induction/intubation/extubation in a difficult airway patient with large neck haematoma

ABSTRACT

Background: A combined paediatric facemask-face tent provided nasal pre/apnoeic oxygenation and reduced aerosol spread in a COVID-19 positive patient during RSI/intubation/extubation.1,2 It avoided severe desaturation and reduced aerosol/droplet spread during difficult intubation/ extubation in a morbidly obese patient.3 We used it in a difficult airway patient with large neck haematoma. Case Report A 56-year-old obese male with HTN and right parotid tumor s/p uneventful parotidectomy, developed neck haematoma and severe desaturation, presented for urgent neck exploration. He had swollen neck/lower jaw (right) and Class IV airway (Fig.1). While in incline position, a modified infant facemask-face tent was secured over his nose.1 He was pre-treated with lidocaine oral spray. He breathed comfortable with 4-5cmH2O nasal CPAP (4LO2/min). SpO2 improved from 96% to 100% (93% Expired O2). GA was titrated with midazolam/fentanyl/lidocaine/propofol. Pressurecontrolled nasal ventilation (PIP 15cm H2O/PEEP 5cm H2O/RR 20/min) was initiated. Videolaryngoscope (VL) revealed vocal cords and swollen larynx and tissues. He was then given succinylcholine/ propofol. Atraumatic VL intubation under the face tent was accomplished smoothly (Fig.2). SpO2 (100%) was maintained. He tolerated the procedure well. Prior to extubation, he received lidocaine (5cc 2%) spray via endotracheal-tube. The nasal mask-face tent was re-secured. He was extubated smoothly without coughing. The circuit was re-connected to the nasal mask. He maintained spontaneous nasal ventilation and 100% SpO2. Discussion: This simple nasal mask-face tent provided pressure-controlled ventilation/oxygenation in a patient with large neck haematoma during GA induction/intubation. It helped lower aerosol/ droplet spread during intubation/extubation. Amid COVID-19 pandemic, it should be used as a universal precaution to improve patient oxygenation and provide additional provider protection. (Figure Presented).