Acute airway obstruction is life-threatening and challenging. Identifying difficult airway is important, while tackling it required preparedness, skills and clear aim.
49-year-old gentleman had few visits of dyspnea to us. On second visit, he was noted to have neck swelling, which claimed it was increasing in size past 3 weeks. An outpatient ultrasound appointment was given.
He came back days later for dyspnea. Further history, he has hoarseness of voice, orthopnea and constitutional symptoms but denied fever, thyroid symptoms or family history of malignancy. He was previously intubated for severe exacerbation of chronic obstructive pulmonary disorder, Cormack-Lehane grade 1. Clinically distress, tachypnic with stridor but able to maintain saturation under room air and responded to nebulizer. Diffuse neck swelling that moves with deglutition, consistency hard and trachea deviated to right.
Surgical reviewed and planned for computed tomography (CT) neck. Airway assessment by Anaesthesiology: good mouth opening and neck extension, Mallampati grade 2 and thyromental distance 2 fingerbreadths. In CT room, symptoms worsened and procedure deferred. Planned for intubation in view of respiratory collapse. Via video-laryngoscope, large mass bilateral laryngeal wall, swollen epiglottis and slit like vocal cord. Endotracheal tube (ETT) was not able to pass through despite with smaller diameter and Bougie.
Between the trial, laryngeal mask airway (LMA) could keep him ventilated. Decision was then made to keep the LMA and transfer to operating theatre for definitive airway.
Discussion & Conclusion
The frequent visits and neck swelling hinted that urgent intervention was required. In such condition, should we have complied to the request of CT or should we had secure the airway that was ‘seemed’ to have time. The LMA became a lifesaving tool for the can’t intubate, can ventilate scenario. The goal in emergency should always be ventilation first as intubation is not the climax.
Airway Management, Secure ventilation, LMA