Anesthetic Management of Large Bronchogenic Cyst With Severe Tracheal Compression in Adults: A Case Report.

Bronchogenic cysts (BCs) are a congenital anomaly, forming fluid-filled sacs in the bronchial tree during fetal development, and are relatively rare in adults. Patients with large BCs in the mediastinum presenting with severe tracheal compression pose a significant challenge to anesthesiologists. The confined and narrow space of the mediastinum exacerbates the compression effect on surrounding structures, leading to potential respiratory or cardiovascular collapse during anesthesia and postoperatively. Herein, we report the stepwise anesthetic management of a patient with a BC in the paratracheal region of superior mediastinum, causing near-complete tracheal compression, scheduled for right posterolateral thoracotomy and tumor excision. The patient presented with dyspnea, chest pain, cough, and severe tracheal compression necessitating meticulous airway management. Utilizing awake fiberoptic intubation with a single-lumen endotracheal tube and one-lung ventilation facilitated by an EZ bronchial blocker, we successfully secured the airway, provided ideal surgical conditions through lung deflation, and ensured perioperative safety. This case underscores the crucial role of comprehending the underlying pathophysiology, anticipating complications, and meticulously planning, preparing, and executing strategies for airway management and perioperative care in patients with mediastinal masses leading to significant tracheal compression.

Awake fiberoptic intubation of a patient with severe multiple trauma in prone position: a case report.

BACKGROUND: Fiberoptic-guided intubation is considered as "gold standard" of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist. CASE PRESENTATION: A man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient's recovery was uneventful, and he was discharged from the hospital one month after the surgery. CONCLUSIONS: Awake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

Anesthesia for a Patient with Base of Tongue Mass undergoing Transoral Robotic Surgery: A Case Report.

Transoral robotic surgery (TORS) is a minimally invasive surgical technique that has recently gained popularity. This involves the use of a robotic system to access and operate on hard-to-reach areas of the body, such as the base of tongue and pharynx. General anesthesia is the technique of choice in TORS as this procedure poses unique challenges due to the patient's airway anatomy, the need for precise surgical movements, and the potential for postoperative complications. Awake fiberoptic intubation (AFOI) is the gold standard for an anticipated difficult airway. This case report describes the anesthetic management for a patient undergoing TORS for a tongue base mass.

Cervical Necrotising Fasciitis Leading to Critical Airway Compromise: A Case Report of Successful Airway Management With Awake Fibreoptic Intubation.

A 56-year-old female patient with a history of breast cancer, anxiety, and depression developed rapid-onset cervical necrotising fasciitis following a fall at home where she sustained multiple rib fractures and lacerations. The case highlights the challenge of managing a rapidly progressing airway obstruction and the successful management of the patient's condition with awake fibreoptic intubation and subsequent surgical intervention.

Remimazolam for Sedation During Fiberoptic Intubation in an Adolescent.

In specific clinical scenarios, fiberoptic intubation (FOI) may be the preferred technique for airway management and endotracheal intubation. In addition to topical anesthesia of the airway, sedation is frequently necessary, especially in younger patients, to facilitate the procedure. The goal is to facilitate the procedure by providing sedation, anxiolysis, and analgesia with maintenance of spontaneous ventilation. Remimazolam is a novel benzodiazepine with a short half-life and limited context sensitive half-life that can be titrated by continuous infusion. These novel properties may make it a suitable agent for sedation during FOI of the trachea. We report the novel use of a combination of remimazolam and remifentanil infusions to provide sedation during FOI in an adolescent. The basic pharmacology of remimazolam is presented and previous reports of its use for sedation during FOI are reviewed.

Massive Ameloblastoma Requiring Awake Nasal Fiberoptic Intubation.

Ameloblastomas are rare tumors that arises from the odontogenic epithelium. Although benign and slow growing, an extensive lesion may cause airway obstruction, making bag-mask ventilation and intubation a significant challenge. Here, we present a 54-year-old male in respiratory distress with an 18x15x13 cm submandibular mass causing airway compromise. The tumor was extensive, occupying most of the oral cavity. Unable to perform direct laryngoscopy because of the tumor burden, we performed an awake nasal fiberoptic intubation to secure the airway. Successful intubation was achieved as well as subsequently tracheostomy. We subsequently provide a discussion on associated challenges and management options for patients with ameloblastomas.

Ludwig's Angina and Treatment Considerations in the COVID-19 Pandemic.

Introduction: Ludwig's angina is a type of severe cellulitis that spreads rapidly and carries a significant risk of airway compromise. Previous complications with COVID-19 are poorly described within the literature. Case Presentation: This case report describes the complication of COVID-19 infection with suspected Ludwig's angina 2 days after admission, resulting in awake fibroscopic endotracheal intubation. Emergent treatment and establishing a secure airway are paramount in these cases. We discuss the role of antibiotics and adjunct treatment in these cases of potential airway compromise. Conclusion: Limited data demonstrate simultaneous infection of COVID-19 with these types of submandibular soft tissue infections in the literature. Previous explorations into this subject are limited, as COVID-19 is a relatively new condition with its own treatment guidelines. We discuss specifically the role of corticosteroid use and surgical intervention in these cases. We wish to highlight awareness and treatment considerations for COVID-19 patients with superimposed Ludwig's angina.

Fiberoptic Intubation vs. Video-Assisted Fiberoptic Intubation in a High-Fidelity Pediatric Simulator: A Randomized Controlled Trial.

INTRODUCTION: Life-threatening hypoxemia during tracheal intubation is more likely to occur in children than adults due to its unique physiological and anatomical nature. Fiberoptic intubation is widely performed in children with difficult airways. However, mastery of fiberoptic intubation requires substantial training, and novice trainees need to attempt fiberoptic intubation in children at high risk of respiratory-related adverse events. Therefore, a safer method than traditional fiberoptic intubation for children with difficult airways is desirable for novice anesthesia trainees. This study aimed to compare the efficacy of video-assisted fiberoptic intubation (VAFI) with that of traditional fiberoptic intubation (FOI) in a high-fidelity pediatric simulator by medical professionals with no experience in tracheal intubation. METHOD: This randomized, controlled, simulation-based study was conducted in a tertiary-care pediatric hospital. Registered nurses working in the operating room were enrolled in this study and randomly assigned to either the FOI or VAFI groups. Participants in the FOI group performed fiberoptic intubation without the aid of any device, whereas those in the VAFI group used a video laryngoscope to obtain a better glottic view. The primary outcome was the time from the moment the tip of the flexible bronchoscope passed between the upper and lower incisors until the completion of tracheal intubation. RESULTS: A total of 28 participants were enrolled in this study. There was no significant difference in the time until the completion of tracheal intubation between FOI and VAFI, with a median time of 55.0 seconds for FOI and 42.5 seconds for VAFI (P = 0.22). Secondary outcomes, including time until passing the vocal cord, the number of intubation attempts, and the first success rate, did not also illustrate the significant difference between the groups. CONCLUSION: This study did not demonstrate the superiority of VAFI over conventional FOI in a high-fidelity pediatric simulator by medical providers with no experience in tracheal intubation.

An optimized "sTOP" strategy-based awake fiberoptic intubation for a patient with severe scoliosis after halo-pelvic traction.

Difficult Airway Society launched the new guideline for awake tracheal intubation (ATI) in adults with the goal of standardizing and promoting ATI techniques to protect the airway in 2020 (Anaesthesia, 2020;75:509). Specifically, the guideline highlighted that the key components of ATI are sedation, topicalization, oxygenation, and performance, coined "sTOP." To the best of our knowledge, anticipated difficult airway is the best indication for ATI. Patients with severe scoliosis undergoing halo-pelvic traction (HPT) are often with head and neck fixation, thereby contributing to the anticipated difficult airways. HPT was first used to fix unstable cervical vertebra segments in 1959, and gradually applied in the treatment of scoliosis (scoliosis or kyphosis Angle greater than 90 degrees is usually considered as severe scoliosis), with favorable efficacy and safety profile, and thus widely used in clinical practice (Clin Orthop Relat Res, 1973;93:179). To date, the improved HPT device usually consists of a head ring composed of 6 ~ 8 cranial nails, a pelvic ring composed of 6 ~ 8 iliac bone nails and 4 telescopic connecting rods, which can achieve all-day continuous traction. Usually, the average traction time was about 8 weeks (Chin Med J (Engt), 2012;125:1297). Our case described a planned awake fiberoptic intubation (AFOI) for a patient with severe scoliosis undergoing HPT via an optimized "sTOP" strategy.

Anesthesia management in a pediatric patient with complicatedly difficult airway: A case report.

BACKGROUND: Reports on perioperative anesthesia management in pediatric patients with difficult airways are scarce. In addition to relatively more difficulties in the technique of endotracheal intubation, the time for manipulation is restricted compared to adults. Securing the airways safely and avoiding the occurrence of hypoxemia in these patients are of significance. CASE SUMMARY: A 9-year-old boy with spastic cerebral palsy, severe malnutrition, thoracic scoliosis, thoracic and airway malformation, laryngomalacia, pneumonia, and epilepsy faced the risk of anesthesia during palliative surgery. After a thorough preoperative evaluation, a detailed scheme for anesthesia and a series of intubation tools were prepared by a team of anesthesiologists. Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways. Given the age and medical condition of the patient, we kept him sedated with spontaneous breathing during endotracheal intubation. The endotracheal intubation was completed on the second attempt after the failure of the first effort. Fortunately, the surgery was successful without postoperative complications. CONCLUSION: Dealing with difficult airways in the pediatric population, proper sedation allows time to intubate without interrupting spontaneous breathing. The appropriate endotracheal intubation method based on the patient's unique characteristics is the key factor in successful management of these rare cases.

High-flow oxygen therapy versus facemask preoxygenation in anticipated difficult airway management (PREOPTI-DAM): an open-label, single-centre, randomised controlled phase 3 trial.

Background: Difficult airway management remains a critical procedure with life-threatening adverse events. Current guidelines suggest high-flow therapy by nasal cannulae (HFNC) as a preoxygenation device in this setting. However, there is an evidence gap to support this recommendation. Methods: The PREOPTI-DAM study is an open-label, single-centre, randomised controlled phase 3 trial done at Nantes University Hospital, France. Patients were aged 18-90 years with one major or two minor criteria of anticipated difficult airway management, and requiring intubation for scheduled surgery, were eligible. Patients with body mass index >35 kg/m2 were excluded. Patients were randomly allocated (1:1) to receive 4-min preoxygenation by HFNC or facemask. Randomisation was stratified according to the intubation strategy (laryngoscopic versus fiberoptic intubation). The primary outcome was the incidence of oxygen desaturation ≤94% or of bag-mask ventilation during intubation. The primary and safety analyses included the intention to treat population. This trial is registered with ClinicalTrials.gov (NCT03604120) and EudraCT (2018-A00434-51). Findings: From September 4 2018 to March 31 2021, 186 patients were enrolled and randomly assigned. One participant withdrew consent and 185 (99.5%) were included in the primary analysis (HFNC, N = 95; Facemask, N = 90). The incidence of the primary outcome was not significantly different between the HFNC and the facemask groups, respectively 2 (2%) versus 7 (8%); adjusted difference, -5.6 [95% confidence interval (CI), -11.8 to 0.6], P = 0.10. In the HFNC group, 76 patients (80%) versus 53 (59%) in the facemask group, reported good or excellent intubation experiences; adjusted difference 20.5 [95% CI, 8.3-32.8], P = 0.016. Comparing HFNC with facemask, severe complication occurred in 22 (23%) versus 27 (30%) patients (P = 0.29), and moderate complication in 14 (15%) versus 18 (20%) patients (P = 0.35). No death or cardiac arrest occurred during the study. Interpretation: Compared with facemask, HFNC did not significantly reduce the incidence of desaturation ≤94% or bag-mask ventilation during anticipated difficult intubation but the trial was underpowered to rule out a clinically significant benefit. Patient satisfaction was improved with HFNC. Funding: Nantes University Hospital and Fisher & Paykel Healthcare.

Head and neck cancer recurrence with limited mouth opening, radiation fibrosis and confirmed COVID-19 infection: Approach to airway management.

We present a case that describes the airway management of a patient with recurrent head and neck cancer and confirmed COVID-19 infection. Securing airway of these patients with anticipated difficulty and at the same time limiting virus exposure to providers can be challenging. The risk of aerosolization during awake tracheal intubation is extreme as it carries a high risk of transmitting respiratory infections. A multidisciplinary team discussion before the procedure highlighted aspects of both airway management and the urgency of surgical procedure where particular care and modifications are required. Successful flexible bronchoscopy and intubation was done under inhalational anaesthetics with spontaneous breathing. Although fiberoptic intubation during sleep,in anticipated difficult airways, have led to enhanced intubation time, this technique was opted to minimize the risk of aerosol generation associated with topicalisation, coughing and hence reduced incidence of cross infection to health care workers.

Awake Fiberoptic Nasotracheal Intubation and Anesthetic Management of a Patient With a Compressed and Deviated Airway From a Massive Thyroid Goiter: A Case Report.

Difficult airway management is a challenge for anesthesiologists, requiring proper assessment, planning, and sometimes a multidisciplinary approach to establish a secure airway. Here we present a case where the patient had a large thyroid goiter with significant tracheal compression. Due to the large size of the thyroid mass and the location of tracheal narrowing, fiberoptic intubation appeared to be challenging, and a surgical airway was not a viable option to obtain a secure airway for a total thyroidectomy. This case report discusses awake fiberoptic intubation and intraoperative anesthetic management of a patient with known airway compression and explores the alternative method for obtaining a definitive airway through venovenous extracorporeal membrane oxygenation.

Acute Emphysematous Epiglottitis: A Case Report.

Epiglottitis is a bacterial infection of the upper respiratory tract that can be rapidly progressive and life-threatening. Though predominantly seen in unvaccinated children, there seems to be a shift with the incidence of adult cases rising following the Haemophilus Influenza B (HiB) vaccine. There are several reports of epiglottitis manifesting as an abscess, but few cases report on the formation of an emphysematous abscess. Additionally, little is known on the bacterial etiology of such infections. Here, we present a case of a patient found to have acute emphysematous epiglottis managed with fiberoptic intubation, drainage, and culture of the abscess. Laryngoscope, 133:2747-2750, 2023.

Management of an Anticipated Difficult Airway in a Pediatric Patient With Stickler Syndrome.

Stickler syndrome (SS) is a congenital autosomal dominant condition that affects the formation of collagen. Of primary importance to the anesthesia provider is the propensity for difficulties in managing the airway due to orofacial abnormalities associated with this syndrome. The authors present a two-year-old infant with SS who required anesthetic care for a cleft palate repair. The potential anesthetic implications of this syndrome are discussed and the importance of proper planning and preparation and the usefulness of ultrasound as an airway evaluation tool are highlighted.

Anesthetic Management of a Large Right Ventricular Mass due to Idiopathic Hypereosinophilic Syndrome in a Patient Undergoing Cardiac Surgery, a Case Report.

Cardiovascular complications of hypereosinophilic syndrome (HES) constitute a significant source of morbidity and mortality, with heart involvement found in approximately 40%-80% of patients. In patients with right heart failure due to an intracardiac mass, induction of general anesthesia poses numerous challenges. The effects of positive pressure ventilation on right ventricular (RV) physiology can quickly lead to precipitous cardiovascular collapse, which increases the importance of maintaining adequate negative pressure ventilation strategies. Current strategies involve awake femoro-femoral cannulation with partial vs full flow femoro-femoral cardiopulmonary bypass (CPB), but both methods increase the risk of intraoperative blood loss due to systemic heparinization prior to sternotomy. In this case report, the authors describe an approach to anesthetizing a patient with severe right ventricular heart failure due to an intracardiac mass due to idiopathic HES. This approach involves femoral cannulation prior to induction of general anesthesia, airway topicalization, inhalational induction with fiberoptic intubation, and sternotomy with aortic/bicaval cannulation before paralysis.

Special Procedures for Pulmonary Disease in the Emergency Department.

In the emergency department, there are infrequent but essential procedures related to pulmonary diseases that emergency physicians must be able to perform. These include thoracentesis, chest tube thoracostomy, tracheostomy manipulation, and fiberoptic intubation.

A Compromised Airway in the Setting of Failed Extracorporeal Membrane Oxygenation Cannulation.

We report a case involving failed extracorporeal membrane oxygenation (ECMO) cannulation in the setting of critical airway stenosis secondary to a large anterior mediastinal mass. The most invasive management option, ECMO, was initially pursued solely to avoid manipulation of a critical airway in case of intubation failure or life-threatening airway bleeding. However, after unexpectedly failing cannulation in two separate cannulation sites with an impending respiratory collapse, awake fiberoptic or emergent rigid bronchoscopy was the remaining viable option. The patient was ultimately intubated via awake fiberoptic intubation even though this modality carried a high complication risk and potential mortality if failed. This case report illustrates both the potential role of ECMO within the airway management hierarchy and the persistent need for contingency planning should ECMO cannulation fail. With the recent enthusiasm for ECMO incorporation into difficult airway management, our report serves to highlight the very serious issue of cannulation failure. There is a limited amount of case reports describing ECMO failure in a critical airway, and little has been described about rescue methods when ECMO fails. Our goal is to remind readers that although ECMO can be an excellent rescue option for a critically ill patient, it cannot be viewed as a last line of therapy. If one is able to rapidly recognize impending ECMO cannulation failure and is prepared for cannulation failure, they can save invaluable time in a decompensating patient.

Awake fiberoptic intubation in a patient with a large thyroid tumor invading the trachea: a case report.

This case report aims to raise awareness about the risk of challenging airway problems in patients with thyroid tumors. We report a case of a patient with a large thyroid tumor invading the trachea, causing trachea narrowing and resulting in breathing difficulties, who required awake tracheal intubation (ATI). A 54-year-old woman underwent surgery for the removal of a thyroid tumor under general anesthesia. The tumor was invading and compressing the trachea, causing difficulty in breathing. To facilitate surgery, thyrocricocentesis and nerve block were considered, but they were difficult to implement. Extracorporeal membrane oxygenation (ECMO) is expensive and has risks of several complications, such as failure of the oxygenation membrane, rupture of the circuit, coagulation of the system, intracranial hemorrhage, acute kidney injury, and infections. The placement of a tracheal stent may worsen airway problems. In this case, the airway was established without ECMO or tracheal stent placement. Local anesthesia of the airway could be an alternative to avoid expensive options and complications, as successful ATI would reduce healthcare costs.

A Prospective Observational Comparison of Two Approaches to Anesthetizing the Trachea for Awake Intubation.

BACKGROUND: Multiple techniques have been described for anesthetizing the lower glottis and trachea prior to awake fiberoptic intubation. The primary aim of this study is to evaluate whether direct application of local anesthetic to the lower airway via an epidural catheter under direct vision is equally efficacious when compared to use of a transtracheal block in adult patients with an anticipated difficult airway. METHODS: Patients age >18 years requiring awake fiberoptic intubation who underwent upper and lower airway topicalization were observed prospectively. Following topicalization of the upper airway, patients underwent either a transtracheal block or had their trachea and lower glottis anesthetized under direct vision via dispersion of local anesthetic through a multi-orifice epidural catheter. Choice of technique was at the discretion of the attending anesthesiologist. The primary outcome was defined as the degree of coughing observed at the time of intubation based on a 4-point ordinal scale. RESULTS: Awake intubations in 88 patients were observed with 44 patients undergoing transtracheal block and 44 patients undergoing the epidural catheter technique. Degree of coughing with intubation was similar for each approach with a coughing score of (0, IQR (0,1)) versus (0, IQR (0,1)) in the epidural catheter and transtracheal groups respectively (p = 0.385). Duration of procedure was less in the transtracheal group (1.35 ± 1.54 min) vs. epidural catheter approach (2.86 ± 2.20 min) (p< 0.001). CONCLUSION: The epidural catheter and transtracheal approach appear to be equally effective at preventing coughing with intubation during awake fiberoptic intubation.