Averting catastrophic outcomes: the fundamentals of “impossible” airways

Excerpt

Recently, a colleague consulted us about the management of a patient with an “impossible” airway. The patient was a 60-yr-old man who presented with stridor due to a significant obstructive lesion in the trachea. The computer tomographic (CT) scan revealed that more than 85% of the tracheal lumen was occluded, extending from the cricoid cartilage to the mid-trachea. He was scheduled to have a laser excision of the lesion under general anesthesia. Having reviewed the CT scan and the patient’s clinical findings, the anesthesia team suggested consulting the cardiac surgery and perfusion team about access for extracorporeal membrane oxygenation (ECMO) in case it was needed before anesthesia was induced. Nevertheless, the laser surgery proceeded without this ECMO consultation as the surgeon felt that initiation of the ECMO prior to surgery was unnecessary and that heparinization for the ECMO might complicate the procedure. They also felt that it was possible to push a small laser tracheal tube (5 mm internal diameter) through the obstruction while the patient was awake, under topical anesthesia. Fortunately, the laser excision of the tracheal lesion performed under general anesthesia was uneventful. While the outcome was a positive one, many would question the wisdom of proceeding without a backup plan in case of failure to oxygenate the patient during intubation and surgery. …