Awake Tracheostomy

They say that anesthesiology is 95% comfy and relaxed and the other 5% is “oh shit”!  It’s a great career choice — pretty flexible hours, great patient contact, broad spectrum medicine, crisis management, leadership role, etc.

There happened to be an interesting case in the OR — awake tracheostomy for a patient coming in from home.

What’s a tracheotomy?

Evaluation of the airway PPT

The Difficult Airway in Head and Neck Tumor Surgery

Anesthesia for tracheostomy for huge maxillofacial tumor. From SJA: CASE REPORT Year : 2014 | Volume : 8 | Issue : 1 | Page : 124-127

Our patient had two prior tracheotomies all with successful decannulation.  His most recent trach was about 2.5 months ago (which a fiberoptic intubation was used with a 6.0 ETT).   He had a neck cancer with a rapidly growing tongue base tumor that seems to be less responsive to chemo than his shrinking neck tumor.  Because of the enlarging size of the tongue base tumor, he is starting to notice worsening stridor without his trach.  The ENT surgeon evaluated his airway just days before and deemed it unintubateable.  Therefore, my plan was to have a pedi FO scope with 5.0 cuffed ETT (smallest available in our OR), glidescope, emergency cric supplies (14g angio cath, 3cc syringe with plunger removed and 7.0 ETT adapter hooked into the end of the syringe), jet ventilator and tubes, and ENT surgeon.

We decided to use a bit of midazolam as well as Precedex for the awake trach.  The dosing on the package says 1 mcg/kg for 10 minutes then 0.7 mcg/kg/hr.  We started with 0.5 mcg/kg for 10 minutes then 0.5 mcg/kg/hr.  This regimen worked well as we started it in preop and monitored his SpO2 as he dozed off but was easily aroused to voice and gentle touch.

The Role of Dexmedetomidine for Awake Trach

Monitors were placed in the OR and we used a face mask running 10 L/min O2 with ETCO2 monitoring.  Every now and then he would obstruct while lying supine, therefore, we placed a nasal trumpet to aid the obstruction.  The surgeon localized the surgical area. See video for procedure.

The patient coughed once the trachea was perforated, but it was short lived as the surgeons were able to place the trach and hookup to our anesthesia circuit.  After confirming ETCO2, we pushed propofol IV and the remainder of the case was performed under general anesthesia (direct laryngoscopy and biopsy by surgeon).

Key take home points

• Effective communication with the patient pre-op: expectations, sedation, potential complications.
• Arm yourself! Do this like you would a difficult airway! Fiberoptic intubation supplies, glidescope, emergency cricothyroidotomy supplies, backup LMA, extra hands on deck (grab your anesthesia colleagues, anesthesia techs, extra help!), ENT… it never hurts to be over prepared!
• Deliberate, effective communication with the ENT colleague across the drape.
• Document any intubation performed, tools used, trachs placed so your anesthesia colleagues will know what worked in the past to secure an airway.
• Breathe a sigh of relief bc these kind of cases are extremely uncommon!  Pat yourself on the back for a job well-done!

Now check out this amazing Case Report on a patient with a massive maxillofacial tumor!

Call for help

April 11, 2010 (CA-3)

My 1st true difficult airway…. something I hope to never see again, but who am I kidding? It’s my job to be an airway expert… therefore, that only means I will be challenging my skills and will someday encounter that dreaded unintubateable airway.

The patient was a friendly, easy-going gal who was an anesthesiologist’s nightmare. She was coming in for a 3 vessel CABG… she was a known difficult IV access (yes, she came from the floor with an infiltrated 22g IV). She stood proud at 5’3″, 255lb, short chin, small mouth opening, and thick neck. She had had her cath done a couple days prior to her surgery — and yes, the radial artery was used. In addition to her already challenging anatomy, the surgeon requested that her other radial artery be spared for grafting.

I go to meet her in the holding area. She was so nice…friendly… had a positive attitude. These are the patients I love to care for. After updating her H&P and checking her consent, I apprehensively started searching for venous access. 3 PIV sticks..with flash but no luck. 2 attempts with U/S…no luck. Luckily, my a-line went in without any trouble. The attending tried several times for a PIV as well with U/S.. no luck.

We wheeled her back to the OR. She had a rather unchallenging R IJ MAC introducer placement (thank goodness!). Now to go to sleep!

We had a glidescope and bougie handy… knowing this intubation could be difficult. (In retrospect, I would’ve had the fiberoptic cart and an LMA within reach). We pre-oxygenated in reverse T-burg for what seemed like forever. Go time: Prop, sux,… glidescope…. barely saw arytenoids…even with a glidescope!! Small mouth opening kept us from truly getting the styletted tube in her mouth. I took a look for what felt like maybe 5 seconds and could eerily hear the sat probe dwindle down… 100….98……95……92….87….84…. time to mask ventilate!! We 2-hand mask her… a very difficult mask! Oral airway in…still difficult. Reposition, jaw lift,…sats 64…52….39… “Call for help” exclaimed my attending! I called out for an LMA and a bougie and told the surgeons to be on standby for an emergency airway.

Fortunately, we were able to place an LMA #4 and slowly ventilate her back up to 100% sat. By now, there were 3 other anesthesiologists and an anesthesia tech who came to help.

We had an airway, but couldn’t proceed with the surgery with just an LMA…we needed to secure her airway. We switched over to a Fast trach LMA#5…one that would accomodate a 7.0 ETT. We used a fiberoptic scope to look down the LMA. It was difficult to discern the structures. She had a pretty small glottic opening…and after several attempts, we were able to guide the fiberoptic scope down into the trachea and secure a breathing tube for ventilation.

Once the tube was secured… I took a step back and realized this could have been a disaster. However, we initiated all the right things in the difficult airway algorithm and saved this woman’s life. It was incredible.

After her surgery, we delivered her to the SICU, intubated. She was extubated the next morning under the supervision of an anesthesiologist. Everything went well. She recovered well from her CABG and was informed to have “difficult airway” written all over her medical record.

Key points:
-Call for help early
-Always have backup airway devices ready
-Even as a resident, don’t depend on your attendings to bail you out of trouble….b/c someday, that “attending” will be you.
-Reflect at the end of a challenging case