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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 36-39

Videolaryngoscope-guided awake tracheal intubation in a patient with invasive medullary thyroid carcinoma causing subglottic airway obstruction


1 Department of Onco-Anaesthesia and Palliative Medicine, NCI, AIIMS, New Delhi, India
2 Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India

Date of Submission24-Aug-2021
Date of Decision21-Oct-2021
Date of Acceptance03-Nov-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Dr. Ram Singh
Department of Onco-Anaesthesia and Palliative Medicine, NCI, AIIMS, Room No. 03, 1st Floor, Academic Block, NCI Jhajjar, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_50_21

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  Abstract 

Head-and-neck tumours are associated with a difficult airway due to the involvement of airway structures and infiltration into surrounding tissues. In clinical practice, awake tracheal intubation (ATI) is mainly performed with a fibreoptic bronchoscope. Videolaryngoscope-guided ATI has been proven to be equally effective in terms of patient comfort, safety profile and success rate. It also takes lesser time as compared to fibreoptic bronchoscopy provided adequate airway topicalisation is done and sedation carefully titrated with a suitable sedative. Formulating a good plan with team members, psychological preparation of the patient and choosing the right technique facilitated successful ATI in our patient with an anticipated difficult airway.

Keywords: Awake tracheal intubation, difficult airway, fibreoptic broncoscope, videolaryngoscope


How to cite this article:
Singh R, Baruah M, Ratre BK, Kumar V. Videolaryngoscope-guided awake tracheal intubation in a patient with invasive medullary thyroid carcinoma causing subglottic airway obstruction. Airway 2022;5:36-9

How to cite this URL:
Singh R, Baruah M, Ratre BK, Kumar V. Videolaryngoscope-guided awake tracheal intubation in a patient with invasive medullary thyroid carcinoma causing subglottic airway obstruction. Airway [serial online] 2022 [cited 2022 May 20];5:36-9. Available from: https://www.arwy.org/text.asp?2022/5/1/36/335893


  Introduction Top


Distortion of the airway caused by intraluminal extension and compression by a thyroid tumour makes airway management a challenging task for the anaesthesiologist.[1] In an anticipated difficult airway, strategic planning, preparedness, assessment and teamwork are important to reduce complications.[2] Awake tracheal intubation (ATI) in a spontaneously breathing patient with the use of fibreoptic bronchoscope (FOB) or videolaryngoscope (VL) is a good choice. A high success rate and better safety profile make ATI a preferred technique over others.[3] We report a patient with subglottic tracheal stenosis due to invasive medullary thyroid cancer scheduled for elective tracheostomy where C-MAC VL facilitated ATI.


  Case Report Top


A 34-year-old male with medullary thyroid carcinoma for the past 2 years presented to the emergency department with increasing difficulty in breathing and stridor on lying down for 15 days. On examination, the patient had significant dyspnoea and stridor with indrawing of chest and use of accessory muscles of breathing. The patient was afebrile with stable vital parameters. Examination of the neck revealed a palpable 1 cm × 1 cm nodule in right lobe of thyroid and a 4 cm × 4 cm nodule at the isthmus with diffuse swelling of left lobe of thyroid [Figure 1]. Contrast-enhanced computed tomography (CECT) of the neck revealed a large lobulated heterogenous mass arising in the right lobe of the thyroid, crossing the midline anteriorly and posteriorly and causing invasion of adjacent tracheal wall with narrowing of airway lumen [Figure 2]. Fibreoptic laryngoscopy revealed normal larynx and vocal cords. A tracheostomy was planned in view of impending airway obstruction. Routine laboratory investigations were normal except for deranged thyroid profile indicative of severe hypothyroidism. The patient was started on oral thyroxin sodium 50 μg once a day.
Figure 1: Neck swelling as seen from the (a) left, (b) front and (c) right side of the neck

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Figure 2: Contrast-enhanced computed tomography of the neck showing (a) coronal and (b) axial views

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Airway examination revealed mouth opening of >5 cm and a modified Mallampati class 1. It was decided to secure the airway under videolaryngoscopy with a microlaryngeal tube (MLT) using ATI. A 6 mm OD MLT was selected based on CECT. The patient was thoroughly explained about the need for and the technique of ATI and written informed consent was obtained. A 20 SWG intravenous (IV) cannula was secured and the patient nebulised with ipratropium 500 μg and levosalbutamol 1.25 mg. The nebulisation was given to preempt bronchospasm in patient with already compromised airway that could have been precipitated by airway manipulation during awake intubation, or following induction of general anaesthesia due to anaesthetics, secretions or aspiration. Airway topicalisation was done using nebulisation with 3 mL of 4% lignocaine solution and 2 puffs of lignocaine spray (10%) onto the oropharyngeal area. An emergency crash cart and a difficult airway cart (along with a range of airway equipment including an adult FOB) were kept ready. A rigid bronchoscope was kept ready for emergency ventilation. A bolus of 0.5 μg/kg of dexmedetomidine was infused over 10 min followed by an infusion of 0.1–0.3 μg/kg/h titrated to achieve a modified Ramsay sedation scale score of 2-3. IV fentanyl 25 μg was given, the patient was positioned supine and preoxygenated for 3 min with 3-4 L/min of oxygen through nasal prongs. Gentle laryngoscopy with # 3 blade of C-MAC VL revealed a Cormack-Lehane grade 2a laryngeal view. Two puffs of 10% lignocaine solution were sprayed onto the laryngopharynx. For better visualisation, the blade was changed to a D-blade resulting in a Cormack-Lehane grade 1 laryngeal view. A tumour polyp was seen beyond the vocal cords. An initial attempt to insert an MLT failed. The patient had slight discomfort and was administered an additional 25 μg of fentanyl. The next attempt at passing a Frova intubating catheter (14 F) failed. A senior and more experienced person could negotiate the Frova intubating catheter past the vocal cords, and a 6.0 mm OD MLT was railroaded and pushed gently beyond the visible growth in the subglottic area. There were minimal haemodynamic changes. The tube position was confirmed by a 2-point check that included visible negotiation of tracheal tube past the vocal cords and capnography. The patient was placed on spontaneous mode of ventilation with a mixture of 50% oxygen and air through the closed circuit. The carina was identified on fibreoptic bronchoscopy (FOB), and the tip of the MLT was seen to be positioned 3 cm above the carina. No intraluminal mass or bleeding was noticed. General anaesthesia was induced using IV fentanyl 50 μg and propofol 100 mg followed by muscle relaxation with rocuronium 35 mg and anaesthesia maintained with sevoflurane. The dexmedetomidine infusion was discontinued. Total dose of drugs used during the procedure was fentanyl 100 μg, dexmedetomidine 40 μg and lignocaine 180 mg. The surgical tracheostomy was completed uneventfully by the otorhinolaryngologist. Neuromuscular blockade was reversed and the patient was shifted to the recovery room for observation on T-piece oxygen at 5 L/min. Subsequently, the patient was able to maintain a saturation of 98% on room air and his breathing pattern improved significantly. He was discharged from the hospital on postoperative day 2 with advice to continue thyroid medications and attend regular follow-up at the otorhinolaryngology clinic.


  Discussion Top


The main concern in our patient was the anticipated difficult airway. A recent guideline on ATI advocates the use of this technique in the presence of the predictors of a difficult airway as it has a better safety profile and a high success rate.[3] There are only a few guidelines available in literature including the Difficult Airway Society guidelines for ATI in the anticipated difficult airway as compared to the unanticipated difficult airway.[3],[4] We had explained the details of the procedure to the patient and had addressed all his queries and concerns. Focussed psychological preparation had helped us to obtain the confidence and cooperation of the patient during ATI. The importance of psychological preparation with empathy and understanding is emphasised in literature.[5] We opted for dexmedetomidine as a sedative agent considering its additional analgesic, anxiolytic and unique sedative action characterised by easy transition from sleep to wakefulness, thereby maintaining 'conscious sedation'.[6],[7] Dexmedetomidine not only has the least effect on haemodynamics and breathing, but it also carries a lower risk of oversedation and airway obstruction in ATI.[4],[6],[7] Dexmedetomidine is also preferred in children for ATI.[8] There is no evidence that metabolism of dexmedetomidine is delayed in hypothyroid patients (our patient was hypothyroid). Fentanyl has also been used alone or in combination with other sedative agents such as clonidine or propofol in some cases, as also remifentanil.[9],[10],[11],[12] We used low-dose fentanyl in titrated doses along with dexmedetomidine. Though airway blocks are considered superior to topical anaesthesia in terms of quality of airway anaesthesia,[13] we chose topical anaesthesia for airway preparation in view of extension of the tumour within the neck. We performed airway topicalisation with 4% lignocaine nebulisation and 10% lignocaine spray and maintained oxygenation using nasal cannula throughout the procedure while closely monitoring the vital signs. Oxygen supplementation is highly recommended during ATI, preferably using high-flow nasal oxygen if available.[3] We preferred C-MAC VL-guided intubation over awake FOB as no predictors of difficult laryngoscopy had been detected. Adequate topicalisation provides equally good patient comfort for awake intubation with VL or FOB,[14] Moreover, videolaryngoscopy has been observed to take less time to intubate with a high success rate and a safety profile and patient satisfaction comparable to FOB.[15]

Thus, formulating a good plan, psychological preparation of the patient, careful titration of sedation with appropriate drugs and meticulous execution of the procedure by choosing the right technique are the keys to successful ATI with minimal complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Price DL, Wong RJ, Randolph GW. Invasive thyroid cancer: Management of the trachea and esophagus. Otolaryngol Clin North Am 2008;41:1155-68, ix-x.  Back to cited text no. 1
    
2.
Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth 2012;109 Suppl 1:i68-85.  Back to cited text no. 2
    
3.
Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020;75:509-28.  Back to cited text no. 3
    
4.
Cabrini L, Baiardo Redaelli M, Ball L, Filippini M, Fominskiy E, Pintaudi M, et al. Awake fiberoptic intubation protocols in the operating room for anticipated difficult airway: A systematic review and meta-analysis of randomized controlled trials. Anesth Analg 2019;128:971-80.  Back to cited text no. 4
    
5.
Reed AF, Han DG. Preparation of the patient for awake intubation. Anesthesiol Clin North Am 1991;9:69-81.  Back to cited text no. 5
    
6.
Lee S. Dexmedetomidine: Present and future directions. Korean J Anesthesiol 2019;72:323-30.  Back to cited text no. 6
    
7.
Johnston KD, Rai MR. Conscious sedation for awake fibreoptic intubation: A review of the lit-erature. Can J Anaesth 2013;60:584-99.  Back to cited text no. 7
    
8.
Bohman JK, Segura L. Awake tracheal intubation in an 8-year-old girl with mccune-albright syndrome. A A Case Rep 2013;1:23-5.  Back to cited text no. 8
    
9.
Hohn A, Kauliņš T, Hinkelbein J, Kauliņa K, Kopp A, Russo SG, et al. Awake tracheotomy in a patient with stridor and dyspnoea caused by a sizeable malignant thyroid tumor: A case report and short review of the literature. Clin Case Rep 2017;5:1891-5.  Back to cited text no. 9
    
10.
Ortega Agón KA, González Maldonado JF. Awake intubation with videolaryngoscopy and ul-trasound-guided percutaneous tracheostomy in a patient with anaplastic thyroid cancer and difficult airway: A case report. Colomb J Anesthesiol 2018;46:159-63.  Back to cited text no. 10
    
11.
Kim SM, Kim HJ. Successful advancement of endotracheal tube with combined fiberoptic bronchoscopy and videolaryngoscopy in a patient with a huge goiter. SAGE Open Med Case Rep 2020;8:2050313X20923232.  Back to cited text no. 11
    
12.
Ye X, Jiang X, Lan H, Yang Y, Lian Q. Difficult airway caused by a subglottic tumor: A case report. Res Sq [Preprint]. 2019. Available from: https://doi.org/10.21203/rs.2.257/v1. [Last accessed on 2021 Aug 24].  Back to cited text no. 12
    
13.
Mathur PR, Jain N, Kumar A, Thada B, Mathur V, Garg D. Comparison between lignocaine nebulization and airway nerve block for awake fiberoptic bronchoscopy-guided nasotracheal intubation: A single-blind randomized prospective study. Korean J Anesthesiol 2018;71:120-6.  Back to cited text no. 13
    
14.
Fitzgerald E, Hodzovic I, Smith AF. 'From darkness into light': Time to make awake intubation with videolaryngoscopy the primary technique for an anticipated difficult airway? Anaesthesia 2015;70:387-92.  Back to cited text no. 14
    
15.
Alhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: A systematic review and meta-analysis. Anaesthesia 2018;73:1151-61.  Back to cited text no. 15
    


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